assistance

ManagingAlarmsinAcuteCareAcrosstheLifeSpan_AlarmFatigue_2018.pdf

soap and water, wipe the electrode area with a washcloth or gauze to roughen a small area of the skin when appropriate. Do not use alcohol for skin preparation; it dries out the skin. [level B]

b. Consider daily ECG electrode changes. [level E] c. Do not use Spo2 finger clip sensor on the ear.

[level C] d. Place Spo2 probe on warm extremities.

[level C]

2. Assess alarm parameter settings and customize according to individual patient’s condition and age to reduce clinically insignificant alarms. Check alarm settings at the start of every shift, with any

AACN Practice Alert

Scope and Impact of the Problem Alarm fatigue is a patient safety risk, occurring when

clinicians are exposed to excessive numbers of alarms, particularly false and clinically insignificant alarms. This overexposure results in sensory overload and desensiti- zation to alarms. Consequently, response to alarms may be delayed or alarms may be missed altogether. Patients’ deaths have been attributed to alarm fatigue when a seri- ous clinical event was missed because the alarm was not heard or was assumed to be false.1 In recent studies,2,3 from 89% to 99% of electrocardiographic (ECG) monitor alarms were found to be false or clinically insignificant. To date, clinical strategies to reduce alarms and alarm fatigue have been focused on ECG and oxygen saturation (Spo2) alarms. However, evidence for these strategies is limited. Interventions presented here are primarily sup- ported by expert opinion and/or have demonstrated success in quality improvement projects. To reduce false and clinically insignificant alarms and alarm fatigue, clinical units should assess their alarm burden and select interventions that address unit-specific needs.

Expected Nursing Practice Bedside Care Providers

1. Use technology correctly and according to manu- facturer’s recommendations to minimize false and technical alarms:

a. Provide proper skin preparation for ECG electrodes. Wash the electrode area with

Managing Alarms in Acute Care Across the Life Span: Electrocardiography and Pulse Oximetry

AACN Levels of Evidence Level A Meta-analysis of quantitative studies or metasyn-

thesis of qualita tive studies with results that consis tently support a specific action, intervention, or treatment (including systematic review of randomized controlled trials)

Level B Well-designed, controlled studies with results that consistently support a specific action, intervention, or treatment

Level C Evidence from qualitative, systematic reviews of qualitative, descriptive, or correlational studies, or randomized controlled trials with inconsistent results

Level D Peer-reviewed professional organizational standards with clinical studies to support recommen- dations

Level E Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organiza- tional standards without clinical studies to support recommendations

Level M Manufacturer’s recommendations only

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change in patient condition and with any change in caregiver. Customize alarms according to unit or hospital policy. [level E]

Nursing Leaders 1. Establish interprofessional teams to gather alarm-

related data and address issues related to alarms, such as the development of policies and proce- dures. Consider developing a culture of suspend- ing alarms when staff are at the bedside performing patient care that may produce false alarms. Stan- dardize monitoring practices across clinical envi- ronments. Develop policies and procedures for nurses to customize bedside monitor alarms. [level E]

2. Ensure that the unit’s default alarm settings are appropriate for the patient population. Collaborate with an interprofessional team, including biomedi- cal engineering, to determine the appropriate default alarm settings for the unit’s patient population. Adjustments may include changes to alarm param- eter limits, on/off status, delay status, and priority level of alarm. [level E]

3. Provide initial and ongoing education for end users of devices with alarms. Provide education on moni- toring systems and alarms, as well as operational effectiveness, to new nurses and all staff members on a periodic basis. Budget for ongoing education when purchasing monitoring systems. [level E]

4. Consider use of an alarm notification system (eg, mid- dleware, monitor watchers/technicians). [level E]

5. Monitor only those patients with clinical indications for monitoring. Collaborate with an interprofessional team to determine which patients in a population or care unit should be monitored and what param- eters to use. When appropriate, use the American Heart Association’s Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings.4 [level C]

Supporting Evidence Bedside Care Providers

1. Use technology correctly and according to manu- facturer’s recommendations.

a. Provide proper skin preparation for ECG electrodes. Research,5 quality improvement reports,6-8 and expert opinion9-11 support proper skin preparation to decrease the

number of false and technical alarms. Proper skin preparation before ECG electrodes are placed decreases skin impedance and signal noise, thereby enhancing conductivity.11 Washing the electrode area with soap and water, wiping with a washcloth or gauze, or when appropriate using the sandpaper on the electrode to roughen the skin (which helps remove part of the stratum corneum [outer layer of the epidermis] to reduce impedance) is the recommended skin preparation.4,5,10 Excessive hair at the electrode site should be clipped.10 Proper skin preparation has been included in quality improvement projects on alarm management as one component of bundled interventions that demonstrated reductions in alarms of 44% to 89%.6-8

b. Consider daily ECG electrode changes. Expert opinion10 and results of quality improvement projects6-8,12,13 suggest that changing ECG electrodes daily may decrease the number of false and technical alarms. In 3 quality improvement projects, daily electrode changes with proper skin prepara- tion resulted in a 19% to 46% reduction in alarms.6,8,12 In another quality improve- ment project, daily electrode changes were included in a bundled intervention, and alarms were reduced overall by 89%.7 A pediatric quality improvement project that included daily electrode changes in an alarm management bundle resulted in 55% reduc- tion in alarms.13 The effect of daily elec- trode changes as an intervention to reduce alarms has not been confirmed through research. Daily electrode changes may not be appropriate in patients with fragile skin such as older adults or premature infants. Soaking electrodes with water during the patient’s bath may reduce pain during electrode removal.13

c. Do not use Spo2 finger clip sensor on the ear. In a study of 30 adult patients under- going pulmonary function tests, Haynes14

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demonstrated that a pulse oximeter finger clip placed on an ear did not provide clinically reliable Spo2 readings when compared with arterial blood gas analysis.

d. Place Spo2 probe on warm extremities. Temperature was found to have an impact on the degree of pulse oximetry error in the operating room.15

2. Assess alarm parameter settings and customize according to the individual patient’s condition. Customizing alarm settings on the bedside moni- tor to reflect a patient’s condition-specific factors and age may reduce clinically insignificant alarms. For example, turning off the atrial fibrillation alarm for a patient with known atrial fibrillation that will not be treated would eliminate alarms that are not actionable for that patient. Education on alarm customization has been provided as part of several quality improvement projects that have demonstrated reductions in total alarms.7,16-18 Nurses should check alarm settings to ensure that the settings are appropriate for the patient’s condi- tion at the start of each shift, with any change in the patient’s condition, and with any change in caregiver, and nurses should customize alarm settings in accordance with unit or hospital policy.

Nursing Leaders 1. Establish interprofessional teams to gather alarm-

related data and address improvement opportuni- ties related to alarms. Using an interprofessional team approach with stakeholders from the clinical, technical, and information technology communi- ties to gather alarm data and develop policies and response algorithms helps to reduce alarms.13,17,19-22 The interprofessional team should include staff nurses. Gathering alarm data will assist in deter- mining the alarms that are most problematic for the specific unit (eg, false alarms, clinically insignif- icant alarms, technical alarms, duplicate alarms). The interprofessional team can establish policies to provide direction on which patients to monitor and on appropriate alarm parameters to optimize alarm systems and reduce alarms. For example, the policy should include appropriate suspension of alarms during patient care, which can decrease

the number of audible alarms by 20%.23 Incorpo- rating this practice into nursing standards of care and unit orientation fosters a culture of appropri- ate alarm use, leading to safer environments for patients.21,22

2. Ensure default alarm settings are appropriate for the patient population. Changing the unit’s alarm default settings has decreased alarm rates,17,24 most likely by reducing the number of clinically insignificant alarms. In a medical-surgical unit with telemetry monitoring, changing the alarm default for high heart rate from 120 to 130 beats per minute resulted in a 50% decrease in the num- ber of alarms.25 In a small pilot randomized trial,26 researchers investigated changes in default alarm settings as a method for reducing alarms. Several quality improvement projects have included changes to unit default settings as part of bundled interven- tions that resulted in reduction in the overall num- ber of alarms. These changes included changing the priority level of an alarm parameter, such as changing the alarm for ventricular tachycardia for >2 beats from high to low priority/nonaudible,16,26 eliminating duplicate alarms,7,12,18 changing alarm parameter default settings from on to off (eg, alarms for premature ventricular contractions),7,27-29 and widening alarm parameter limits (eg, increasing high heart rate limit and decreasing low heart rate limit).16,18,30 Widening alarm parameter limits was also supported by a recent systematic review.24 In a simulation study, increasing Spo2 alarm delays from 5 to 15 seconds decreased alarms by 70%, and decreasing the alarm limits from 90% to 88% decreased alarms by 45%.22 By combining these 2 approaches, alarms were reduced by 85%. In a pediatric quality improvement project, the Spo2 alarm delay was increased from 5 to 10 seconds and the high respiratory rate limit was increased, which resulted in an additional 25% reduction in alarms on the unit.13

However, changing default alarm parameter set- tings must be undertaken with caution because of the potential patient safety risk if actionable alarms are inadvertently eliminated by default alarm set- tings that are too wide or are inappropriate for the patient population.24,31 An interprofessional team

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should determine the appropriate default alarm settings for the unit’s patient population. In addition to changing the unit’s default alarm settings, consider development of alarm limit profiles for specialty patient groups (eg, based on age or diagnosis).

3. Provide initial and ongoing education on devices with alarms. Education increases understanding of how monitoring systems and their alarms should be managed.17,32 Quality improvement projects to reduce alarms have included education of nursing staff.18,28 One project demonstrated that after receiving education and retraining, nurses indi- vidualized alarm settings at the outset, instead of adjusting settings in response to continual activa- tion of an alarm.18 Education must be robust, given the complexity of monitoring systems.28 The cost for educating end users of technology should be included in budgets.

4. Consider use of an alarm notification system. Alarm notification systems (eg, middleware, monitor watchers/technicians) are an additional safety measure to help nurses manage alarms. Notifying nurses of alarms via pagers or phones may be useful on units where alarm audibility is difficult because of the unit’s layout.33 Escalation rules and delays can be programmed into some systems to route an alarm to another caregiver if no response is received and to decrease the number of alarms to which the nurse is exposed.16,33 Reduction of alarms was demonstrated in a quality improve- ment project using a paging system with an alarm escalation strategy and programmed delay times.33 Successful implementation requires unit-specific decisions about the type of device used, which alarms are forwarded to the device, and what rules are in place for delays, acknowledgment, and esca- lation.34 One study has demonstrated the potential for monitor watchers to reduce nurses’ exposure to alarms by intercepting false and clinically insignifi- cant alarms.35 Insufficient evidence exists to support the use of monitor watchers to improve patients’ outcomes,36 although other potential benefits have been suggested, such as reducing nurses’ time man- aging technical issues.4,37 One study demonstrated

faster communication between monitor watchers and nurses using a 2-way communication badge, compared with a 1-way pager system.38 Imple- menting alarm notification systems requires cau- tion to ensure that alarm fatigue is not exacerbated by increasing the number of notifications to which nurses are exposed.

5. Monitor only those patients with clinical indica- tions for monitoring. Expert opinion and research recommend monitoring only those patients with clinical indications for monitoring and for only as long as necessary, which can significantly decrease the number of clinically insignificant alarms.39-41 An interprofessional team should determine which patients in a population or care unit should be mon- itored and for what parameters. In 2017, the Amer- ican Heart Association published an update of their 2004 standards for ECG monitoring in hospitalized patients, specifying who should be monitored and for how long.4

Implementation/Organizational Support for Practice

Bedside Care Providers Provide proper skin preparation for and placement

of ECG electrodes. Use proper Spo2 probe and placement. Check alarm settings at the start of each shift, with

any change in the patient’s condition, and with any change in caregiver.

Customize alarm parameter settings for individual patients in accordance with unit or hospital policy.

Nurse Leaders Organize an interprofessional alarm management

team. Develop unit-specific default parameters and alarm

management policies. Provide ongoing education on monitoring systems

and alarm management for unit staff. Develop policies/procedures for monitoring only

those patients with clinical indications for monitoring.

Need More Information or Help? 1. Contact a clinical practice specialist for additional

information: Go to www.aacn.org, click Clinical

e20 CriticalCareNurse Vol 38, No. 2, APRIL 2018 www.ccnonline.org

Resources, and scroll down to select AACN Practice Resource Network.

2. AAMI Foundation alarm resources: http://www .aami.org/thefoundation/content.aspx? ItemNumber=1730

3. ECRI Institute alarm resources: https://www.ecri .org/resource-center/Pages/Alarms.aspx

4. National Association of Clinical Nurse Specialists Alarm Fatigue Toolkit: http://nacns.org/professional -resources/toolkits-and-reports/alarm-fatigue -toolkit/

5. The Joint Commission National Patient Safety Goal on clinical alarm safety (NPSG.06.01.01): https:// www.jointcommission.org/assets/1/6/NPSG _Chapter_HAP_Jan2017.pdf

Original Authors: Stacy Jepsen, MS, APRN, ACNS-BC, CCRN, and Susan Sendelbach, RN, PhD, CCNS, FAHA

Contributing Authors: Halley Ruppel, RN, MSN, CCRN, Marjorie Funk, RN, PhD, FAHA, FAAN, and Sharon Wahl, MSN, APRN-CCNS, CCRN

Approved by the Clinical Resources Task Force, August 2017.

Financial Disclosures None reported.

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