Critical Care Alarm Fatigue and Monitor Customization: Alarm Frequencies and Context Factors.

BACKGROUND: Alarm fatigue among nurses working in the intensive care unit has garnered considerable attention as a national patient safety priority. A viable solution for reducing the frequency of alarms and unnecessary noise is intensive care unit alarm monitor customization. LOCAL PROBLEM: A 24-bed cardiovascular and thoracic surgery intensive care unit in a large academic medical center identified a high rate of alarms and associated noise as a problem contributing to nurse alarm fatigue. METHODS: An alarm monitor quality improvement project used both alarm frequency and nurse surveys before and after implementation to determine the effectiveness of interventions. Multimodal interventions included nurse training sessions, informational flyers, organizational policies, and an alarm monitor training video. Unexpected results inspired an extensive investigation and secondary analysis, which included examining the data-capturing capabilities of the alarm monitors and the impact of context factors. RESULTS: Alarm frequencies unexpectedly increased after the intervention. The software data-capturing features of the alarm monitors for determining frequency did not accurately measure nurse interactions with monitors. Measured increases in patient census, nurse staffing, and data input from medical devices from before to after the intervention substantially affected project results. CONCLUSIONS: Alarm frequencies proved an unreliable measure of nurse skills and practices in alarm customization. Documented changes in context factors provided strong anecdotal evidence of changed circumstances that clarified project results and underscored the critical importance of contemporaneous collection of context data. Designs and methods used in quality improvement projects must include reliable outcome measures to achieve meaningful results.

ARTEMIS: An alarm threshold and policy mining system for the intensive care unit.

BACKGROUND: Alarm fatigue is a major technology-induced hazard for patients and staff in intensive care units. Too many - mostly unnecessary - alarms cause desensitisation and lack of response in medical staff. Unsuitable alarm policies are one reason for alarm fatigue. But changing alarm policies is a delicate issue since it concerns patient safety. OBJECTIVE: We present ARTEMIS, a novel, computer-aided clinical decision support system for policy makers that can help to considerably improve alarm policies using data from hospital information systems. METHODS: Policy makers can use different policy components from ARTEMIS' internal library to assemble tailor-made alarm policies for their intensive care units. Alternatively, policy makers can provide even more highly customised policy components as Python functions using data the hospital information systems. This can even include machine learning models - for example for setting alarm thresholds. Finally, policy makers can evaluate their system of policies and compare the resulting alarm loads. RESULTS: ARTEMIS reports and compares numbers of alarms caused by different alarm policies for an easily adaptable target population. ARTEMIS can compare policies side-by-side and provides grid comparisons and heat maps for parameter optimisation. For example, we found that the utility of alarm delays varies based on target population. Furthermore, policy makers can introduce virtual parameters that are not in the original data by providing a formula to compute them. Virtual parameters help measuring and alarming on the right metric, even if the patient monitors do not directly measure this metric. CONCLUSION: ARTEMIS does not release the policy maker from assessing the policy from a medical standpoint. But as a knowledge discovery and clinical decision support system, it provides a strong quantitative foundation for medical decisions. At comparatively low cost of implementation, ARTEMIS can have a substantial impact on patients and staff alike - with organisational, economic, and clinical benefits for the implementing hospital.

Automated Electronic Alert for the Care and Outcomes of Adults With Acute Kidney Injury: A Randomized Clinical Trial.

Importance: Despite the expansion of published electronic alerts for acute kidney injury (AKI), there are still concerns regarding their effect on the clinical outcomes of patients. Objective: To evaluate the effect of the AKI alert combined with a care bundle on the care and clinical outcomes of patients with hospital-acquired AKI. Design, Setting, and Participants: This single-center, double-blind, parallel-group randomized clinical trial was conducted in a tertiary teaching hospital in Nanjing, China, from August 1, 2019, to December 31, 2021. The inclusion criteria were inpatient adults aged 18 years or older with AKI, which was defined using the Kidney Disease: Improving Global Outcomes creatinine criteria. Participants were randomized 1:1 to either the alert group or the usual care group, which were stratified by medical vs surgical ward and by intensive care unit (ICU) vs non-ICU setting. Analyses were conducted on the modified intention-to-treat population. Interventions: A programmatic AKI alert system generated randomization automatically and sent messages to the mobile telephones of clinicians (alert group) or did not send messages (usual care group). A care bundle accompanied the AKI alert and consisted of general, nonindividualized, and nonmandatory AKI management measures. Main Outcomes and Measures: The primary outcome was maximum change in estimated glomerular filtration rate (eGFR) within 7 days after randomization. Secondary patient-centered outcomes included death, dialysis, AKI progression, and AKI recovery. Care-centered outcomes included diagnostic and therapeutic interventions for AKI. Results: A total of 2208 patients (median [IQR] age, 65 [54-72] years; 1560 males [70.7%]) were randomized to the alert group (n = 1123) or the usual care group (n = 1085) and analyzed. Within 7 days of randomization, median (IQR) maximum absolute changes in eGFR were 3.7 (-6.4 to 19.3) mL/min/1.73 m2 in the alert group and 2.9 (-9.2 to 16.9) mL/min/1.73 m2 in the usual care group (P = .24). This result was robust in all subgroups in an exploratory analysis. For care-centered outcomes, patients in the alert group had more intravenous fluids (927 [82.6%] vs 670 [61.8%]; P < .001), less exposure to nonsteroidal anti-inflammatory drugs (56 [5.0%] vs 119 [11.0%]; P < .001), and more AKI documentation at discharge (560 [49.9%] vs 296 [27.3%]; P < .001) than patients in the usual care group. No differences were observed in patient-centered secondary outcomes between the 2 groups. Conclusions and Relevance: Results of this randomized clinical trial showed that the electronic AKI alert did not improve kidney function or other patient-centered outcomes but changed patient care behaviors. The findings warrant the use of a combination of high-quality interventions and AKI alert in future clinical practice. Trial Registration: ClinicalTrials.gov Identifier: NCT03736304.

Minimising alarm pressure on a single room NICU through automated withdrawal of resolved alarms.

AIM: In 2017, the Leiden University Medical Centre implemented a secondary alarm system using handheld devices to ensure accurate patient monitoring on the single room NICU. Initially, alarms remained active on the handheld devices until one of the caregivers in the alarm chain accepted the alarm. In 2020, a bidirectional communication protocol (BCP) was implemented, enabling automated withdrawal of resolved alarms. The aim of this study was to evaluate the effect of this implementation on the alarm duration and pressure. METHODS: Data of all alarms of the secondary alarm chain in the 90 days before and after the implementation were analysed and compared between both periods. RESULTS: Following the implementation of the BCP, 60% of the alarms were withdrawn before the designated nurse responded. Despite a significant higher total number of alarms, the median alarm duration decreased from 9 (7-14) to 6 (4-10) s, the acceptance rate of the designated nurse increased from 93% to 95% and the median time of alarm sounding per phone per hour significantly decreased from 71 (51-101) to 51 (35-69) s following implementation of the BCP. CONCLUSION: This study showed that automated withdrawal of resolved alarms significantly reduces alarm duration and pressure on a NICU.

[Development of Vital Signal Monitoring System Based on Accelerometer].

OBJECTIVE: Reduce the number of false alarms and measurement time caused by movement interference by the sync waveform of the movement. METHODS: Vital signal monitoring system based on motion sensor was developed, which collected and processed the vital signals continuously, optimized the features and results of vital signals and transmitted the vital signal results and alarms to the interface. RESULTS: The system was tested in many departments, such as digestive department, cardiology department, internal medicine department, hepatobiliary surgery department and emergency department, and the total collection time was 1 940 h. The number of false electrocardiograph (ECG) alarms decreased by 82.8%, and the proportion of correct alarms increased by 28%. The average measurement time of non-invasive blood pressure (NIBP) decreased by 16.1 s. The total number of false respiratory rate measurement decreased by 71.9%. CONCLUSIONS: False alarms and measurement failures can be avoided by the vital signal monitoring system based on accelerometer to reduce the alarm fatigue in clinic.

Alert-Grouping: Smart Personalization of Monitoring System Thresholds to Help Healthcare Teams Struggle with Alarm Fatigue in Intensive Care.

In Intensive Care Units (ICUs), patients are monitored using various devices that generate alerts when specific metrics, such as heart rate and oxygen saturation, exceed predetermined thresholds. However, these alerts can be inaccurate and lead to alert fatigue, resulting in errors and inaccurate diagnoses. We propose Alert grouping, a "Smart Personalization of Monitoring System Thresholds to Help Healthcare Teams Struggle Alarm Fatigue in Intensive Care" model. The alert grouping looks at patients at the individual and cluster levels, and healthcare-related constraints to assist medical and nursing teams in setting personalized alert thresholds of vital parameters. By simulating the function of ICU patient bed devices, we demonstrate that the proposed alert grouping model effectively reduces the number of alarms overall, improving the alert system's validity and reducing alarm fatigue. Implementing this personalized alert model in ICUs boosts medical and nursing teams' confidence in the alert system, leading to better care for ICU patients by significantly reducing alarm fatigue, thereby improving the quality of care for ICU patients.

Alarm Fatigue among Nurses Working in Critical Care Setting in a Tertiary Hospital, Nepal.

Background Alarm fatigue is a well-recognized patient safety concern in critical care settings. It occurs when nurses become overwhelmed by the total number of alarm signals which can result in alarm desensitization and eventually contributes to missing of serious and important changes in a patient's condition, thus failing to respond properly. Objective To find out alarm fatigue and its associated factors among nurses working in critical care setting. Method A cross-sectional study design with convenient sampling technique was used to select 56 nurses working at different critical care settings in Dhulikhel Hospital. A selfconstructed semi structured questionnaire and nurses alarm fatigue questionnaire was used for the survey. Frequency, percentage, mean and standard deviation were used for descriptive statistics whereas Independent t-test and One-way ANOVA were used for inferential statistics. Result The result shows that more than half of the nurses were less than 25 years, single and more than two-third of the participants worked in Adult Intensive Care Unit. Out of total obtainable score 44, the overall mean score of the Alarm Fatigue was 28.03±12.813. The result showed that there was no significant difference between alarm fatigue and selected socio-demographic and work related characteristics. Conclusion The alarm fatigue among nurses working in critical care settings was found to be higher in this study. Since alarm fatigue is directly related to patients' safety, the effective management of medical device alarms can reduce alarm fatigue and prevent potentially dangerous outcomes.

A Spatiotemporal and Multisensory Approach to Designing Wearable Clinical ICU Alarms.

In health care, auditory alarms are an important aspect of an informatics system that monitors patients and alerts clinicians attending to multiple concurrent tasks. However, the volume, design, and pervasiveness of existing Intensive Care Unit (ICU) alarms can make it difficult to quickly distinguish their meaning and importance. In this study, we evaluated the effectiveness of two design approaches not yet explored in a smartwatch-based alarm system designed for ICU use: (1) using audiovisual spatial colocalization and (2) adding haptic (i.e., touch) information. We compared the performance of 30 study participants using ICU smartwatch alarms containing auditory icons in two implementations of the audio modality: colocalized with the visual cue on the smartwatch's low-quality speaker versus delivered from a higher quality speaker located two feet away from participants (like a stationary alarm bay situated near patients in the ICU). Additionally, we compared participant performance using alarms with two sensory modalities (visual and audio) against alarms with three sensory modalities (adding haptic cues). Participants were 10.1% (0.24s) faster at responding to alarms when auditory information was delivered from the smartwatch instead of the higher quality external speaker. Meanwhile, adding haptic information to alarms improved response times to alarms by 12.2% (0.23s) and response times on their primary task by 10.3% (0.08s). Participants rated learnability and ease of use higher for alarms with haptic information. These small but statistically significant improvements demonstrate that audiovisual colocalization and multisensory alarm design can improve user response times.

Observing sources of system resilience using in situ alarm simulations.

Alarm fatigue (and resultant alarm nonresponse) threatens the safety of hospitalized patients. Historically threats to patient safety, including alarm fatigue, have been evaluated using a Safety I perspective analyzing rare events such as failure to respond to patients' critical alarms. Safety II approaches call for learning from the everyday adaptations clinicians make to keep patients safe. To identify such sources of resilience in alarm systems, we conducted 59 in situ simulations of a critical hypoxemic-event alarm in medical/surgical and intensive care units at a tertiary care pediatric hospital between December 2019 and May 2022. Response timing, observations of the environment, and postsimulation debrief interviews were captured. Four primary means of successful alarm responses were mapped to domains of Systems Engineering Initiative for Patient Safety framework to inform alarm system design and improvement.

Ten Years Later, Alarm Fatigue Is Still a Safety Concern.

Ten years after the publication of a landmark article in AACN Advanced Critical Care, alarm fatigue continues to be an issue that researchers, clinicians, and organizations aim to remediate. Alarm fatigue contributes to missed alarms and medical errors that result in patient death, increased clinical workload and burnout, and interference with patient recovery. Led by the American Association of Critical-Care Nurses, national patient safety organizations continue to prioritize efforts to battle alarm fatigue and have proposed alarm management strategies to mitigate the effects of alarm fatigue. Similarly, clinical efforts now use simulation studies, individualized alarm thresholds, and interdisciplinary teams to optimize alarm use. Finally, engineering research efforts have innovated the standard alarm to convey information more effectively for medical users. By focusing on patient and provider safety, clinical workflow, and alarm technology, efforts to reduce alarm fatigue over the past 10 years have been grounded in an evidence-based and personnel-focused approach.

The effects of alarm fatigue on the tendency to make medical errors in nurses working in intensive care units.

BACKGROUND: Alarm fatigue resulting from exposure to multiple alarms is an important problem that threatens patient safety. The fact that each device in intensive care units works with different alarm systems increases the number and variety of alarms. AIM: The aim of this study was to determine the effects of alarm fatigue on the tendency of nurses working in intensive care units to make medical errors. STUDY DESIGN: A cross-sectional and correlational design were used in this study. The study was carried out with 382 intensive care nurses who could be reached via an electronic questionnaire. Data were collected using a 'Personal Information Form', the 'Alarm Fatigue Scale (AFS)' and the 'Medical Error Tendency Scale in Nursing (METSN)'. RESULTS: The mean age of the nurses who were included in the study was 31.52 ± 5.66. While 70.2% of the participants were women, 67% had bachelor's degrees, and 65.4% had been working in the intensive care unit for 1-5 years. The mean total METSN score of the participants was 229.29 ± 15.32, and their mean total AFS score was 20.02 ± 6.15. A negative and weak significant correlation was found between the total mean AFS and METSN scores of the participants (r = -0.275; p < .001). As the alarm fatigue levels of the participants increased, their medical error tendencies increased. It was determined that a one-unit increase in the alarm fatigue level of intensive care nurses increased their tendency to make medical errors by 0.263 units (p < .001). CONCLUSIONS: It was found that the nurses had a low tendency to make medical errors and moderate levels of alarm fatigue, and an increase in their alarm fatigue levels significantly increased their medical error tendencies. RELEVANCE TO CLINICAL PRACTICE: Institutions should establish alarm management procedures in units with multiple alarm systems, such as intensive care units, and examine the effects of alarms on employees.

A brief questionnaire for measuring alarm fatigue in nurses and physicians in intensive care units.

When exposed to hundreds of medical device alarms per day, intensive care unit (ICU) staff can develop "alarm fatigue" (i.e., desensitisation to alarms). However, no standardised way of quantifying alarm fatigue exists. We aimed to develop a brief questionnaire for measuring alarm fatigue in nurses and physicians. After developing a list of initial items based on a literature review, we conducted 15 cognitive interviews with the target group (13 nurses and two physicians) to ensure that the items are face valid and comprehensible. We then asked 32 experts on alarm fatigue to judge whether the items are suited for measuring alarm fatigue. The resulting 27 items were sent to nurses and physicians from 15 ICUs of a large German hospital. We used exploratory factor analysis to further reduce the number of items and to identify scales. A total of 585 submissions from 707 participants could be analysed (of which 14% were physicians and 64% were nurses). The simple structure of a two-factor model was achieved within three rounds. The final questionnaire (called Charité Alarm Fatigue Questionnaire; CAFQa) consists of nine items along two scales (i.e., the "alarm stress scale" and the "alarm coping scale"). The CAFQa is a brief questionnaire that allows clinical alarm researchers to quantify the alarm fatigue of nurses and physicians. It should not take more than five minutes to administer.

Battling Alarm Fatigue in the Pediatric Intensive Care Unit.

Pediatric intensive care unit nurses can be exposed to hundreds of alarms per patient they care for each shift. The exposure to so many alarms can cause nurses to be desensitized to future alarms and thus increase the time to respond to alarms. This is one of the largest patient safety concerns within health care today. Steps should be taken to mitigate the number of alarms nurses experience so that they can properly respond to actionable alarms.

Auditory roughness: a delicate balance.

Auditory roughness in medical alarm sounds is an important design attribute, and has been shown to impact user performance and perception. While roughness can assist in decreased signal-to-noise ratios (perceived loudness) and communicate urgency, it might also impact patient recovery. Therefore, considerations of neuroscience correlates, music theory, and patient impact are critical aspects to investigate in order to optimise alarm design.

Staff perspectives on the influence of patient characteristics on alarm management in the intensive care unit: a cross-sectional survey study.

BACKGROUND: High rates of clinical alarms in the intensive care unit can result in alarm fatigue among staff. Individualization of alarm thresholds is regarded as one measure to reduce non-actionable alarms. The aim of this study was to investigate staff's perceptions of alarm threshold individualization according to patient characteristics and disease status. METHODS: This is a cross-sectional survey study (February-July 2020). Intensive care nurses and physicians were sampled by convenience. Data was collected using an online questionnaire. RESULTS: Staff view the individualization of alarm thresholds in the monitoring of vital signs as important. The extent to which alarm thresholds are adapted from the normal range varies depending on the vital sign monitored, the reason for clinical deterioration, and the professional group asked. Vital signs used for hemodynamic monitoring (heart rate and blood pressure) were most subject to alarm individualizations. Staff are ambivalent regarding the integration of novel technological features into alarm management. CONCLUSIONS: All relevant stakeholders, including clinicians, hospital management, and industry, must collaborate to establish a "standard for individualization," moving away from ad hoc alarm management to an intelligent, data-driven alarm management. Making alarms meaningful and trustworthy again has the potential to mitigate alarm fatigue - a major cause of stress in clinical staff and considerable hazard to patient safety. TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov (NCT03514173) on 02/05/2018.

Fast & scrupulous: Gesture-based alarms improve accuracy and reaction times under various mental workload levels. An ERSP study.

In high-risk environments, fast and accurate responses to warning systems are essential to efficiently handle emergency situations. The aim of the present study was twofold: 1) investigating whether hand action videos (i.e., gesture alarms) trigger faster and more accurate responses than text alarm messages (i.e., written alarms), especially when mental workload (MWL) is high; and 2) investigating the brain activity in response to both types of alarms as a function of MWL. Regardless of MWL, participants (N = 28) were found to be both faster and more accurate when responding to gesture alarms than to written alarms. Brain electrophysiological results suggest that this greater efficiency might be due to a facilitation of the action execution, reflected by the decrease in mu and beta power observed around the response time window observed at C3 and C4 electrodes. These results suggest that gesture alarms may improve operators' performances in emergency situations.

Stats on the desats: alarm fatigue and the implications for patient safety.

BACKGROUND: Physiological monitoring systems, like Masimo, used during inpatient hospitalisation, offer a non-invasive approach to capture critical vital signs data. These systems trigger alarms when measurements deviate from preset parameters. However, often non-urgent or potentially false alarms contribute to 'alarm fatigue,' a form of sensory overload that can have adverse effects on both patients and healthcare staff. The Joint Commission, in 2021, announced a target to mitigate alarm fatigue-related fatalities through improved alarm management. Yet, no established guidelines are presently available. This study aims to address alarm fatigue at the Mayo Clinic to safeguard patient safety, curb staff burnout and improve the sensitivity of oxygen saturation monitoring to promptly detect emergencies. METHODS: A quality improvement project was conducted to combat minimise the false alarm burden, with data collected 2 months prior to intervention commencement. The project's goal was to decrease the total alarm value by 20% from 55%-85% to 35%-75% within 2 months, leveraging quality improvement methodologies. INTERVENTIONS: February to April 2021, we implemented a two-pronged intervention: (1) instituting a protocol to evaluate patients' continuous monitoring needs and discontinuing it when appropriate, and (2) introducing educational signage for patients and Mayo Clinic staff on monitoring best practices. RESULTS: Baseline averages of red alarms (158.6), manual snoozes (37.8) and self-resolves (120.7); the first postintervention phase showed reductions in red alarms (125.5), manual snoozes (17.8) and self-resolves (107.8). Second postintervention phase recorded 138 red alarms, 13 manual snoozes and 125 self-resolves. Baseline comparison demonstrated an average of 16.92% reduction of alarms among both interventions (p value: 0.25). CONCLUSION: Simple interventions like education and communication techniques proved instrumental in lessening the alarm burden for patients and staff. The findings underscore the practical use and efficacy of these methods in any healthcare setting, thus contributing to mitigating the prevalent issue of alarm fatigue.

Effects of multitasking on interpreting a spearcon sequence display for monitoring multiple patients.

Spearcons are time-compressed speech phrases. When arranged in a sequence representing vital signs of multiple patients, spearcons may be more informative than conventional auditory alarms. However, multiple resource theory suggests that certain timeshared tasks might interfere with listeners' ability to understand spearcons. We tested the relative interference with spearcon identification from the following ongoing tasks: (1) manual tracking, (2) linguistic detection of spoken target words, (3) arithmetic true-false judgments, or (4) an ignored background speech control. Participants were 80 non-clinicians. The linguistic task worsened spearcon identification more than the tracking task, p < .001, and more than ignored background speech, p = .012. The arithmetic task worsened spearcon identification more than the tracking task, p < .001. The linguistic task and arithmetic task both worsened performance, p = .674. However, no ongoing task affected participants' ability to detect which patient(s) in a sequence had abnormal vital signs. Future research could investigate whether timeshared tasks affect non-speech auditory alerts.