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      Clinical Alarms in Intensive Care Units: Perceived Obstacles of Alarm Management and Alarm Fatigue in Nurses

      research-article
      , RN, MSN, , PhD, RN , , PhD, RN, , PhD, RN
      Healthcare Informatics Research
      Korean Society of Medical Informatics
      Critical Care, Nurse, Clinical Alarms, Fatigue, Recognition

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          Abstract

          Objectives

          The purpose of this descriptive study was to investigate the current situation of clinical alarms in intensive care unit (ICU), nurses' recognition of and fatigue in relation to clinical alarms, and obstacles in alarm management.

          Methods

          Subjects were ICU nurses and devices from 48 critically ill patient cases. Data were collected through direct observation of alarm occurrence and questionnaires that were completed by the ICU nurses. The observation time unit was one hour block. One bed out of 56 ICU beds was randomly assigned to each observation time unit.

          Results

          Overall 2,184 clinical alarms were counted for 48 hours of observation, and 45.5 clinical alarms occurred per hour per subject. Of these, 1,394 alarms (63.8%) were categorized as false alarms. The alarm fatigue score was 24.3 ± 4.0 out of 35. The highest scoring item was "always get bothered due to clinical alarms". The highest scoring item in obstacles was "frequent false alarms, which lead to reduced attention or response to alarms".

          Conclusions

          Nurses reported that they felt some fatigue due to clinical alarms, and false alarms were also obstacles to proper management. An appropriate hospital policy should be developed to reduce false alarms and nurses' alarm fatigue.

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          Most cited references28

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          Monitor alarm fatigue: an integrative review.

          Alarm fatigue is a national problem and the number one medical device technology hazard in 2012. The problem of alarm desensitization is multifaceted and related to a high false alarm rate, poor positive predictive value, lack of alarm standardization, and the number of alarming medical devices in hospitals today. This integrative review synthesizes research and non-research findings published between 1/1/2000 and 10/1/2011 using The Johns Hopkins Nursing Evidence-Based Practice model. Seventy-two articles were included. Research evidence was organized into five main themes: excessive alarms and effects on staff; nurse's response to alarms; alarm sounds and audibility; technology to reduce false alarms; and alarm notification systems. Non-research evidence was divided into two main themes: strategies to reduce alarm desensitization, and alarm priority and notification systems. Evidence-based practice recommendations and gaps in research are summarized.
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            Monitor alarm fatigue: standardizing use of physiological monitors and decreasing nuisance alarms.

            Reliance on physiological monitors to continuously "watch" patients and to alert the nurse when a serious rhythm problem occurs is standard practice on monitored units. Alarms are intended to alert clinicians to deviations from a predetermined "normal" status. However, alarm fatigue may occur when the sheer number of monitor alarms overwhelms clinicians, possibly leading to alarms being disabled, silenced, or ignored. Excessive numbers of monitor alarms and fear that nurses have become desensitized to these alarms was the impetus for a unit-based quality improvement project. Small tests of change to improve alarm management were conducted on a medical progressive care unit. The types and frequency of monitor alarms in the unit were assessed. Nurses were trained to individualize patients' alarm parameter limits and levels. Monitor software was modified to promote audibility of critical alarms. Critical monitor alarms were reduced 43% from baseline data. The reduction of alarms could be attributed to adjustment of monitor alarm defaults, careful assessment and customization of monitor alarm parameter limits and levels, and implementation of an interdisciplinary monitor policy. Although alarms are important and sometimes life-saving, they can compromise patients' safety if ignored. This unit-based quality improvement initiative was beneficial as a starting point for revamping alarm management throughout the institution.
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              Poor prognosis for existing monitors in the intensive care unit.

              To identify areas requiring the most urgent improvement in the intensive care unit (ICU); and to accurately determine the positive predictive value of routine critical care patient monitoring alarms, as well as the common causes for false-positive alarms. Prospective, observational study. A multidisciplinary ICU in a university-affiliated children's hospital (excluding children with primary heart disease). The occurrence rate, cause, and appropriateness of all alarms from tracked monitors were recorded by a trained observer and validated by the bedside nurse over a 10-wk period for a single bedspace at a time. After 298 monitored hrs, 86% of a total 2,942 alarms were found to be false-positive alarms, while an additional 6% were classified as clinically irrelevant true alarms. Only 8% of all alarms tracked during the study period were determined to be true alarms with clinical significance. Alarms were also classified according to whether they were clearly associated with a "patient intervention" (18%), were clearly not associated with a patient intervention (74%), or had unclear association to interventions (8%). While 11% of "nonpatient intervention" alarms were clinically significant true alarms, only 2% of "patient intervention" alarms were so. Positive predictive values for the various devices ranged from < 1% for the pulse oximeter's heart rate signal to 74% for the arterial catheter's mean systemic blood pressure signal during periods free from patient interventions. The pulse oximeter caused false-positive alarms most frequently, with common reasons being bad data format/bad connection and poor contact. Efforts to develop intelligent monitoring systems have more potential to deliver significantly improved patient care by initially targeting especially weak areas in ICU monitoring, such as pulse oximetry reliability.
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                Author and article information

                Journal
                Healthc Inform Res
                Healthc Inform Res
                HIR
                Healthcare Informatics Research
                Korean Society of Medical Informatics
                2093-3681
                2093-369X
                January 2016
                31 January 2016
                : 22
                : 1
                : 46-53
                Affiliations
                Department of Nursing, Inha University, Incheon, Korea.
                Author notes
                Corresponding Author: Hwasoon Kim, PhD, RN. Department of Nursing, Inha University, 100 Inha-ro, Nam-gu, Incheon 22212, Korea. Tel: +82-32-860-8208, Fax: +82-32-874-5880, khs0618@ 123456inha.ac.kr
                Article
                10.4258/hir.2016.22.1.46
                4756058
                26893950
                e7a03c31-7b76-43a7-8a18-6b8718d86d89
                © 2016 The Korean Society of Medical Informatics

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 06 November 2015
                : 17 December 2015
                : 19 December 2015
                Categories
                Original Article

                Bioinformatics & Computational biology
                critical care,nurse,clinical alarms,fatigue,recognition
                Bioinformatics & Computational biology
                critical care, nurse, clinical alarms, fatigue, recognition

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