Patient Monitoring Alarms in an Intensive Care Unit: Observational Study With Do-It-Yourself Instructions.

BACKGROUND: As one of the most essential technical components of the intensive care unit (ICU), continuous monitoring of patients' vital parameters has significantly improved patient safety by alerting staff through an alarm when a parameter deviates from the normal range. However, the vast number of alarms regularly overwhelms staff and may induce alarm fatigue, a condition recently exacerbated by COVID-19 and potentially endangering patients. OBJECTIVE: This study focused on providing a complete and repeatable analysis of the alarm data of an ICU's patient monitoring system. We aimed to develop do-it-yourself (DIY) instructions for technically versed ICU staff to analyze their monitoring data themselves, which is an essential element for developing efficient and effective alarm optimization strategies. METHODS: This observational study was conducted using alarm log data extracted from the patient monitoring system of a 21-bed surgical ICU in 2019. DIY instructions were iteratively developed in informal interdisciplinary team meetings. The data analysis was grounded in a framework consisting of 5 dimensions, each with specific metrics: alarm load (eg, alarms per bed per day, alarm flood conditions, alarm per device and per criticality), avoidable alarms, (eg, the number of technical alarms), responsiveness and alarm handling (eg alarm duration), sensing (eg, usage of the alarm pause function), and exposure (eg, alarms per room type). Results were visualized using the R package ggplot2 to provide detailed insights into the ICU's alarm situation. RESULTS: We developed 6 DIY instructions that should be followed iteratively step by step. Alarm load metrics should be (re)defined before alarm log data are collected and analyzed. Intuitive visualizations of the alarm metrics should be created next and presented to staff in order to help identify patterns in the alarm data for designing and implementing effective alarm management interventions. We provide the script we used for the data preparation and an R-Markdown file to create comprehensive alarm reports. The alarm load in the respective ICU was quantified by 152.5 (SD 42.2) alarms per bed per day on average and alarm flood conditions with, on average, 69.55 (SD 31.12) per day that both occurred mostly in the morning shifts. Most alarms were issued by the ventilator, invasive blood pressure device, and electrocardiogram (ie, high and low blood pressure, high respiratory rate, low heart rate). The exposure to alarms per bed per day was higher in single rooms (26%, mean 172.9/137.2 alarms per day per bed). CONCLUSIONS: Analyzing ICU alarm log data provides valuable insights into the current alarm situation. Our results call for alarm management interventions that effectively reduce the number of alarms in order to ensure patient safety and ICU staff's work satisfaction. We hope our DIY instructions encourage others to follow suit in analyzing and publishing their ICU alarm data.

Impact of Alarm Fatigue on the Work of Nurses in an Intensive Care Environment-A Systematic Review.

BACKGROUND: In conditions of intensive therapy, where the patients treated are in a critical condition, alarms are omnipresent. Nurses, as they spend most of their time with patients, monitoring their condition 24 h, are particularly exposed to so-called alarm fatigue. The purpose of this study is to review the literature available on the perception of clinical alarms by nursing personnel and its impact on work in the ICU environment. METHODS: A systematic review of the literature was carried out according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) protocol. The content of electronic databases was searched through, i.e., PubMed, OVID, EBSCO, ProQuest Nursery, and Cochrane Library. The keywords used in the search included: "intensive care unit," "nurse," "alarm fatigue," "workload," and "clinical alarm." The review also covered studies carried out among nurses employed at an adult intensive care unit. Finally, seven publications were taken into consideration. Data were analyzed both descriptively and quantitatively, calculating a weighted average for specific synthetized data. RESULTS: In the analyzed studies, 389 nurses were tested, working in different intensive care units. Two studies were based on a quality model, while the other five described the problem of alarms in terms of quantity, based on the HTF (Healthcare Technology Foundation) questionnaire. Intensive care nurses think that alarms are burdensome and too frequent, interfering with caring for patients and causing reduced trust in alarm systems. They feel overburdened with an excessive amount of duties and a continuous wave of alarms. Having to operate modern equipment, which is becoming more and more advanced, takes time that nurses would prefer to dedicate to their patients. There is no clear system for managing the alarms of monitoring devices. CONCLUSION: Alarm fatigue may have serious consequences, both for patients and for nursing personnel. It is necessary to introduce a strategy of alarm management and for measuring the alarm fatigue level.

Body-Worn Versus Bell-and-Pad Alarm Device for the Management of Monosymptomatic Nocturnal Enuresis in Children: A Randomized Controlled Trial.

PURPOSE: The purpose of this study was to compare the effectiveness of bell-and-pad alarm therapy to body-worn alarm therapy for the management of monosymptomatic enuresis in children 6 to 16 years of age. DESIGN: A prospective, randomized, adaptive clinical control trial. SUBJECTS AND SETTING: The sample comprised 86 children who attended a continence clinic for treatment of monosymptomatic enuresis and met the criteria for enuresis alarm therapy as per International Children's Continence Society (ICCS) guidelines. Subjects were randomly allocated to an experimental group (body-worn alarm, n = 41) or a control group (bell-and-pad alarm, n = 45). The study setting was a single-site specialist continence service in regional Victoria, Australia. Treatment was administered in the child's home. METHODS: Alarm therapy was administered by the child and/or parent for an initial period of 8 weeks at which time the child underwent a review with the continence nurse specialist. If the child had achieved 14 consecutive dry nights, the therapy was deemed successful and ceased. Children who had not become dry continued therapy for a further 8 weeks up to a maximum of 16 weeks, with a final review was instituted. Each child kept a diary for the duration of alarm therapy to report on frequency of wet/dry nights, times of alarm, response to alarm, and response to sensation to void (without alarm). The 2 types of alarm devices were compared with respect to categorical variables using dichotomous cross-tabulations and χ tests of independence based on the most positive outcome versus the other outcomes. RESULTS: Dryness in accordance with the criteria outlined by the ICCS guidelines was achieved in 18 children (43.9%) in the body-worn alarm group versus 29 children (64.4%) in the routine (bell-and-pad) group (P = .056). The bell-and-pad alarm performed better on 7 out of the 9 indicators, including the primary outcome measure of the child attained dryness for 14 nights or more, nightly alarm use, alarm woke child, alarm woke parent (P = .022), false (positive) alarms (P = .039), child turned alarm off and went back to sleep (P = .003), and child was compliant with alarm use. The body-worn device produced higher proportions of the most positive outcomes for 2 of the 9 indicators: relapse (P = .076) and false (negative) nonalarms (P = .066). CONCLUSIONS: Study findings suggests that the bell-and-pad alarm is preferable to the body-worn alarm. Additional research is recommended using other body-worn alarm devices across a larger population in order to establish the more definitive findings needed for clinical decision-making.

The influence of nursing activities score on clinical alarms service.

OBJECTIVES: to estimate the magnitude of the Nursing Activities Score effect on multiparametric monitor alarm response and staff response time. METHODS: an observational, cross-sectional study outlined as an open cohort, performed in an Adult General Intensive Care Unit. The time taken for alarms triggered by the multi-parameter monitors was timed and characterized as attended or not. RESULTS: the study obtained a total of 254 alarms triggered from the multiparameter monitors of 63 patients. The mean number of alarms triggered was 4.5 alarms per period/observation and 1.5 alarms/hour. The study showed that the Nursing Activities Score is associated with an additional probability of 4% (p < 0.05) of an alarm being met, for each additional point in the scale, and reduction in team response time. CONCLUSION: it has been verified that Nursing Activities Score has a direct relationship with the attendance and with the response time to the alarms triggered.

Unit-level variation in bed alarm use in US hospitals.

Bed and chair alarms are widely used in hospitals, despite lack of effectiveness and unintended negative consequences. In this cross-sectional, observational study, we examined alarm prevalence and contributions of patient- and unit-level factors to alarm use on 59 acute care nursing units in 57 US hospitals participating in the National Database of Nursing Quality Indicators®. Nursing unit staff reported data on patient-level fall risk and fall prevention measures for 1,489 patients. Patient-level propensity scores for alarm use were estimated using logistic regression. Expected alarm use on each unit, defined as the mean patient propensity-for-alarm score, was compared with the observed rate of alarm use. Over one-third of patients assessed had an alarm in the "on" position. Patient characteristics associated with higher odds of alarm use included recent fall, need for ambulation assistance, poor mobility judgment, and altered mental status. Observed rates of unit alarm use ranged from 0% to 100% (median 33%, 10th percentile 5%, 90th percentile 67%). Expected alarm use varied less (median 31%, 10th percentile 27%, and 90th percentile 45%). Only 29% of variability in observed alarm use was accounted for by expected alarm use. Unit assignment was a stronger predictor of alarm use than patient-level fall risk variables. Alarm use is common, varies widely across hospitals, and cannot be fully explained by patient fall risk factors; alarm use is driven largely by unit practices. Alarms are used too frequently and too indiscriminately, and guidance is needed for optimizing alarm use to reduce noise and encourage mobility in appropriate patients.

Call Bell Usage: Tracking the Effect of Hourly Staff Rounding.

Hourly rounding by nursing staff helps to proactively manage patient needs and minimize the number of unscheduled calls from patients. The focus of this study was to determine if an increased emphasis on hourly rounding had an effect on call bell usage on an oncology unit. Patient call bell usage requests, such as asking for water or repositioning, and the total number of all alarms, such as bed exit alarms and lavatory assist alarms, decreased. Subsequent patient satisfaction surveys showed an increase in patient perception of how quickly help was received.

Nurses' responses to monitor alarms in an intensive care unit: An observational study.

OBJECTIVE: The present study aimed to determine the types of monitor alarms and nurses' responses to them in an adult intensive care unit. DESIGN AND METHODS: This was an observational descriptive research study conducted in the adult intensive care unit of a university hospital in the Mediterranean region of Turkey. The nonparticipant observation method was used. Data were collected by two observers using a semi-structured observation form developed according to literature. RESULTS: Between August 2016 and January 2017, 13 registered nurses were observed for 328 hours. There were 1781 alarms, which included alarms for blood pressure (37.6%), respiration and oxygen saturation (35.3%) and heart rate and arrhythmia (27.1%). Nurses responded to approximately half (46.9%) of the alarms that required a response. Responses to alarms included silencing them, responding to the patient's clinical condition and solving contact and transmission problems. CONCLUSION: In the present study, according to response requirement, the division of the alarms was different. The number of alarms that do not reflect the clinical status of the patient was high. It was found that as the false alarm rate increased, the response rate of nurses to these alarms decreased.

Double Trouble: Patients With Both True and False Arrhythmia Alarms.

BACKGROUND: Patients with both true and false arrhythmia alarms pose a challenge because true alarms might be buried among a large number of false alarms, leading to missed true events. OBJECTIVE: To determine (1) the frequency of patients with both true and false arrhythmia alarms; (2) patient, clinical, and electrocardiographic characteristics associated with both true and false alarms; and (3) the frequency and types of true and false arrhythmia alarms. METHODS: This was a secondary analysis using data from an alarm study conducted at a tertiary academic medical center. RESULTS: Of 461 intensive care unit patients, 211 (46%) had no arrhythmia alarms, 12 (3%) had only true alarms, 167 (36%) had only false alarms, and 71 (15%) had both true and false alarms. Ventricular pacemaker, altered mental status, mechanical ventilation, and cardiac intensive care unit admission were present more often in patients with both true and false alarms than among other patients (P < .001). Intensive care unit stays were longer in patients with only false alarms (mean [SD], 106 [162] hours) and those with both true and false alarms (mean [SD], 208 [333] hours) than in other patients. Accelerated ventricular rhythm was the most common alarm type (37%). CONCLUSIONS: An awareness of factors associated with arrhythmia alarms might aid in developing solutions to decrease alarm fatigue. To improve detection of true alarms, further research is needed to build and test electrocardiographic algorithms that adjust for clinical and electrocardiographic characteristics associated with false alarms.

Respiratory Volume Monitoring in the Perioperative Setting Across Multiple Centers.

BACKGROUND: The prevalence of nuisance (technical) alarms is the leading cause of alarm fatigue resulting in decreased awareness and a reduction in effective care. The Joint Commission identified in their National Patient Safety goals alarm fatigue as a major safety issue. The introduction of noninvasive respiratory volume monitoring (RVM) has implications for effective perioperative respiratory status management. We evaluated this within the Kaiser Permanente health system. METHODS: This observational study was conducted at 4 hospitals in the Kaiser Permanente system. Standard data from RVM, pulse oximetry, and capnography were collected postoperatively in the post-anesthesia care unit (PACU) and/or on the general hospital floor. Device-specific alarm types, rates, and respective actions were recorded and analyzed by non-study staff. RESULTS: RVM was applied to 247 subjects (143 females, body mass index 32.3 ± 8.7 kg/m2, age 60.9 ± 13.9 y) providing 2,321 h. RVM alarms occurred 605 times (0.25 alarms/h); 64% were actionable and addressed, 17% were not addressed, 13% were self-resolved, and only 6% were nuisance. In a subgroup, RVM completed all 127 h of monitoring, whereas oximetry with capnography only completed 51 h with 12.9 alarms/h (73% nuisance). The overall RVM alarm rate was significantly lower than with either pulse oximeters or capnography monitors. We saw a nearly 1,000-fold reduction in nuisance alarms compared to capnography and a 20-50-fold reduction in nuisance alarms compared to pulse oximetry. CONCLUSIONS: Our study indicates that alarm fatigue due to nuisance alarms continues to be a clinical challenge in perioperative settings. Among the 3 common technologies for respiratory function monitoring, RVM had the lowest rate of overall technical alarms and the highest rate of compliance. Furthermore, with early interventions, none of the subjects monitored with RVM suffered any negative outcomes.

Team-Based Intervention to Reduce the Impact of Nonactionable Alarms in an Adult Intensive Care Unit.

BACKGROUND: Nonactionable alarms comprise over 70% of alarms and contribute a threat to patient safety. Few studies have reported approaches to translate and sustain these interventions in clinical settings. PURPOSE: This study tested whether an interprofessional team-based approach can translate and implement effective alarm reduction interventions in the adult intensive care unit. METHODS: The study was a prospective, cohort, pre- and postdesign with repeated measures at baseline (preintervention) and post-phase I and II intervention periods. The settings for the most prevalent nonactionable arrhythmia and bedside parameter alarms were adjusted during phases I and II, respectively. RESULTS: The number of total alarms was reduced by 40% over a 14-day period after both intervention phases were implemented. The most prevalent nonactionable parameter alarms decreased by 47% and arrhythmia alarms decreased by 46%. CONCLUSIONS: It is feasible to translate and sustain system-level alarm management interventions addressing alarm fatigue using an interprofessional team-based approach.

Machine learning applied to multi-sensor information to reduce false alarm rate in the ICU.

Studies reveal that the false alarm rate (FAR) demonstrated by intensive care unit (ICU) vital signs monitors ranges from 0.72 to 0.99. We applied machine learning (ML) to ICU multi-sensor information to imitate a medical specialist in diagnosing patient condition. We hypothesized that applying this data-driven approach to medical monitors will help reduce the FAR even when data from sensors are missing. An expert-based rules algorithm identified and tagged in our dataset seven clinical alarm scenarios. We compared a random forest (RF) ML model trained using the tagged data, where parameters (e.g., heart rate or blood pressure) were (deliberately) removed, in detecting ICU signals with the full expert-based rules (FER), our ground truth, and partial expert-based rules (PER), missing these parameters. When all alarm scenarios were examined, RF and FER were almost identical. However, in the absence of one to three parameters, RF maintained its values of the Youden index (0.94-0.97) and positive predictive value (PPV) (0.98-0.99), whereas PER lost its value (0.54-0.8 and 0.76-0.88, respectively). While the FAR for PER with missing parameters was 0.17-0.39, it was only 0.01-0.02 for RF. When scenarios were examined separately, RF showed clear superiority in almost all combinations of scenarios and numbers of missing parameters. When sensor data are missing, specialist performance worsens with the number of missing parameters, whereas the RF model attains high accuracy and low FAR due to its ability to fuse information from available sensors, compensating for missing parameters.

Emergency department monitor alarms rarely change clinical management: An observational study.

STUDY OBJECTIVE: Monitor alarms are prevalent in the ED. Continuous electronic monitoring of patients' vital signs may alert staff to physiologic decompensation. However, repeated false alarms may lead to desensitization of staff to alarms. Mitigating this could involve prioritizing the most clinically-important alarms. There are, however, little data on which ED monitor alarms are clinical meaningful. We evaluated whether and which ED monitor alarms led to observable changes in patients' ED care. METHODS: This prospective, observational study was conducted in an urban, academic ED. An ED physician completed 53 h of observation, recording patient characteristics, alarm type, staff response, whether the alarm was likely real or false, and whether it changed clinical management. The primary outcome was whether the alarm led to an observable change in patient management. Secondary outcomes included the type of alarms and staff responses to alarms. RESULTS: There were 1049 alarms associated with 146 patients, for a median of 18 alarms per hour of observation. The median number of alarms per patient was 4 (interquartile range 2-8). Alarms changed clinical management in 8 out of 1049 observed alarms (0.8%, 95% CI, 0.3%, 1.3%) in 5 out of the 146 patients (3%, 95% CI, 0.2%, 5.8%). Staff did not observably respond to most alarms (63%). CONCLUSION: Most ED monitor alarms did not observably affect patient care. Efforts at improving the clinical significance of alarms could focus on widening alarm thresholds, customizing alarms parameters for patients' clinical status, and on utilizing monitoring more selectively.

Customizing Physiologic Alarms in the Emergency Department: A Regression Discontinuity, Quality Improvement Study.

INTRODUCTION: Clinical alarms promote patient safety by alerting clinicians when there is an indication or change in a condition requiring a response. An excessive volume of alarm fires, however, contributes to sensory overload and desensitization, referred to as alarm fatigue, which has significant implications when alarms are missed. This evidence-based, practice project aimed to implement and evaluate a program that reduces the number of clinically nonactionable, physiologic alarms in an emergency department. Although alarm fatigue is an important negative consequence, the focus of this project is not on alarm fatigue but on measures to reduce the volume of clinically nonactionable alarms that lead to alarm fatigue. The Iowa Model was used as a conceptual framework. METHODS: This project involved adjusting default alarm settings and implementing an education plan on the safe use of alarms. The sample population included all patients on physiologic monitors at an emergency department. Retrospective data were collected, and regression discontinuity design was applied to compare the rate of alarm fires triggered by the physiologic monitor between pre- and postimplementation of an alarm protocol. RESULTS: A significant change in the rate of alarm fires occurred with an estimated reduction of 14.96 (P = 0.003). There were no reports of adverse outcomes such as a delay in responding to a change in patient condition or delay leading to cardiopulmonary arrest. DISCUSSION: A reduction in nonactionable, physiologic alarms was attained after implementing multimodal strategies inclusive of adjusting default settings, staff education on managing alarms, and emphasis on staff accountability.

The influence of nursing activities score on clinical alarms service / La influencia de la nursing activities score en el servicio de alarmas clínicas / A influência do nursing activities score no atendimento aos alarmes clínicos

ABSTRACT Objectives: to estimate the magnitude of the Nursing Activities Score effect on multiparametric monitor alarm response and staff response time. Methods: an observational, cross-sectional study outlined as an open cohort, performed in an Adult General Intensive Care Unit. The time taken for alarms triggered by the multi-parameter monitors was timed and characterized as attended or not. Results: the study obtained a total of 254 alarms triggered from the multiparameter monitors of 63 patients. The mean number of alarms triggered was 4.5 alarms per period/observation and 1.5 alarms/hour. The study showed that the Nursing Activities Score is associated with an additional probability of 4% (p < 0.05) of an alarm being met, for each additional point in the scale, and reduction in team response time. Conclusion: it has been verified that Nursing Activities Score has a direct relationship with the attendance and with the response time to the alarms triggered.

RESUMEN Objetivos: estimar la magnitud del efecto del Nursing Activities Score en la atención a las alarmas de los monitores multiparamétricos y en el tiempo de respuesta del equipo. Métodos: estudio observacional, seccional delineado como una cohorte abierta, realizado en una Unidad de Terapia Intensiva General de Adultos. El tiempo hasta la atención de las alarmas disparadas de los monitores multiparamétricos fue cronometrado y caracterizados como atendidos o no. Resultados: el estudio obtuvo un total de 254 alarmas disparadas de los monitores multiparamétricos de 63 pacientes. El promedio de alarmas disparadas fue de 4,5 alarmas por período/observación y 1,5 alarmas/hora. El estudio demostró que el Nursing Activities Score está asociado a una probabilidad adicional de 4% (p < 0,05) de una alarma ser atendida, para cada punto adicional en la escala, y reducción en el tiempo de respuesta del equipo. Conclusiones: se verificó que Nursing Activities Score tiene relación directa con la atención y con el tiempo de respuesta a las alarmas disparadas.

RESUMO Objetivos: estimar a magnitude do efeito do Nursing Activities Score no atendimento aos alarmes dos monitores multiparamétricos e no tempo de resposta da equipe. Métodos: estudo observacional, seccional delineado como coorte aberta, realizado em uma Unidade de Terapia Intensiva geral de adultos. O tempo até o atendimento dos alarmes disparados dos monitores multiparamétricos foi cronometrado e caracterizado como atendido ou não. Resultados: o estudo obteve um total de 254 alarmes disparados dos monitores multiparamétricos de 63 pacientes. A média de alarmes disparados foi de 4,5 alarmes por período/observação e 1,5 alarmes/hora. O estudo demonstrou que o Nursing Activities Score está associado a uma probabilidade adicional de 4% (p < 0,05) de um alarme ser atendido, para cada ponto adicional na escala, e redução no tempo de resposta da equipe. Conclusões: verificou-se que Nursing Activities Score possui relação direta com o atendimento e com o tempo de resposta aos alarmes disparados.

Nurse Responses to Physiologic Monitor Alarms on a General Pediatric Unit.

BACKGROUND: Hospitalized children generate up to 152 alarms per patient per day outside of the intensive care unit. In that setting, as few as 1% of alarms are clinically important. How nurses make decisions about responding to alarms, given an alarm's low specificity for detecting clinical deterioration, remains unclear. OBJECTIVE: Our objective was to describe how bedside nurses think about and act upon monitor alarms for hospitalized children. DESIGN, SETTING, PARTICIPANTS: This was a qualitative study that involved the direct observation of nurses working on a general pediatric unit at a large children's hospital. MEASUREMENTS: We used a structured tool that included predetermined categories to assess nurse responses to monitor alarms. Data on alarm frequency and type were pulled from bedside monitors. RESULTS: We conducted 61.3 patient-hours of observation with nine nurses, in which we documented 207 nurse responses to patient alarms. For 67% of alarms heard outside of the room, the nurse decided not to respond without further assessment. Nurses most commonly cited reassuring clinical context (eg, medical team in room), as the rationale for alarm nonresponse. The nurse deemed clinical intervention necessary in only 14 (7%) of the observed responses. CONCLUSION: Nurses rely on clinical and contextual details to determine how to respond to alarms. Few of the alarm responses in our study resulted in a clinical intervention. These findings suggest that multiple system-level and educational interventions may be necessary to improve the efficacy and safety of continuous monitoring.

Electronic Alerts for Acute Kidney Injury Amelioration (ELAIA-1): a completely electronic, multicentre, randomised controlled trial: design and rationale.

INTRODUCTION: Acute kidney injury (AKI) is common among hospitalised patients and under-recognised by providers and yet carries a significant risk of morbidity and mortality. Electronic alerts for AKI have become more common despite a lack of strong evidence of their benefits. We designed a multicentre, randomised, controlled trial to evaluate the effectiveness of AKI alerts. Our aim is to highlight several challenges faced in the design of this trial, which uses electronic screening, enrolment, randomisation, intervention and data collection. METHODS AND ANALYSIS: The design and implementation of an electronic alert system for AKI was a reiterative process involving several challenges and limitations set by the confines of the electronic medical record system. The trial will electronically identify and randomise 6030 adults with AKI at six hospitals over a 1.5-2 year period to usual care versus an electronic alert containing an AKI-specific order set. Our primary outcome will be a composite of AKI progression, inpatient dialysis and inpatient death within 14 days of randomisation. During a 1-month pilot in the medical intensive care unit of Yale New Haven Hospital, we have demonstrated feasibility of automating enrolment and data collection. Feedback from providers exposed to the alerts was used to continually improve alert clarity, user friendliness and alert specificity through refined inclusion and exclusion criteria. ETHICS AND DISSEMINATION: This study has been approved by the appropriate ethics committees for each of our study sites. Our study qualified for a waiver of informed consent as it presents no more than minimal risk and cannot be feasibly conducted in the absence of a waiver. We are committed to open dissemination of our data through clinicaltrials.gov and submission of results to the NIH data sharing repository. Results of our trial will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT02753751; Pre-results.

Contribution of Electrocardiographic Accelerated Ventricular Rhythm Alarms to Alarm Fatigue.

BACKGROUND: Excessive electrocardiographic alarms contribute to "alarm fatigue," which can lead to patient harm. In a prior study, one-third of audible electrocardiographic alarms were for accelerated ventricular rhythm (AVR), and most of these alarms were false. It is uncertain whether true AVR alarms are clinically relevant. OBJECTIVES: To determine from bedside electrocardiographic monitoring data (1) how often true AVR alarms are acknowledged by clinicians, (2) whether such alarms are actionable, and (3) whether such alarms are associated with adverse outcomes ("code blue," death). METHODS: Secondary analysis using data from a study conducted in an academic medical center involving 5 adult intensive care units with 77 beds. Electronic health records of 23 patients with 223 true alarms for AVR were examined. RESULTS: The mean age of the patients was 62.9 years, and 61% were white and male. All 223 of the true alarms were configured at the warning level (ie, 2 continuous beeps), and 215 (96.4%) lasted less than 30 seconds. Only 1 alarm was acknowledged in the electronic health record. None of the alarms were clinically actionable or led to a code blue or death. CONCLUSIONS: True AVR alarms may contribute to alarm fatigue. Hospitals should reevaluate the need for close monitoring of AVR and consider configuring this alarm to an inaudible message setting to reduce the risk of patient harm due to alarm fatigue. Prospective studies involving larger patient samples and varied monitors are warranted.

Use, utility and methods of telehealth for patients with COPD in England and Wales: a healthcare provider survey.

Introduction: Although the effectiveness of domiciliary monitoring (telehealth) to improve outcomes in chronic obstructive pulmonary disease (COPD) is controversial, it is being used in the National Health Service (NHS). Aim: To explore the use of teleheath for COPD across England and Wales, to assess the perceptions of clinicians employing telehealth in COPD and to summarise the techniques that have been used by healthcare providers to personalise alarm limits for patients with COPD enrolled in telehealth programmes. Methods: A cross-sectional survey consisting of 14 questions was sent to 230 COPD community services in England and Wales. Questions were designed to cover five aspects of telehealth in COPD: purpose of use, equipment type, clinician perceptions, variables monitored and personalisation of alarm limits. Results: 65 participants completed the survey from 52 different NHS Trusts. 46% of Trusts had used telehealth for COPD, and currently, 31% still provided telehealth services to patients with COPD. Telehealth is most commonly used for baseline monitoring and to allow early detection of exacerbations, with 54% believing it to be effective. The three most commonly monitored variables were oxygen saturation, heart rate and breathlessness. A variety of methods were used to set alarm limits with the majority of respondents believing that at least 40% of alarms were false. Conclusion: Around one-third of responded community COPD services are using telehealth, believing it to be effective without robust evidence, with a variety of variables monitored, a variety of hardware and varying techniques to set alarm limits with high false alarm frequencies.

The impact of the NHS electronic-alert system on the recognition and management of acute kidney injury in acute medicine.

To address inconsistencies in the recognition and management of acute kidney injury (AKI), an electronic-alert (e-alert) system was implemented by NHS England in 2015. This study aimed to describe its impact within acute medicine in the West Midlands. All admissions to included acute medical units were screened for AKI in two phases, before and after the e-alert was introduced. Data describing recognition and management of patients with AKI were collected. In the 10 units that participated in both phases, recognition of AKI by clinicians significantly improved from 67.9% in 2015 to 76.1% in 2016 (p=0.04). Further analysis of the data found that the presence of an e-alert had a limited effect on recognition and management, suggesting it was not the primary cause of the improvements. Multiple avenues of research have been recommended to clarify the impact of the e-alert system and to improve deficiencies in management that were identified in the data.

Evaluation of Telemetry Utilization on Medical-Surgical Units.

Alarm fatigue is the most common contributing factor in alarm-related sentinel events. Researchers have demonstrated a 35% overuse of telemetry, a key factor in alarm fatigue. This project evaluates practice patterns for the ordering and discontinuation of telemetry on medical-surgical units. Practice patterns were reviewed to determine if they aligned with the American Heart Association evidence-based practice guidelines for telemetry monitoring and whether the order indication was congruent with the patient's clinical status. Nurse's attitudes and practices related to alarm safety were evaluated.