ALARMED: Adverse events in Low-risk patients with chest pain Receiving continuous electrocardiographic Monitoring in the Emergency Department. A pilot study

"Turn it off!": diabetes device alarm fatigue considerations for the present and the future

Safe and widespread use of diabetes technology is constrained by alarm fatigue: when someone receives so many alarms that he or she becomes less likely to respond appropriately. Alarm fatigue and related usability issues deserve consideration at every stage of alarm system design, especially as new technologies expand the potential number and complexity of alarms. The guiding principle should be patient wellbeing, while taking into consideration the regulatory and liability issues that sometimes contribute to building excessive alarms. With examples from diabetes devices, we illustrate two complementary frameworks for alarm design: a "patient safety first" perspective and a focus on human factors. We also describe opportunities and challenges that will come with new technologies such as remote monitoring, adaptive alarms, and ever-closer integration of glucose sensing with insulin delivery.

Early recognition of acutely deteriorating patients in non-intensive care units: assessment of an innovative monitoring technology

BACKGROUND

Continuous vital sign monitoring has the potential to detect early clinical deterioration. While commonly employed in the intensive care unit (ICU), accurate and noninvasive monitoring technology suitable for floor patients has yet to be used reliably.

OBJECTIVE

To establish the accuracy of the Earlysense continuous monitoring system in predicting clinical deterioration.

DESIGN

Noninterventional prospective study with retrospective data analysis.

SETTING

Two medical wards in 2 academic medical centers.

PATIENTS

Patients admitted to a medical ward with a diagnosis of an acute respiratory condition.

INTERVENTION

Enrolled patients were monitored for heart rate (HR) and respiration rate (RR) by the Earlysense monitor with the alerts turned off.

MEASUREMENTS

Retrospective analysis of vital sign data was performed on a derivation cohort to identify optimal cutoffs for threshold and 24-hour trend alerts. This was internally validated through correlation with clinical events recognized through chart review.

RESULTS

Of 113 patients included in the study, 9 suffered major clinical deterioration. Alerts were found to be infrequent (2.7 and 0.2 alerts per patient-day for threshold and trend alert, respectively). For the threshold alerts, sensitivity and specificity in predicting deterioration was found to be 82% and 67%, respectively, for HR and 64% and 81%, respectively, for RR. For trend alerts, sensitivity and specificity were 78% and 90% for HR, and 100% and 64% for RR, respectively.

CONCLUSIONS

The Earlysense monitor was able to continuously measure RR and HR, providing low alert frequency. The current study provides data supporting the ability of this system to accurately predict patient deterioration.

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.

Alarm fatigue

The number of false high alarms in the hospital setting remains a serious problem. False alarms have desensitized care providers and, at times, have led to dire consequences for patients. Efforts by both industry and clinicians are beginning to address this situation in collaborative approaches. Research is needed to establish an evidence base around issues such as which patients need to be monitored, and what the threshold settings and delay settings should be on devices. Initial and ongoing education needs to be considered for any new medical device, and be included in the hospital's annual budget.

Is telemetry useful in evaluating chest pain patients in an observation unit?

Since the development of coronary care units (CCUs), telemetry has rapidly become the standard of care in evaluating patients with suspected acute coronary syndromes, regardless of the probability for ischemia. However, there is no data to support this practice. Our objective was to evaluate the utility of routine cardiac monitoring in a chest pain observation unit. We prospectively studied the utility of routine cardiac monitoring in 249 consecutive patients admitted to an observation unit in an academic Emergency Department over a 6-month period. All the patients presented with chest pain thought to be cardiac ischemia. Observation included serial cardiac enzymes, ECG cardiac monitoring, and exercise testing in a designated chest pain observation unit. These patients were determined to be at low risk for an acute coronary event by two criteria: first, the symptoms had resolved by the time of observation unit admission, and second, the initial ECG was normal, unchanged or non-diagnostic for acute ischemia. Adverse outcomes included cardiac arrest, hospital admission secondary to cardiac dysrhythmia, or alteration in the patient's medical therapy upon discharge from the observation unit, secondary to cardiac dysrhythmia. There were 249 patients included with a median age of 52 with 60% women. Fifteen percent of the patients were, subsequently, admitted to the hospital for further evaluation of ischemia based on enzyme, ECG, and exercise testing results. One patient with known Tachy-Brady syndrome was noted to have 1.5-2 s pauses while sleeping, and discharged with instructions to hold beta blocker therapy pending results of a continuous loop recorder. Of the remaining 248 patients, no patient suffered a cardiac arrest, no patient was admitted to the hospital secondary to cardiac dysrhythmia, and no alteration in a patient's medical therapy was made secondary to cardiac dysrhythmia. No patient returned to the Emergency Department within 72 h with cardiac arrest, acute dysrhythmia or acute myocardial infarction. Although telemetry may be the standard of care in evaluating the patients with suspected acute coronary syndromes, regardless of the probability of an acute ischemic syndrome, in those patients with a normal or non diagnostic ECG and resolved symptoms, routine cardiac monitoring is unnecessary.

Medical device alarms

The high number of false positive alarms has long been known to be a serious problem in critical care medicine - yet it remains unresolved. At the same time, threats to patient safety due to missing or suppressed alarms are being reported. The purpose of this paper is to present results from a workshop titled "Too many alarms? Too few alarms?" organized by the Section Patient Monitoring and the Workgroup Alarms of the German Association of Biomedical Engineering of the Association for Electrical, Electronic and Information Technologies. The current situation regarding alarms and their problems in intensive care, such as lack of clinical relevance, alarm fatigue, workload increases due to clinically irrelevant alarms, usability problems in alarm systems, problems with manuals and training, and missing alarms due to operator error are outlined, followed by a discussion of solutions and strategies to improve the current situation. Finally, the need for more research and development, focusing on signal quality considerations, networking of medical devices at the bedside, diagnostic alarms and predictive warnings, usability of alarm systems, education of healthcare providers, creation of annotated clinical databases for testing, standardization efforts, and patient monitoring in the regular ward, are called for.

Cardiopulmonary monitors and clinically significant events in critically ill children

Cardiopulmonary monitors (CPMs) generate false alarm rates ranging from 85%-99% with few of these alarms actually representing serious clinical events. The overabundance of clinically insignificant alarms in hospitals desensitizes the clinician to true-positive alarms and poses significant safety issues. In this IRB-approved externally funded study, we sought to assess the clinical conditions associated with true and false-positive CPM alarms and attempted to define optimal alarm parameters that would reduce false-positive alarm rates (as they relate to clinically significant events) and thus improve overall CPM performance in critically ill children. Prior to the study, clinically significant events (CSEs) were defined and validated. Over a seven-month period in 2009, critically ill children underwent evaluation of CSEs while connected to a CPM. Comparative CPM and CSE data were analyzed with an aim to estimate sensitivity, specificity, and positive and negative predictive values for CSEs. CPM and CSE data were evaluated in 98 critically ill children. Overall, 2,245 high priority alarms were recorded with 68 CSEs noted in 45 observational days. During the course of the study, the team developed a firm understanding of CPM functionality, including the pitfalls associated with aggregation and analysis of CPM alarm data. The inability to capture all levels of CPM alarms represented a significant study challenge. Selective CPM data can be easily queried with standard reporting, however the default settings with this reporting exclude critical information necessary in compiling a coherent study denominator database. Although the association between CPM alarms and CSEs could not be comprehensively evaluated, preliminary analysis reflected poor CPM alarm specificity. This study provided the necessary considerations for the proper design of a future study that improves the positive predictive value of CPM alarms. In addition, this investigation has resulted in improved awareness of CPM alarm parameter settings and associated false-positive alarms. This information has been incorporated into nursing educational programs.

Monitor alarm fatigue: standardizing use of physiological monitors and decreasing nuisance alarms

BACKGROUND

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.

PURPOSE

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.

METHODS

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.

RESULTS

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.

DISCUSSION

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.

ALaRMED: adverse events in low-risk chest pain patients receiving continuous ECG monitoring in the emergency department: a survey of Canadian emergency physicians

OBJECTIVE

Current guidelines suggest that most patients who present to an emergency department (ED) with chest pain should be placed on a continuous electrocardiographic monitoring (CEM) device. We surveyed emergency physicians to determine their perception of current occupancy rates of CEM and to assess their attitudes toward prescribing monitors for low-risk chest pain patients in the ED.

METHODS

We conducted a cross-sectional, self-administered Internet and mail survey of a random sample of 300 members of the Canadian Association of Emergency Physicians. Main outcome measures included the perceived frequency of fully occupied monitors in the ED and physicians' willingness to forgo CEM in certain chest pain patients.

RESULTS

The response rate was 66% (199 respondents). The largest group of respondents (43%; 95% confidence interval [CI] 36%-50%) indicated that monitors were fully occupied 90%-100% of the time during their most recent ED shift. When asked how often they were forced to choose a patient for monitor removal because of the limited number of monitors, 52% (95% CI 45%-60%) of respondents selected 1-3 times per shift. Ninety percent (95% CI 84%-93%) of respondents indicated that they would forgo CEM in certain cardiac chest pain patients if there was good evidence that the risk of a monitor-detected adverse event was very low.

CONCLUSION

Emergency physicians report that monitors are often fully occupied in Canadian EDs, and most are willing to forgo CEM in certain chest pain patients. A large prospective study of CEM in low-risk chest pain patients is warranted.

A National Online Survey on the Effectiveness of Clinical Alarms

Purpose To develop a national online survey to be administered by the American College of Clinical Engineers Healthcare Technology Foundation to hospitals and healthcare workers to determine the problems associated with alarms in hospitals.

Methods An online survey was developed by a 16-member task force representing professionals from clinical engineering, nursing, and technology to evaluate the reasons health-care workers do not respond to clinical alarms.

Results A total of 1327 persons responded to the survey; most (94%) worked in acute care hospitals. About half of the respondents were registered nurses (51%), and one-third of respondents (31%) worked in a critical care unit. Most respondents (>90%) agreed or strongly agreed with the statements covering the purpose of clinical alarms and the need for prioritized and easily differentiated audible and visual alarms. Likewise, many respondents identified nuisance alarms as problematic; most agreed or strongly agreed that the alarms occur frequently (81%), disrupt patient care (77%), and can reduce trust in alarms and cause caregivers to disable them (78%).

Conclusions Effective clinical alarm management relies on (1) equipment designs that promote appropriate use, (2) clinicians who take an active role in learning how to use equipment safely over its full range of capabilities, and (3) hospitals that recognize the complexities of managing clinical alarms and devote the necessary resources to develop effective management schemes.

A clinical decision rule to identify which chest pain patients can safely be removed from cardiac monitoring in the emergency department

STUDY OBJECTIVE

We determine the rate of serious arrhythmias in a cohort of monitored emergency department (ED) chest pain patients and derive a clinical decision rule that can identify which patients can safely be taken off continuous cardiac monitoring at initial physician assessment.

METHODS

A secondary analysis of a prospectively collected cohort was completed in a university-affiliated tertiary care center. Consecutive patients with a primary complaint of chest pain who underwent cardiac monitoring in the ED in January to April 2000 were included. Serious arrhythmias were defined as those requiring treatment in the ED. Multivariate recursive partitioning analysis was undertaken to derive a decision rule.

RESULTS

Nine hundred ninety-two consecutive chest pain patients were monitored in the ED during the study period, of whom 14% and 12% had myocardial infarction and unstable angina, respectively. There were 17 patients (1.7%) with serious arrhythmias detected in the ED. The following decision rule was derived: patients can be removed from cardiac monitoring if they are pain free at the initial physician assessment and have a normal or nonspecific ECG result. The rule had 100% sensitivity (95% confidence interval 80% to 100%) for serious arrhythmias. Applying this rule would have allowed physicians to immediately remove 29% of patients from cardiac monitoring.

CONCLUSION

Serious arrhythmias are uncommon in monitored ED chest pain patients. A simple clinical decision rule could be used to safely identify low-risk patients who can be removed from continuous monitoring if its performance is prospectively validated in an independent patient population.