American Association of Critical-Care Nurses (AACN) Practice Alert Addresses Alarm Fatigue in ICU

American Association of Critical-Care Nurses (AACN) 2013 National Teaching Institute and Critical Care Exposition. Sunday June 23, 2013

Hospitals need to minimize the risk associated with the ubiquitous patient safety issue of alarm fatigue, which has again been singled out by the ECRI Institute as the top technology hazard for 2013. The institute is a federal patient safety organization of the US Department of Health and Human Services. "We all know there are a lot of devices in the ICU everybody's on a monitor, and a lot of other devices at the bedside have alarms on them," said Marjorie Funk, PhD, RN, professor at the Yale School of Nursing in New Haven, Connecticut. "The problem now is that a lot of patients outside the ICU are on monitors and other devices, and many of the alarms produced are false," she told Medscape Medical News. Dr. Funk discussed the issue of alarm fatigue at the American Association of Critical-Care Nurses (AACN) 2013 National Teaching Institute and Critical Care Exposition in Boston, Massachusetts. During her presentation, Dr. Funk listed contributors to the cacophony of alarm sounds on a hospital unit, which include infusion pumps, feeding devices, ventilators, and monitors. In addition, the battery-operated telemetry monitors frequently used outside the ICU have alarms to indicate a low battery, she noted. The staffs become overwhelmed by the sheer number of alarms and can miss or have a delayed response to alarms. In fact, it's estimated that approximately 90% of alarms in various ICU settings are either false or insignificant, according to a series of studies. Over time, "the staff becomes overwhelmed by the sheer number of alarms," Dr. Funk said, "and can miss or have a delayed response to alarms that can lead to sentinel events or patient death." One key way to reduce alarm fatigue is to eliminate unnecessary monitoring wherever possible. As part of the PULSE trial, Dr. Funk and her team evaluated the use of electrocardiographic (ECG) monitoring in cardiac units. They found that 26% of more than 4300 patients on monitors did not meet American Heart Association practice standards for monitoring ( J Am Coll Cardiol. 2013;61[10 suppl]:E1496). "If we eliminate unnecessary monitoring, it should result in a reduction in the overall alarm burden," Dr. Funk said. A new practice alert from the American Association of Critical-Care Nurses outlines evidence-based protocols to reduce false or non-actionable alarms and improve the effective use of these monitoring aids. Clinical alarms designed to alert nurses to changes in their patients conditions have become a continual barrage of noise that poses a significant threat to patient safety, the AACN stated. Since 1983, the average number of alarms in an ICU has increased from six to 40, despite the fact that humans have difficulty learning more than six different alarm sounds, according to the AACN. The sensory overload from sounds emitted by monitors, infusion pumps, ventilators and other devices can cause a person to become desensitized to the alarms. Such alarm fatigue may result in delayed responses or missed alarms, sometimes contributing to patient deaths. Based on the latest available evidence, the AACN practice alert summarizes expected nursing practice related to alarm management, including:

 Provide proper skin preparation for ECG electrodes, which can improve conductivity and decrease the number of false alarms; Change ECG electrodes daily; Customize alarm parameters and levels on ECG monitors; Customize delay settings and threshold settings on oxygen saturation via puls e oximetry monitors. The combination of appropriate alarm delays and threshold settings optimizes the monitor to its highest potential, producing an alarm when action is required; Provide initial and ongoing education about devices with alarms; Establish interprofessional teams to address issues related to alarms, such as the development of policies and procedures; Monitor only those patients with clinical indications for monitoring. This alert is the latest in a series of guidelines issued by AACN to standardize practice and update nurses and other healthcare providers on new healthcare advances and trends. Additional alerts address ventilator associated pneumonia, pulmonary artery pressure monitoring, dysrhythmia monitoring, ST segment monitoring, family presence during resuscitation and invasive procedures and verification of feeding-tube placement. Reference: http://news.nurse.com

Reaction:
As a student, I learned that most of the devices in the ICU did have programmable settings/limits that the RN could adjust per patient and would reduce the number of useless alarms. For some reason, the RN's rarely adjusted these parameters. I got excellent tele experience during my time there; the experienced RN's would often send me to assess the alarm, and report my perceived level of severity. They did not utilize the alarm parameters, but did utilize the phenomenon as an incredible teaching opportunity. Of course I meant overwhelmed; not overwhelmed but the message is still the same. Basically, the same argument could be said of hand washing. Nurses who claim that they are overwhelmed and fatigued by the numbers of alarms that go off during their shifts could also say that they cannot possibly keep up with washing their hands every time they should wash their hands because they have hand washing fatigue. We absolutely do need to get alarms and things that beep down to the necessary ones only (e.g. as mentioned in the article, the person's pulse does not need to audibly beep when on a cardiac monitor or oximeter) but nurses need to be very careful about using excuses for such actions as ignoring alarms. The main question that needs to be explored is this: How much of the problem is alarm fatigue and how much of it is alarm ignorance? How many alarms are simply ignored by nurses as opposed to those nurses being overwhelmed by a constant barrage of alarms? This is a great thing to see happen. I have been chastised and told I had questionable judgement for practicing what I called senseless noise control in clinical situations most would expect to be more enlightened and open to quality improvement. I have found the most useful idea to keep in mind and use to teach is that of: "Treat the patient, not the monitor". IRENE ANN L. PEROCHO