The Clinical Issue and Research Questions Developed Using PICOT

EVIDENCE- BASED CARE SHEET

Authors Hillary Mennella, DNP, ANCC-BC

Cinahl Information Systems, Glendale, CA

Penny March, PsyD Cinahl Information Systems, Glendale, CA

Reviewers Obiamaka Oji, DNP, APRN, FNP-BC

Cinahl Information Systems, Glendale, CA

Nursing Executive Practice Council Glendale Adventist Medical Center,

Glendale, CA

Editor Diane Pravikoff, RN, PhD, FAAN

Cinahl Information Systems, Glendale, CA

June 29, 2018

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2018, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

Alarm Fatigue and Patient Safety

What We Know › Technologic advances during the past 25 years have contributed to widespread use in the

clinical setting of monitoring equipment and medical devices with built-in audible alarms and predetermined normal parameters. Although it is known that distinguishing between more than 6 different alarm sounds is difficult,healthcare clinicians are expected to be able to identify the different sounds of each alarm and react appropriately. Currently, there is no standardization of alarm sounds from manufacturers of monitoring equipment and medical devices(2,3,5,6,7,9,11)

• Alarm fatigue is defined as sensory overload as a result of hearing numerous alarm sounds. Many alarms sound similar and it is estimated that over 90% of alarms are false, or “nuisance,” alarms that do not require clinical intervention. As a result, healthcare clinicians can become desensitized to alarm sounds, are slower to respond to alarms, and may develop a false sense of security regarding patient safety. Alarm fatigue contributes to system failures and increases the risk for patient harm and death(2,3,5,6,7,9,11)

–According to researchers in a study on the current situation of clinical alarms in intensive care units (ICUs), nurses reported fatigue due to frequent clinical and false alarms, leading to reduced response and attention to alarms in the ICU(5)

• Monitoring equipment and medical devices that frequently contribute to alarm fatigue include bed and chair alarms; patient call systems; EKG machines; infusion and IV pumps; wound vacuum, sequential compression, pulse oximetry, diabetes-related, and feeding devices; electronic fetal, vital sign, and central station monitors; and ventilators(2,3,6,7,9,11)

› Alarm fatigue is becoming increasingly recognized as a key contributing factor to noise pollution, clinician complacency, and sentinel events in the healthcare setting. Several organizations call for the development of alarm management initiative programs to minimize the risk for patient harm(2,3,6,7,9,11)

• According to a practice alert issued in 2018 by the American Association of Critical-Care Nurses (AACN), a multidisciplinary effort is needed to reduce alarm fatigue, improve patient safety, and provide initial and serial education to staff regarding proper use of monitoring equipment and medical devices. The AACN recommends collaborative efforts by clinical nurse specialists, staff nurses, hospital administrators, physicians, biomedical engineers, and systems analysts to establish specific policies and procedures regarding alarm management(2)

• Since 2007, the ECRI Institute, which is a nonprofit patient safety organization that was formerly called the Emergency Care Research Institute, has identified alarm fatigue as a critical hazard to patients in the healthcare industry(7)

–the ECRI Institute named “inadequate alarm configuration policies and practices” as the number one health technology threat contributing to patient harm. The ECRI Institute offers webinars and clinical site evaluations regarding alarm management(7)

–The ECRI Institute executive brief,Top 10 Health Technology Hazards for 2016, cited “failure to recognize and respond to an actionable clinical alarm condition in a timely manner can result in serious patient injury or death” as the second health technology

threat. The ECRI Institute states that patients are at risk in the following situations when(8)

- an alarm condition is not detected by a medical device (e.g.,physiologic monitor, ventilator, infusion pump) - the condition is detected, but does not successfully notify clinical staff members who are equipped to respond to the

alarm - the condition is successfully communicated to clinical staff, but not appropriately addressed

• The Association for the Advancement of Medical Instrumentation (AAMI) established a workgroup committee under the Healthcare Safety Technology Institute (HTSI) to review evidence-based practice, recommend best practices for alarm management, and collaborate with other organizations to identify areas for research regarding reducing alarm fatigue and increasing patient safety(3)

• According to a 2013 sentinel event alert issued by The Joint Commission (TJC), 98 alarm-related events were reported during the period January 2009 to June 2012; of these, 80 resulted in patient fatalities and 13 resulted in permanent loss of function. Falls, ventilator use, delays in treatment, and medication errors were related to sentinel events involving alarms. The majority of alarm-related sentinel events occurred in intensive care units, general medical units, telemetry units, and emergency departments. Contributing factors to alarm-related sentinel events include alarm fatigue, alarm settings that are not customized to the patient, inadequate staff training regarding proper use of equipment, equipment malfunction and failure, alarm settings that are not integrated with other medical devices, and insufficient staffing to respond to alarm sounds(1,11)

–Researchers conducted a study on the use of medical setting protocols for cardiac telemetry (CT) placement, and found a 31% CT order discrepancy with 72% having no indication for CT placement. After adjustments to patients' status, they achieved a 42% reduction in cost. A perceived 27% reduction in alarm fatigue was further reported by nurses(1)

–Reducing the harm associated with clinical alarm systems is TJC National Patient Safety Goal (NPSG) 6 for 2016; this NPSG was created in 2013 and continues as an annual NPSG (for more information, see Evidence-Based Care Sheet: National Patient Safety Goals (The Joint Commission, 2016): Improve the Safety Clinical Alarm Systems). To comply with this NPSG, hospitals must improve the safety of clinical alarm systems by establishing alarm system safety as a hospital priority and identifying the most important alarm signals to manage. By 2016, hospitals must establish specific policies and procedures for managing alarms and educate staff members and independent licensed contractors regarding alarm management(10)

–Hospitals have numerous internal variables (e.g., number of patient beds and units, various types of alarms) that may affect system-wide alarm management and establishing alarm system safety program can be extremely challenging.(12)Hospitals must understand that alarm management is always evolving along with patient and staff needs, and will require continued management to accommodate changes and needs(13)

› Minimizing risk for patient harm requires a collaborative effort in healthcare organizations to develop and implement risk reduction strategies. The AACN, TJC, ERCI, and AAMI recommend the following risk reduction strategies for alarm management:(2,7,11)

• Each hospital has specific needs and unique characteristics. Hospitals must identify, document, and track these needs and characteristics to create a successful alarm management program. Experts recommend classifying internal alarms by identifying the following:(12,13)

–The frequency, alarm type, and device –Alarm variations by the time and day and variations by room and unit –Alarm parameters and thresholds –Which alarms are linked to patient harm(12)

• Hospitals have a duty to address the alarm management initiative by –developing a comprehensive program that involves stakeholders from throughout the organization(8)

–establishing an interdisciplinary alarm management committee with member representation by clinicians, biomedical engineering, hospital administrators, systems analysts, risk management, and information technology; nurses and nursing leaders, particularly those with clinical IT leadership skills, should be part of the interdisciplinary alarm management committee(13)

–developing policies and procedures for alarm management by creating guidelines for alarm settings and modifying safe limit parameter settings for individual patients

–implementing noise reduction strategies to decrease noise pollution and decrease staff and patient stress (e.g., using single-use sensors in EKG leads)

–assessing the acoustics in patient care areas to determine if critical alarm sounds are audible –reviewing and tracking trends in alarm-related sentinel events –reporting alarm-related sentinel events to the ERCI, FDA, AAMI, and TJC to improve the study of effective prevention

strategies and education regarding alarm management –maintaining and routinely checking alarms for proper operation –providing healthcare clinicians with adequate initial and serial training regarding equipment

• Changes in technology can decrease alarm fatigue –Investing in smart alarms to decrease the number of false alarms can decrease alarm fatigue; smart alarms use an

algorithm to calculate multiple parameters of physiologic data to recognize vital sign patterns –Standardizing alarm sounds can decrease alarm fatigue –The remote EarlySense system is a motion-sensing device that is embedded in a flat sensor plate in the patient’s mattress;

it is designed to monitor for continuous heart rate and respiration rate and allow for freedom of movement. In a controlled study of 7,643 patient medical records in a California hospital, investigators compared continuous heart rate and respiration rate monitoring in a 33-bedmedical-surgical unit designated as the intervention unit with a “sister” control unit for a 9-month preimplementation period and a 9-month postimplementation period. The intervention unit, which implemented the EarlySense system,reported a low alarm frequency of 2.2 alerts per 100 recording hours and a low alarm burden (e.g., attending to false alarms) compared with results of other studies of alarm frequency and burden in ICU and postanesthesia units, which showed161–730 alerts per 100 recording hours(4)

• Healthcare providers can implement strategies during the provision of patient care to decrease alarm fatigue by –preparing the patient’s skin (e.g., shaving chest hair, washing skin with soap and water) for optimal EKG electrode

placement and contact to improve EKG conductivity and by changing EKG electrodes daily to prevent drying –customizing medical device alarm parameters specific to the patient’s clinical needs –suspending alarm sounds during short periods of patient manipulation (e.g., bathing) –monitoring only patients who have a clinical indication for monitoring

- Investigators found that of 4,678 observations of 3,250 patients on cardiac units who were receiving EKG monitoring, 26% did not meet the practice standards for cardiac monitoring by the American Heart Association(9)

What We Can Do › Learn about alarm fatigue so you can accurately assess your patients’ safety needs; share this information with your

colleagues › Reduce alarm fatigue, minimize risk for patient harm, and improve patient safety by

• collaborating to organize an alarm management committee in your facility to develop policies and procedures regarding alarm management

• participating in an alarm management safety review provided by the ERCI Institute; for more information, see https://www.ecri.org/resource-center/Pages/Alarms.aspx

• collaborating with members of your staff to identify alarm hazards in your facility and to develop risk reduction strategies • providing initial and serial education to staff regarding proper equipment use and alarm fatigue • implementing risk reduction strategies

Coding Matrix References are rated using the following codes, listed in order of strength:

M Published meta-analysis

SR Published systematic or integrative literature review

RCT Published research (randomized controlled trial)

R Published research (not randomized controlled trial)

C Case histories, case studies

G Published guidelines

RV Published review of the literature

RU Published research utilization report

QI Published quality improvement report

L Legislation

PGR Published government report

PFR Published funded report

PP Policies, procedures, protocols

X Practice exemplars, stories, opinions

GI General or background information/texts/reports

U Unpublished research, reviews, poster presentations or other such materials

CP Conference proceedings, abstracts, presentation

References 1. Alsaad, A. A., Alman, C. R., Thompson, K. M., Park, S. H., Monteau, R. E., & Maniaci, M. J. (2017). A multidisciplinary approach to reducing alarm fatigue and cost through

appropriate use of cardiac telemetry. Postgraduate Medical Journal, 93(1101), 430-435. doi:10.1136/postgradmedj-2016-134764 (R)

2. American Association of Critical-Care Nurses. (2018, April 3). Alarm management. Retrieved June 19, 2018, from http://www.aacn.org/wd/practice/content/practicealerts/alarm-management-practice-alert.pcms?menu=practice (G)

3. Association for the Advancement of Medical Instrumentation (AAMI). (n.d.). Clinical alarm systems. Retrieved June 19, 2018, from http://www.aami.org/htsi/alarms/ (GI)

4. Brown, H., Terrence, J., Vasquez, P., Bates, D. W., & Zimilichman, E. (2014). Continuous monitoring in an inpatient medical-surgical unit: A controlled clinical trial. American Journal of Medicine, 127(3), 226-232. doi:http://dx.doi.org/10.1016/j.amjmed.2013.12.004 (R)

5. Cho, O. M., Kim, H., Lee, Y. W., & Cho, I. (2016). Clinical alarms in intensive care units: Perceived obstacles of alarm management and alarm fatigue in nurses. Healthcare Informatics Research, 22(1), 46-53. doi:10.4258/hir.2016.22.1.46 (R)

6. Cvach, M., Dang, D., Foster, J., & Irechukwu, J. (n.d.). Clinical alarms and the impact on patient safety. Initiatives in Safe Patient Care, 1-7. (RV)

7. ECRI Institute. (2018). Alarm safety resource site. Retrieved June 19, 2018, from https://www.ecri.org/Forms/Pages/Alarm_Safety_Resource.aspx (GI)

8. ECRI Institute. (2018). Executive brief. Top 10 health technology hazards for 2018. Retrieved June 19, 2018, from http://www.ecri.org/components/HDJournal/Pages/ Top_10_hazards_for_2018.aspx (GI)

9. Funk, M., Stephens, K., May, J., Fennie, K., Feder, S., & Drew, B. (2013). An alarming rate of unnecessary monitoring in the practical use of the latest standards of electrocardiography (PULSE) trial. Journal of American College of Cardiology, 61(10 suppl), E:1496. doi:10.1016/S0735-1097(13)61496-5 (R)

10. The Joint Commission. (2016). Comprehensive accreditation manual: CAMH for hospitals. Oakwood Terrace, IL: The Joint Commission. (G)

11. The Joint Commission (TJC). (2013). The Joint Commission Sentinel Event Alert. Retrieved June 19, 2018, from http://www.jointcommission.org/sea_issue_50/ (G)

12. Sweeney, E. (2014). Preparing for The Joint Commission’s alarm safety deadline. Healthcare Leadership Review, 33(5), 10-11. (X)

13. Venella, J. J. (2016, January 28). Smarter alarm management fights alarm fatigue. Medscape. Retrieved June 19, 2018, from http://www.medscape.com/viewarticle/857531 (GI)