Ventilator Alarms in Intensive Care Units: Frequency, Duration, Priority, and Relationship to Ventilator Parameters.

Ventilator alarms have long been presumed to contribute substantially to the overall alarm burden in the intensive care unit. In a prospective observational study, we determined that each ventilator triggered an alarm cascade of up to 8 separate notifications once every 6 minutes. In 1 intensive care unit with different ventilator manufacturers, the distribution of high-priority alarms was manufacturer dependent with 8.6% of alarms from 1 type and 89.8% of alarms from another type of ventilator. Alarm limits were not a function of patient-specific ventilator settings.

Technological Distractions (Part 2): A Summary of Approaches to Manage Clinical Alarms With Intent to Reduce Alarm Fatigue.

OBJECTIVE: Alarm fatigue is a widely recognized safety and quality problem where exposure to high rates of clinical alarms results in desensitization leading to dismissal of or slowed response to alarms. Nonactionable alarms are thought to be especially problematic. Despite these concerns, the number of clinical alarm signals has been increasing as an everincreasing number of medical technologies are added to the clinical care environment. DATA SOURCES: PubMed, SCOPUS, Embase, and CINAHL. STUDY SELECTION: We performed a systematic review of the literature focused on clinical alarms. We asked a primary key question; "what interventions have been attempted and resulted in the success of reducing alarm fatigue?" and 3-secondary key questions; "what are the negative effects on patients/families; what are the balancing outcomes (unintended consequences of interventions); and what human factor approaches apply to making an effective alarm?" DATA EXTRACTION: Articles relevant to the Key Questions were selected through an iterative review process and relevant data was extracted using a standardized tool. DATA SYNTHESIS: We found 62 articles that had relevant and usable data for at least one key question. We found that no study used/developed a clear definition of "alarm fatigue." For our primary key question 1, the relevant studies focused on three main areas: quality improvement/bundled activities; intervention comparisons; and analysis of algorithm-based false and total alarm suppression. All sought to reduce the number of total alarms and/or false alarms to improve the positive predictive value. Most studies were successful to varying degrees. None measured alarm fatigue directly. CONCLUSIONS: There is no agreed upon valid metric(s) for alarm fatigue, and the current methods are mostly indirect. Assuming that reducing the number of alarms and/or improving positive predictive value can reduce alarm fatigue, there are promising avenues to address patient safety and quality problem. Further investment is warranted not only in interventions that may reduce alarm fatigue but also in defining how to best measure it.

Technologic Distractions (Part 1): Summary of Approaches to Manage Alert Quantity With Intent to Reduce Alert Fatigue and Suggestions for Alert Fatigue Metrics.

OBJECTIVE: To provide ICU clinicians with evidence-based guidance on tested interventions that reduce or prevent alert fatigue within clinical decision support systems. DESIGN: Systematic review of PubMed, Embase, SCOPUS, and CINAHL for relevant literature from 1966 to February 2017. PATIENTS: Focus on critically ill patients and included evaluations in other patient care settings, as well. INTERVENTIONS: Identified interventions designed to reduce or prevent alert fatigue within clinical decision support systems. MEASUREMENTS AND MAIN RESULTS: Study selection was based on one primary key question to identify effective interventions that attempted to reduce alert fatigue and three secondary key questions that covered the negative effects of alert fatigue, potential unintended consequences of efforts to reduce alert fatigue, and ideal alert quantity. Data were abstracted by two reviewers independently using a standardized abstraction tool. Surveys, meeting abstracts, "gray" literature, studies not available in English, and studies with non-original data were excluded. For the primary key question, articles were excluded if they did not provide a comparator as key question 1 was designed as a problem, intervention, comparison, and outcome question. We anticipated that reduction in alert fatigue, including the concept of desensitization may not be directly measured and thus considered interventions that reduced alert quantity as a surrogate marker for alert fatigue. Twenty-six articles met the inclusion criteria. CONCLUSION: Approaches for managing alert fatigue in the ICU are provided as a result of reviewing tested interventions that reduced alert quantity with the anticipated effect of reducing fatigue. Suggested alert management strategies include prioritizing alerts, developing sophisticated alerts, customizing commercially available alerts, and including end user opinion in alert selection. Alert fatigue itself is studied less frequently, as an outcome, and there is a need for more precise evaluation. Standardized metrics for alert fatigue is needed to advance the field. Suggestions for standardized metrics are provided in this document.

Use of pagers with an alarm escalation system to reduce cardiac monitor alarm signals.

Alarm fatigue desensitizes nurses to alarm signals and presents potential for patient harm. This project describes an innovative method of communicating cardiac monitor alarms to pagers using an alarm escalation algorithm. This innovation was tested on 2 surgical progressive care units over a 6-month period. There was a significant decrease in mean frequency and duration of high-priority monitor alarms and improvement in nurses' perception of alarm response time, using this method of alarm communication.

Clinician Perspectives on Continuous Monitor Use in a Children's Hospital: A Qualitative Study.

BACKGROUND AND OBJECTIVES: Variation in continuous cardiopulmonary monitor (cCPM) use across children's hospitals suggests preference-based use. We sought to understand how clinical providers make decisions to use cCPMs. METHODS: We conducted a qualitative study using semi-structed interviews with clinicians (nurses, respiratory therapists [RTs], and resident and attending physicians) from 2 hospital medicine units at a children's hospital. The interview guide employed patient cases and open-ended prompts to elicit information about workflows and decision-making related to cCPM, and we collected basic demographic information about participants. We used an inductive approach following thematic analysis to code transcripts and create themes. RESULTS: We interviewed 5 nurses, 5 RTs, 7 residents, and 7 attending physicians. We discovered that clinicians perceive a low threshold for starting cCPM, and this often occurred as a default action at admission. Clinicians thought of cCPMs as helping them cope with uncertainty. Despite acknowledging considerable flaws in how cCPMs were used, they were perceived as a low-risk intervention. Although RNs and RTs were most aware of the patient's current condition and number of alarms, physicians decided when to discontinue monitors. No structured process for identifying when to discontinue monitors existed. CONCLUSIONS: We concluded that nurses, physicians, and RTs often default to cCPM use and lack a standardized process for identifying when cCPM should be discontinued. Interventions aiming to reduce monitor use will need to account for or target these factors.

Daily electrode change and effect on cardiac monitor alarms: an evidence-based practice approach.

Frequent monitor alarms are distracting and interfere with clinicians performing critical tasks. This article describes a quality improvement rapid-cycle change approach to explore the benefits of changing electrodes daily on the number of cardiac monitor alarms. Eight days of baseline and intervention data were compared for 2 adult acute care units. Average alarms per bed per day were reduced by 46% on both units. Daily electrocardiogram electrode change reduces the number of cardiac monitor alarms.

An evidence-based approach to fall risk assessment, prevention, and management: lessons learned.

Nurses at an academic medical institution undertook a fall safety initiative. Using an evidence-based approach, they created a risk stratification tool, developed a comprehensive protocol, investigated fall-prevention products and technologies, and piloted the protocol and products/technologies before the full implementation. This article describes their journey and lessons learned along the way, the most compelling of which is the need for a simple, guided, and time-efficient approach to implementing the best practices into clinical care.