Reducing patient harm associated with clinical alarm systems is a national patient safety goal that is a multifaceted problem, requiring systematic and interdisciplinary coordinated solutions [1]. Collaborative partnerships between Health Care Organizations (HCO) and patient monitoring vendors can create a change management paradigm that meets this Joint Commission patient safety goal. In addition, this collaboration can also be used to further understand and improve upon the emotional pressure caregivers feel in alarm-rich environments, precipitating alarm fatigue [2].

Clinical consultants from a patient monitoring vendor and HCO agreed upon a Scope of Work to identify alarm management opportunities through 3 days of onsite observations. This included policy and procedure review, and analysis of alarm data. A validated Alarm Fatigue Survey (AFS) was electronically distributed to measure baseline alarm fatigue in staff [2]. Additionally, three sites encompassing four telemetry units, 1 NICU, and 1 ICU were in scope. Observations, baseline AFS data from 109 respondents, and alarm data were analyzed with opportunities categorized into people, process, and technology categories.

The team found that people and process opportunities were often interconnected:

Opportunities related to understanding alarm policies led to varying practices related to alarm response and alarm parameter adjustments.
Additional research is needed on SpO2 utilization in telemetry environments. Utilization criteria should be present in the policy.
Opportunities related to skin prep and electrode maintenance written into policy and procedure led to nuisance alarms and delayed interaction with technical alarms.

30 days of alarm data further validated the opportunities derived from onsite activities:

SpO2 low limit alarms were a top 3 alarm on all tele units.
Skin prep and electrode maintenance opportunities were validated. ECG leads-off reminder alarms accounted for 53% of one unit’s alarms; the initial ECG leads-off alarm accounted for 4.69%, suggesting alarm response opportunities.

Tailoring alarms to patient needs is supported as best practice; this practice reduces the occurrence of non-actionable alarms [3]. For example, autonomy to make a SpO2 low limit change by 1% could reduce low SpO2 alarms by 33% and 30% in two respective tele units. The same units would reduce HR alarms by 34% and 61% with a high HR limit change from 120 bpm to 130 bpm.

Technology recommendations included:

Guidance from a patient monitoring policy for patient profile usage with ECG or SpO2-only monitoring.
Aperiodic SpO2 mode in the monitoring system
An end user is allowed to pause alarms in the NICU to reduce SpO2 alarms during direct care.

An interdisciplinary team from an HCO and patient monitoring vendor can identify actionable alarm management opportunities through a people, process, and technology assessment framework.

References:

National Patient Safety Goals. The Joint Commission. 2021. URL: https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2021/npsg_chapter_hap_jan2021.pdf [accessed 2022-08-22]
Torabizadeh, C., Yousefinya, A., Zand, F., Rakhshan, M., & Fararooei, M. (2017). A nurses’ alarm fatigue questionnaire: development and psychometric properties. Journal of Clinical Monitoring and Computing, 31(6), 1305-1312.
Graham, K. C., & Cvach, M. (2010). Monitor alarm fatigue: standardizing use of physiological monitors and decreasing nuisance alarms. American Journal of Critical Care, 19(1), 28-34.

Valerie Fernald MSN, RN, CCRN, CNML

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