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Seitz‐Rasmussen HES, Føns‐Sønderskov M, Kodal A, Bestle MH. Improving patient outcomes following vital sign monitoring protocol failure: A retrospective cohort study. Health Sci Rep 2024; 7:e1754. [PMID: 38698792 PMCID: PMC11063259 DOI: 10.1002/hsr2.1754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 11/08/2023] [Accepted: 11/21/2023] [Indexed: 05/05/2024] Open
Abstract
Background and Aims Vital sign monitoring needs to be timely and correct to recognize deteriorating patients early and trigger the relevant clinical response. The aim of this study is to retrospectively evaluate compliance specifically toward the regional vital sign monitoring protocol the so called early warning score protocol (EWS-protocol) 72 h before a medical emergency team response (MET-response) and thereby illuminate whether poor compliance translates into a worse patient outcome. Methods It was investigated all eligible patients that underwent MET responses during the calendar year 2019. The inclusion criteria encompassed somatic patients above 18 years of age admitted to the hospital and detailed evaluations of the medical records of the included patients were conducted. Results Four hundred and twenty-nine MET-responses were included in the final analysis. EWS-protocol failure was observed for more than half the patients within all the time frames assessed. Thirty-day mortality was significantly higher for patients subject to EWS protocol failure in the timeframes 24-16, 16-8, 8-0 h before MET response. Adjusting for admission length, age, and gender, patients subject to EWS-protocol failure had an odds ratio (OR) of 1.9, 2.0, 2.1, 2.3 for mortality in the time frames 72-48, 24-16, 16-8, and 8-0 h before the MET-response, respectively. The adjusted OR for ICU-admission was 1.7, and 1.6 for patients subject to EWS-protocol failure in the time frames 16-8 and 8-0 h before MET-response, respectively. Conclusion According to all the data analysis in this article, there is evidence that compliance toward the NEWS-protocol is poor. EWS-protocol failure is associated with a significant higher mortality and ICU-admission rate.
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Affiliation(s)
| | - Morten Føns‐Sønderskov
- Department of Anesthesiology and Intensive CareCopenhagen University Hospital, North ZealandHilleroedDenmark
| | - Anne‐Marie Kodal
- Department of Anesthesiology and Intensive CareCopenhagen University Hospital, North ZealandHilleroedDenmark
| | - Morten H. Bestle
- Department of Anesthesiology and Intensive CareCopenhagen University Hospital, North ZealandHilleroedDenmark
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2
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Ng J, Christensen M. Registered nurses' knowledge and interpretation of ECG rhythms: A cross-sectional study. Nurs Crit Care 2023. [PMID: 38156358 DOI: 10.1111/nicc.13013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 11/01/2023] [Accepted: 11/03/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Electrocardiographic (ECG) monitoring and recording are seen as the most commonly used non-invasive diagnostic tool to identify cardiac arrhythmia and myocardial damage in the clinical setting. There is an expectation that critical care nurses are ideally trained to interpret abnormalities and morphology in the ECG more proficiently than nurses from general ward areas. However, the ability to interpret and recognise ECG abnormalities is dependent on which critical care area nurses are currently working in and their level of experience. AIM The aim of this study was to investigate registered nurses' knowledge in being able to identify and interpret select electrocardiographic rhythms. STUDY DESIGN This was a cross-sectional study that evaluated registered nurses' knowledge of electrocardiogram rhythm identification and interpretation. A convenience sample of 105 registered nurses currently enrolled in a 2-year Master's programme leading to critical care specialism and advanced practice nurse award were recruited. A 20-item multiple choice questionnaire that provided examples of electrocardiogram rhythm (n=14) abnormalities and rhythm abnormalities caused by electrolyte disturbances (n=6) RESULTS: The study included registered nurses from critical care and general ward areas. The overall results were poor with only 55% of questions answered correctly. Coronary care nurses scored the highest in identifying ECG rhythms (12/20 ± 1.58; p < .001). When ECG abnormalities associated with electrolyte imbalances were analysed, both groups were unable to identify the effects of hypokalaemia and hypomagnesaemia effectively (p = .748). Length of time as a registered nurse (r = -0.304, p = .002) and length of time in current work environment were weakly correlated (r = -0.328, p = .001). Having a critical care background showed a positive relationship with nursing knowledge of ECG rhythm identification (r = 0.614, p < .001). CONCLUSION The results of this study demonstrate that nurses have a poor knowledge of ECG rhythm identification and interpretation, a consistent finding from other work. A possible solution is a revamp of education and training associated with ECG recognition and morphology. RELEVANCE TO CLINICAL PRACTICE Monitoring and assessing ECG morphology provide important details about cardio-electroconductive stability, especially with fluctuations in serum electrolyte levels seen in critical illness or trauma. For this, critical nurses must improve their proficiency through education/training or internal quality improvement activities in detecting abnormalities associated with ECG changes beyond those most easily recognizable rhythms such as atrial fibrillation or ventricular tachycardia.
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Affiliation(s)
- Jessie Ng
- School of Nursing, Hong Kong Polytechnic University, Kowloon, Hong Kong SAR
| | - Martin Christensen
- School of Nursing, Hong Kong Polytechnic University, Kowloon, Hong Kong SAR
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Lehet CR, Lopez JA, Frank RJ, Cvach M. Technological Intervention to Improve Alarm Management in Acute Care Telemetry Units. Biomed Instrum Technol 2023; 57:67-74. [PMID: 37343111 PMCID: PMC10512988 DOI: 10.2345/0899-8205-57.2.67] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
Background: Telemetry monitoring is intended to improve patient safety and reduce harm. However, excessive monitor alarms may have the undesired effect of staff ignoring, silencing, or delaying a response due to alarm fatigue. Outlier patients, or those patients who are responsible for generating the most monitor alarms, contribute to excessive monitor alarms. Methods: Daily alarm data reports at a large academic medical center indicated that one or two patient outliers generated the most alarms daily. A technological intervention aimed at reminding registered nurses (RNs) to adjust alarm thresholds for patients who triggered excessive alarms was implemented. The notification was sent to the assigned RN's mobile phone when a patient exceeded the unit's seven-day average of alarms per day by greater than 400%. Results: A reduction in average alarm duration was observed across the four acute care telemetry units (P < 0.001), with an overall decrease of 8.07 seconds in the postintervention versus preintervention period. However, alarm frequency increased significantly (χ23 = 34.83, P < 0.001). Conclusion: Implementing a technological intervention to notify RNs to adjust alarm parameters may reduce alarm duration. Reducing alarm duration may improve RN telemetry management, alarm fatigue, and awareness. More research is needed to support this conclusion, as well as to determine the cause of the observed increase in alarm frequency.
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Gourishankar A, Evangelista M, Ellsworth M, Hsu J. Utility and Impact Analysis of Inpatient Pediatric Physiologic Monitoring. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1749679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
AbstractThis study aimed to study the practice and effect of monitoring hospitalized pediatric patients in terms the length of stay (LOS). We have performed a prospective, observational study of pediatric patients in the general ward from October to December 2016. We have recorded the use of cardiac monitor, pulse oximeter, or both, and as per physician order at patient admission. We have studied the proportions of monitoring in different patient groups. We have applied a linear regression model to investigate the relationship between LOS and cardiopulmonary monitoring, orders, and medical complexity. Among 399 patients, patients with cardiac and pulse oximeter monitoring with orders were 68 and 82%, respectively. The pulmonary group had more monitoring than the neurology group of patients. LOS was shorter in patients without monitoring; the median difference for the cardiac monitoring was one day (interquartile range [IQR] = 1), and the pulse oximeter was 0.5 days (IQR = 1). Cardiac monitoring order increased LOS by 22% (95% confidence interval [CI]: 0.5, 48%) and complex past medical history increased it by 25% (95% CI: 4, 51%). Our study highlights the variable practice in using monitors, emphasizing a standardized approach. The judicious use of monitoring may reduce prolonged hospitalization. Selective use of physiologic monitoring of ill-appearing or at risk of hypoxemia or cardiac dysrhythmia will reduce overuse.
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Affiliation(s)
- Anand Gourishankar
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, United States
| | - Monaliza Evangelista
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Texas Health, McGovern Medical School at Houston, Texas, United States
| | - Misti Ellsworth
- Division of Pediatric Infectious Disease, Department of Pediatrics, University of Texas Health, McGovern Medical School at Houston, Texas, United States
| | - Jean Hsu
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, United States
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Suba S, Hoffmann TJ, Fleischmann KE, Schell-Chaple H, Prasad P, Marcus GM, Badilini F, Hu X, Pelter MM. Premature ventricular complexes during continuous electrocardiographic monitoring in the intensive care unit: Occurrence rates and associated patient characteristics. J Clin Nurs 2022. [PMID: 35712789 DOI: 10.1111/jocn.16408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/25/2022] [Accepted: 06/01/2022] [Indexed: 11/27/2022]
Abstract
AIMS AND OBJECTIVES This study examined the occurrence rate of specific types of premature ventricular complex (PVC) alarms and whether patient demographic and/or clinical characteristics were associated with PVC occurrences. BACKGROUND Because PVCs can signal myocardial irritability, in-hospital electrocardiographic (ECG) monitors are typically configured to alert nurses when they occur. However, PVC alarms are common and can contribute to alarm fatigue. A better understanding of occurrences of PVCs could help guide alarm management strategies. DESIGN A secondary quantitative analysis from an alarm study. METHODS The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist was followed. Seven PVC alarm types (vendor-specific) were described, and included isolated, couplet, bigeminy, trigeminy, run PVC (i.e. VT >2), R-on-T and PVCs/min. Negative binomial and hurdle regression analyses were computed to examine the association of patient demographic and clinical characteristics with each PVC type. RESULTS A total of 797,072 PVC alarms (45,271 monitoring hours) occurred in 446 patients, including six who had disproportionately high PVC alarm counts (40% of the total alarms). Isolated PVCs were the most frequent type (81.13%) while R-on-T were the least common (0.29%). Significant predictors associated with higher alarms rates: older age (isolated PVCs, bigeminy and couplets); male sex and presence of PVCs on the 12-lead ECG (isolated PVCs). Hyperkalaemia at ICU admission was associated with a lower R-on-T type PVCs. CONCLUSIONS Only a few distinct demographic and clinical characteristics were associated with the occurrence rate of PVC alarms. Further research is warranted to examine whether PVCs were associated with adverse outcomes, which could guide alarm management strategies to reduce unnecessary PVC alarms. RELEVANCE TO CLINICAL PRACTICE Targeted alarm strategies, such as turning off certain PVC-type alarms and evaluating alarm trends in the first 24 h of admission in select patients, might add to the current practice of alarm management.
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Affiliation(s)
- Sukardi Suba
- School of Nursing, University of Rochester, Rochester, New York, USA
| | - Thomas J Hoffmann
- Department of Epidemiology and Biostatistics, School of Medicine, and Office of Research, School of Nursing, University of California, San Francisco (UCSF), San Francisco, California, USA
| | | | - Hildy Schell-Chaple
- Center for Nursing Excellence & Innovation, UCSF Medical Center, San Francisco, California, USA
| | - Priya Prasad
- Department of Medicine, School of Medicine, UCSF, San Francisco, California, USA
| | - Gregory M Marcus
- Department of Medicine, School of Medicine, UCSF, San Francisco, California, USA
| | - Fabio Badilini
- Department of Physiological Nursing, School of Nursing, UCSF, San Francisco, California, USA
| | - Xiao Hu
- School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Michele M Pelter
- Department of Physiological Nursing, School of Nursing, UCSF, San Francisco, California, USA
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Nurses’ clinical alarm-related behaviors and influencing factors in China †. FRONTIERS OF NURSING 2022. [DOI: 10.2478/fon-2022-0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Abstract
Objective
To explore the nurses’ behaviors regarding clinical alarms, analyze the related influencing factors, and provide rationales for alarm management.
Methods
A cross-sectional survey was conducted in China. The self-made questionnaire of nurses’ clinical alarm-related knowledge, attitude, and behavior (NCAKAB) was used.
Results
The valid response rate was 98.66% (n = 2368). The average nurses’ clinical alarm-related behaviors (NCAB) score was 65.14 ± 7.95 (out of 85). The dimension scores of NCAB from high to low were alarm learning (4.02 ± 0.85, out of 5), alarm response (27.99 ± 3.64, out of 35), alarm setting (19.24 ± 3.88, out of 25), alarm recognition (7.63 ± 1.68, out of 10) and alarm notification (6.25 ± 1.84, out of 10). There were significant differences in alarm behavior scores between nurses of different ages (F = 4.619, P = 0.000), nursing stints (F = 9.564, P = 0.000), professional titles (F = 4.425, P = 0.004), departments (F = 9.166, P = 0.000), and hospital levels (t = 2.705, P = 0.007). The study showed that nurses’ total alarm behavior scores were positively correlated with the total alarm knowledge score (r = 0.267; P < 0.001) and the total alarm attitude score (r = 438; P < 0.001).
Conclusions
Nurses scored highest in alarm learning, followed by alarm response, alarm setting, alarm recognition, and alarm notification behavior. The factors that influenced alarm behavior included age, title, department, nursing stint, hospital level, professional title, alarm-related training, willingness to participate in alarm-related training, whether or not departments have improved alarm management over the last 3 years, and whether or not departments have formulated norms for alarm management. Nurses with higher scores for clinical alarm knowledge had higher correlating scores for alarm behavior; similarly, nurses with higher scores for clinical alarm attitude had higher scores for alarm-related behavior.
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Dykes PC, Lowenthal G, Lipsitz S, Salvucci SM, Yoon C, Bates DW, An PG. Reducing ICU Utilization, Length of Stay, and Cost by Optimizing the Clinical Use of Continuous Monitoring System Technology in the Hospital. Am J Med 2022; 135:337-341.e1. [PMID: 34717901 DOI: 10.1016/j.amjmed.2021.09.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/16/2021] [Accepted: 09/22/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Continuous monitoring system technology (CMST) aids in earlier detection of deterioration of hospitalized patients, but whether improved outcomes are sustainable is unknown. METHODS This interrupted time series evaluation explored whether optimized clinical use of CMST was associated with sustained improvement in intensive care unit (ICU) utilization, hospital length of stay, cardiac arrest rates, code blue events, mortality, and cost across multiple adult acute care units. RESULTS A total of 20,320 patients in the postoptimized use cohort compared with 16,781 patients in the preoptimized use cohort had a significantly reduced ICU transfer rate (1.73% vs 2.25%, P = .026) corresponding to 367.11 ICU days saved over a 2-year period, generating an estimated cost savings of more than $2.3 million. Among patients who transferred to the ICU, hospital length of stay was decreased (8.37 vs 9.64 days, P = .004). Cardiac arrest, code blue, and mortality rates did not differ significantly. CONCLUSION Opportunities exist to promote optimized adoption and use of CMST at acute care facilities to sustainably improve clinical outcomes and reduce cost.
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Affiliation(s)
- Patricia C Dykes
- Center for Patient Safety, Research and Practice, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
| | - Graham Lowenthal
- Center for Patient Safety, Research and Practice, Brigham and Women's Hospital, Boston, Mass
| | - Stuart Lipsitz
- Center for Patient Safety, Research and Practice, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | | | - Catherine Yoon
- Center for Patient Safety, Research and Practice, Brigham and Women's Hospital, Boston, Mass
| | - David W Bates
- Center for Patient Safety, Research and Practice, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Perry G An
- Adult In-patient Medicine, Newton-Wellesley Hospital, Newton, Mass
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Karapas ET, Bobay K. Reducing Cardiac Telemetry Nuisance Alarms Through Evidence-Based Interventions. J Nurs Care Qual 2021; 36:355-360. [PMID: 33734186 DOI: 10.1097/ncq.0000000000000556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiac telemetry nuisance alarms due to leads off and poor signal increase staff workflow interruptions, decrease staff trust in technology, and can compromise patient safety. LOCAL PROBLEM Interventions were directed at reducing nuisance alarms on a 32-bed, non-intensive care - a cardiac telemetry unit. METHODS A nursing staff education module with evidence-based practices for reducing nuisance alarms, a daily care protocol for patients on cardiac telemetry monitoring, and daily audits of protocol adherence were implemented. RESULTS Staff pre- and posttest comparisons on their knowledge relating to nuisance alarms and the evidence-based protocol demonstrated a significant mean increase of 3.02 (95% CI, 2.55-3.48). Daily audits for 7 weeks demonstrated an average of 58.46% staff adherence. Telemetry technician call volume reduction was 16% postimplementation, while nuisance alarms were not reduced significantly. CONCLUSIONS This rapid-cycle, quality improvement process resulted in minimal reduction in nuisance alarms but improved staff awareness of the issue and reduced workflow interruptions.
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Affiliation(s)
- Eleftheria T Karapas
- College of Nursing and Health Sciences, Lewis University, Romeoville, Illinois (Dr Karapas); and Niehoff School of Nursing, Loyola University, Chicago, Illinois (Dr Bobay)
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Ceylan B, Baran L, Güneş ÜY. Frequency of Clinical Alarms in Intensive Care Units and Nurses' Sensitivity to Them: An Observational Study. Am J Crit Care 2021; 30:186-192. [PMID: 34161978 DOI: 10.4037/ajcc2021382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND All clinical alarms require nurses to respond even if an intervention is not needed. Nurses are expected to respond appropriately to each alarm and establish priorities among their care practices accordingly. This study was conducted to examine the number and types of clinical device alarms used in intensive care units, the duration of their activation, and nurses' degree of sensitivity to them. METHODS This observational study was conducted in 4 intensive care units in a university hospital in Turkey. A total of 20 nurses (5 from each unit) were observed for a total of 80 hours. The alarms were categorized as valid, false, or technical. RESULTS During the study observation period, the mean number of alarms sounding per hour per bed was 1.8. A total of 144 alarms were recorded, of which 70.8% were valid, 15.3% were false, and 13.9% were technical. The mean duration of alarm activation was 8 minutes for valid alarms, 14 minutes for false alarms, and 53 minutes for technical alarms. CONCLUSIONS Nurses' responses to alarms differ depending on alarm type; for alarms that do not require an emergency intervention, nurses tend to respond late or not at all.
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Affiliation(s)
- Burcu Ceylan
- Burcu Ceylan is an assistant professor, Fundamentals of Nursing Department, Faculty of Health Sciences, Izmir Katip Celebi University, Cigli–Izmir, Turkey
| | - Leyla Baran
- Leyla Baran is a research assistant, Department of Nursing, Faculty of Health Sciences, Mardin Artuklu University, Mardin, Turkey
| | - Ülkü Yapucu Güneş
- Ülkü Yapucu Güneş is a professor, Fundamentals of Nursing Department, Faculty of Nursing, Ege University, Bornova–Izmir, Turkey
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Chen Y, Nasrawi D, Massey D, Johnston ANB, Keller K, Kunst E. Final-year nursing students' foundational knowledge and self-assessed confidence in interpreting cardiac arrhythmias: A cross-sectional study. NURSE EDUCATION TODAY 2021; 97:104699. [PMID: 33341065 DOI: 10.1016/j.nedt.2020.104699] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 11/18/2020] [Accepted: 11/30/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Graduating nurses should possess knowledge and understanding of cardiac arrhythmia interpretation, so they can assess abnormal and life-threatening arrhythmias. However, literature around nursing students' foundational knowledge in cardiac arrhythmia interpretation remains scarce. OBJECTIVES To examine final-year nursing students' foundational knowledge and self-assessed confidence in interpreting cardiac arrhythmias. DESIGN Cross-sectional study design. SETTINGS Two Australian universities (one regional and the other large metropolitan). PARTICIPANTS Nursing students in the final year of a program of study leading to initial registration as a registered nurse. METHODS An online survey was adopted to examine final-year nursing students' foundational knowledge and their self-assessed confidence when interpreting cardiac rhythms. RESULTS A total of 114 participants completed surveys, representing a response rate of 22%. More than 70% of the participants were able to interpret asystole, sinus rhythm, and sinus bradycardia. Over 50% correctly identified ventricular tachycardia, atrial flutter, sinus tachycardia, atrial fibrillation, and ventricular fibrillation. Under 15% of the participants were able to interpret junctional rhythm, paced rhythm, and unifocal/multifocal premature ventricular contractions. Self-assessed confidence levels were generally lower than the accuracy rates of arrhythmia interpretation. Although many participants acknowledged that learning arrhythmia interpretation was difficult and challenging, most of them had positive perceptions and wanted to learn more. CONCLUSION Nursing curricula need to be supported and strategies need to be implemented to standardise educational electrocardiogram interpretation programs, which are critical to improving final-year nursing students' foundational knowledge and confidence in interpreting cardiac arrhythmias and enhancing patient safety.
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Affiliation(s)
- Yingyan Chen
- School of Health and Human Sciences, Gold Coast Campus, Southern Cross University, Bilinga, QLD 4225, Australia.
| | - Dima Nasrawi
- School of Health and Human Sciences, Gold Coast Campus, Southern Cross University, Bilinga, QLD 4225, Australia.
| | - Debbie Massey
- School of Health and Human Sciences, Gold Coast Campus, Southern Cross University, Bilinga, QLD 4225, Australia.
| | - Amy N B Johnston
- The University of Queensland, School of Nursing, Midwifery and Social Work, Tri Woolloongabba, QLD 4102, Australia; Princess Alexandra Hospital, Department of Emergency Medicine, Ipswich Rd, Woolloongabba, QLD 4102, Australia.
| | - Kathryn Keller
- Christine E. Lynn College of Nursing, Florida Atlantic University, United States.
| | - Elicia Kunst
- School of Health and Human Sciences, Gold Coast Campus, Southern Cross University, Bilinga, QLD 4225, Australia.
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11
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Sowan AK, Staggers N, Berndt A, Austin T, Reed CC, Malshe A, Kilger M, Fonseca E, Vera A, Chen Q. Improving the Safety, Effectiveness, and Efficiency of Clinical Alarm Systems: Simulation-Based Usability Testing of Physiologic Monitors. JMIR Nurs 2021; 4:e20584. [PMID: 34345793 PMCID: PMC8328265 DOI: 10.2196/20584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 08/18/2020] [Accepted: 01/03/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Clinical alarm system safety is a national patient safety goal in the United States. Physiologic monitors are associated with the highest number of device alarms and alarm-related deaths. However, research involving nurses' use of physiologic monitors is rare. Hence, the identification of critical usability issues for monitors, especially those related to patient safety, is a nursing imperative. OBJECTIVE This study examined nurses' usability of physiologic monitors in intensive care units with respect to the effectiveness and efficiency of monitor use. METHODS In total, 30 nurses from 4 adult intensive care units completed 40 tasks in a simulation environment. The tasks were common monitoring tasks that were crucial for appropriate monitoring and safe alarm management across four categories of competencies: admitting, transferring, and discharging patients using the monitors (7 tasks); managing measurements and monitor settings (23 tasks); performing electrocardiogram (ECG) analysis (7 tasks); and troubleshooting alarm conditions (3 tasks). The nurse-monitor interaction was video-recorded. The principal investigator and two expert intensive care units nurse educators identified, classified, and validated task success (effectiveness) and the time of task completion (efficiency). RESULTS Among the 40 tasks, only 2 (5%) were successfully completed by all the nurses. At least 1-27 (3%-90%) nurses abandoned or did not correctly perform 38 tasks. The task with the shortest completion time was "take monitor out of standby" (mean 0:02, SD 0:01 min:s), whereas the task "record a 25 mm/s ECG strip of any of the ECG leads" had the longest completion time (mean 1:14, SD 0:32 min:s). The total time to complete 37 navigation-related tasks ranged from a minimum of 3 min 57 s to a maximum of 32 min 42 s. Regression analysis showed that it took 6 s per click or step to successfully complete a task. To understand the nurses' thought processes during monitor navigation, the authors analyzed the paths of the 2 tasks with the lowest successful completion rates, where only 13% (4/30) of the nurses correctly completed these 2 tasks. Although 30% (9/30) of the nurses accessed the correct screen first for task 1 and task 2, they could not find their way easily from there to successfully complete the 2 tasks. CONCLUSIONS Usability testing of physiologic monitors revealed major ineffectiveness and inefficiencies in the current nurse-monitor interactions. The results indicate the potential for safety and productivity issues in completing routine tasks. Training on monitor use should include critical monitoring functions that are necessary for safe, effective, efficient, and appropriate monitoring to include knowledge of the shortest navigation path. It is imperative that vendors' future monitor designs mimic clinicians' thought processes for successful, safe, and efficient monitor navigation.
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Affiliation(s)
- Azizeh K Sowan
- School of Nursing University of Texas Health at San Antonio San Antonio, TX United States
| | - Nancy Staggers
- School of Nursing and Department of Biomedical Informatics University of Utah Salt Lake City, UT United States
| | - Andrea Berndt
- School of Nursing University of Texas Health at San Antonio San Antonio, TX United States
| | | | | | - Ashwin Malshe
- College of Business University of Texas at San Antonio San Antonio, TX United States
| | - Max Kilger
- College of Business University of Texas at San Antonio San Antonio, TX United States
| | | | - Ana Vera
- University Health San Antonio, TX United States
| | - Qian Chen
- College of Electrical and Computer Engineering University of Texas at San Antonio San Antonio, TX United States
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12
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Milhomme D, Pomerleau E. [Factors influencing the nurse’s decision to set and modulate alarm parameters of bedside monitoring in intensive care : an integrative review of literature]. Rech Soins Infirm 2020; 140:57-68. [PMID: 32524802 DOI: 10.3917/rsi.140.0057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Introduction : In critical care units, improper alarm settings for bedside monitoring systems promotes numerous alarms and may lead to nurse fatigue.
Purpose : Achieve an integrative review of the literature to identify the factors that influence the nurse in her decision to set and modulate the alarm parameters of bedside monitoring systems in the intensive care unit. Method : An integrative review of the literature according to the five steps of the Whittemore and Knafl method was carried out from the literature related to the field of critical care.
Results : The factors related to the nurse’s decision to set or modulate the alarm parameters of the monitoring systems are divided into two themes : personal factors and contextual factors.
Discussion : Certain factors identified in this integrative review were also identified as elements that contribute to the clinical surveillance process carried out by expert nurses in a critical care context.
Conclusion : The results of this study suggest the need to focus empirically on the factors influencing the nurse’s decision to adjust and modulate alarm parameters in critical care monitoring systems.
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13
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Dursun Ergezen F, Kol E. Nurses' responses to monitor alarms in an intensive care unit: An observational study. Intensive Crit Care Nurs 2020; 59:102845. [PMID: 32238311 DOI: 10.1016/j.iccn.2020.102845] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 02/11/2020] [Accepted: 03/01/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The present study aimed to determine the types of monitor alarms and nurses' responses to them in an adult intensive care unit. DESIGN AND METHODS This was an observational descriptive research study conducted in the adult intensive care unit of a university hospital in the Mediterranean region of Turkey. The nonparticipant observation method was used. Data were collected by two observers using a semi-structured observation form developed according to literature. RESULTS Between August 2016 and January 2017, 13 registered nurses were observed for 328 hours. There were 1781 alarms, which included alarms for blood pressure (37.6%), respiration and oxygen saturation (35.3%) and heart rate and arrhythmia (27.1%). Nurses responded to approximately half (46.9%) of the alarms that required a response. Responses to alarms included silencing them, responding to the patient's clinical condition and solving contact and transmission problems. CONCLUSION In the present study, according to response requirement, the division of the alarms was different. The number of alarms that do not reflect the clinical status of the patient was high. It was found that as the false alarm rate increased, the response rate of nurses to these alarms decreased.
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Affiliation(s)
| | - Emine Kol
- Nursing Faculty, Akdeniz University, Antalya, Turkey
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14
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McGillion M, Ouellette C, Good A, Bird M, Henry S, Clyne W, Turner A, Ritvo P, Ritvo S, Dvirnik N, Lamy A, Whitlock R, Lawton C, Walsh J, Paterson K, Duquette J, Sanchez Medeiros K, Elias F, Scott T, Mills J, Harrington D, Field M, Harsha P, Yang S, Peter E, Bhavnani S, Devereaux PJ. Postoperative Remote Automated Monitoring and Virtual Hospital-to-Home Care System Following Cardiac and Major Vascular Surgery: User Testing Study. J Med Internet Res 2020; 22:e15548. [PMID: 32186521 PMCID: PMC7113803 DOI: 10.2196/15548] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 10/31/2019] [Accepted: 12/16/2019] [Indexed: 01/20/2023] Open
Abstract
Background Cardiac and major vascular surgeries are common surgical procedures associated with high rates of postsurgical complications and related hospital readmission. In-hospital remote automated monitoring (RAM) and virtual hospital-to-home patient care systems have major potential to improve patient outcomes following cardiac and major vascular surgery. However, the science of deploying and evaluating these systems is complex and subject to risk of implementation failure. Objective As a precursor to a randomized controlled trial (RCT), this user testing study aimed to examine user performance and acceptance of a RAM and virtual hospital-to-home care intervention, using Philip’s Guardian and Electronic Transition to Ambulatory Care (eTrAC) technologies, respectively. Methods Nurses and patients participated in systems training and individual case-based user testing at two participating sites in Canada and the United Kingdom. Participants were video recorded and asked to think aloud while completing required user tasks and while being rated on user performance. Feedback was also solicited about the user experience, including user satisfaction and acceptance, through use of the Net Promoter Scale (NPS) survey and debrief interviews. Results A total of 37 participants (26 nurses and 11 patients) completed user testing. The majority of nurse and patient participants were able to complete most required tasks independently, demonstrating comprehension and retention of required Guardian and eTrAC system workflows. Tasks which required additional prompting by the facilitator, for some, were related to the use of system features that enable continuous transmission of patient vital signs (eg, pairing wireless sensors to the patient) and assigning remote patient monitoring protocols. NPS scores by user group (nurses using Guardian: mean 8.8, SD 0.89; nurses using eTrAC: mean 7.7, SD 1.4; patients using eTrAC: mean 9.2, SD 0.75), overall NPS scores, and participant debrief interviews indicated nurse and patient satisfaction and acceptance of the Guardian and eTrAC systems. Both user groups stressed the need for additional opportunities to practice in order to become comfortable and proficient in the use of these systems. Conclusions User testing indicated a high degree of user acceptance of Philips’ Guardian and eTrAC systems among nurses and patients. Key insights were provided that informed refinement of clinical workflow training and systems implementation. These results were used to optimize workflows before the launch of an international RCT of in-hospital RAM and virtual hospital-to-home care for patients undergoing cardiac and major vascular surgery.
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Affiliation(s)
- Michael McGillion
- School of Nursing, McMaster University, Hamilton, ON, Canada.,Population Health Research Institute, Hamilton, ON, Canada
| | | | - Amber Good
- Population Health Research Institute, Hamilton, ON, Canada
| | - Marissa Bird
- School of Nursing, McMaster University, Hamilton, ON, Canada
| | | | - Wendy Clyne
- Hope for the Community CIC, Coventry, United Kingdom
| | | | | | | | - Nazari Dvirnik
- Population Health Research Institute, Hamilton, ON, Canada.,McMaster University, Hamilton, ON, Canada
| | - Andre Lamy
- Population Health Research Institute, Hamilton, ON, Canada.,Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Richard Whitlock
- Population Health Research Institute, Hamilton, ON, Canada.,Department of Surgery, McMaster University, Hamilton, ON, Canada
| | | | - Jake Walsh
- Hamilton Health Sciences, Hamilton, ON, Canada
| | | | - Janine Duquette
- Cardiac and Vascular Program, Hamilton Health Sciences, Hamilton, ON, Canada
| | | | - Fadi Elias
- Population Health Research Institute, Hamilton, ON, Canada.,McMaster University, Hamilton, ON, Canada
| | - Ted Scott
- Hamilton Health Sciences, Hamilton, ON, Canada
| | - Joseph Mills
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | | | - Mark Field
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | | | | | - Elizabeth Peter
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Sanjeev Bhavnani
- Scripps Clinic & Research Foundation, San Diego, CA, United States
| | - P J Devereaux
- Population Health Research Institute, Hamilton, ON, Canada.,Departments of Health Research Methods, Evidence, and Impact (HEI) and Medicine, McMaster University, Hamilton, ON, Canada
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Research Outcomes of Implementing CEASE: An Innovative, Nurse-Driven, Evidence-Based, Patient-Customized Monitoring Bundle to Decrease Alarm Fatigue in the Intensive Care Unit/Step-down Unit. Dimens Crit Care Nurs 2019; 38:160-173. [PMID: 30946125 DOI: 10.1097/dcc.0000000000000357] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The research literature is replete with evidence that alarm fatigue is a real phenomenon in the clinical practice environment and can lead to desensitization of the need to respond among nursing staff. A few studies attest to the effectiveness of incorporating parts of the American Association of Critical-Care Nurses recommended nursing practices for alarm management. No studies could be found measuring the effectiveness of the American Association of Critical-Care Nurses recommendations in their entirety or the effectiveness of a nursing-driven, evidence-based, patient-customized monitoring bundle. PURPOSE/RESEARCH QUESTION The purpose of this study was to describe the effect of implementing CEASE, a nurse-driven, evidence-based, patient-customized monitoring bundle on alarm fatigue. CEASE is an acronym for Communication, Electrodes (daily changes), Appropriateness (evaluation), Setup alarm parameters (patient customization), and Education (ongoing). RESEARCH QUESTIONS (1) In a 36-bed intensive care unit/step-down unit (ICU/SDU) with continuous hemodynamic and respiratory monitoring, does application of an evidence-based, patient-customized monitoring bundle compared with existing monitoring practice lead to less alarm fatigue as measured by the number of hemodynamic and respiratory monitoring alarms? (2) In a 36-bed ICU/SDU with continuous hemodynamic and respiratory monitoring, does application of an evidence-based, patient-customized monitoring bundle compared with existing monitoring practice lead to less alarm fatigue as measured by duration of alarms? and (3) In a 36-bed ICU/SDU with continuous hemodynamic and respiratory monitoring, does application of an evidence-based, patient-customized monitoring bundle compared with existing monitoring practice lead to less alarm fatigue as measured by nurse perception? METHODS This was an institutional review board approved exploratory, nonrandomized, pretest and posttest, 1-group, quasi-experimental study, without-comparators design describing difference in pretest and posttest measures following CEASE Bundle implementation. The study was conducted over a 6-month period. Convenience sample of 74 registered nurses staffing a 36-bed ICU/SDU using the CEASE Bundle participated. Preimplementation/postimplementation number of alarms and alarm duration time for a 30-day period were downloaded from the monitoring system and compared. Nurses completed an electronic 36-item Clinical Alarms Survey provided by the Healthcare Technology Foundation: 35 before implementation and 18 after implementation. Researchers measured CEASE alarm bundle adherence. χ and t-tests determined statistical significance. RESULTS Total number of monitoring alarms decreased 31% from 52 880 to 36 780 after CEASE Bundle implementation. Low-priority Level 1 alarms duration time significantly decreased 23 seconds (t = 1.994, P = .045). Level 2 duration time did not change. High-priority Level 3 alarms duration time significantly increased to 246 seconds (t = 4.432, P < .0001). CEASE alarm bundle adherence significantly improved to 22.4% (χ = 5.068, P = .0244). Nurses perceived a significant decrease in nuisance alarm occurrence (68% to 44%) postimplementation (χ = 3.243, P = .0417). No adverse patient events occurred. CONCLUSIONS Decreased total number of monitoring alarms improved nurse perception of alarm fatigue. Continued monitoring of CEASE Bundle adherence by nursing staff is required. Longer high-priority Level 3 alarms duration suggests need for further research.
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Suba S, Sandoval CP, Zègre-Hemsey JK, Hu X, Pelter MM. Contribution of Electrocardiographic Accelerated Ventricular Rhythm Alarms to Alarm Fatigue. Am J Crit Care 2019; 28:222-229. [PMID: 31043402 DOI: 10.4037/ajcc2019314] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Excessive electrocardiographic alarms contribute to "alarm fatigue," which can lead to patient harm. In a prior study, one-third of audible electrocardiographic alarms were for accelerated ventricular rhythm (AVR), and most of these alarms were false. It is uncertain whether true AVR alarms are clinically relevant. OBJECTIVES To determine from bedside electrocardiographic monitoring data (1) how often true AVR alarms are acknowledged by clinicians, (2) whether such alarms are actionable, and (3) whether such alarms are associated with adverse outcomes ("code blue," death). METHODS Secondary analysis using data from a study conducted in an academic medical center involving 5 adult intensive care units with 77 beds. Electronic health records of 23 patients with 223 true alarms for AVR were examined. RESULTS The mean age of the patients was 62.9 years, and 61% were white and male. All 223 of the true alarms were configured at the warning level (ie, 2 continuous beeps), and 215 (96.4%) lasted less than 30 seconds. Only 1 alarm was acknowledged in the electronic health record. None of the alarms were clinically actionable or led to a code blue or death. CONCLUSIONS True AVR alarms may contribute to alarm fatigue. Hospitals should reevaluate the need for close monitoring of AVR and consider configuring this alarm to an inaudible message setting to reduce the risk of patient harm due to alarm fatigue. Prospective studies involving larger patient samples and varied monitors are warranted.
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Affiliation(s)
- Sukardi Suba
- Sukardi Suba is a doctoral student, Department of Physiological Nursing, School of Nursing, University of California, San Francisco (UCSF), San Francisco, California. Cass Piper Sandoval is an adult critical care clinical nurse specialist and clinical nurse coordinator, Interventional Cardiology, UCSF Heart and Vascular Center, UCSF Health, San Francisco, California. Jessica K. Zègre-Hemsey is an assistant professor, School of Nursing and an adjunct assistant professor, Department of Emergency Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. Xiao Hu is a professor, Department of Physiological Nursing, School of Nursing, and Department of Neurological Surgery, and a core member, Institute for Computational Health Sciences, UCSF-UC Berkeley Joint Graduate Program in Bioengineering, UCSF. Michele M. Pelter is an assistant professor, School of Nursing, and director, ECG Monitoring Research Lab, UCSF.
| | - Cass Piper Sandoval
- Sukardi Suba is a doctoral student, Department of Physiological Nursing, School of Nursing, University of California, San Francisco (UCSF), San Francisco, California. Cass Piper Sandoval is an adult critical care clinical nurse specialist and clinical nurse coordinator, Interventional Cardiology, UCSF Heart and Vascular Center, UCSF Health, San Francisco, California. Jessica K. Zègre-Hemsey is an assistant professor, School of Nursing and an adjunct assistant professor, Department of Emergency Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. Xiao Hu is a professor, Department of Physiological Nursing, School of Nursing, and Department of Neurological Surgery, and a core member, Institute for Computational Health Sciences, UCSF-UC Berkeley Joint Graduate Program in Bioengineering, UCSF. Michele M. Pelter is an assistant professor, School of Nursing, and director, ECG Monitoring Research Lab, UCSF
| | - Jessica K Zègre-Hemsey
- Sukardi Suba is a doctoral student, Department of Physiological Nursing, School of Nursing, University of California, San Francisco (UCSF), San Francisco, California. Cass Piper Sandoval is an adult critical care clinical nurse specialist and clinical nurse coordinator, Interventional Cardiology, UCSF Heart and Vascular Center, UCSF Health, San Francisco, California. Jessica K. Zègre-Hemsey is an assistant professor, School of Nursing and an adjunct assistant professor, Department of Emergency Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. Xiao Hu is a professor, Department of Physiological Nursing, School of Nursing, and Department of Neurological Surgery, and a core member, Institute for Computational Health Sciences, UCSF-UC Berkeley Joint Graduate Program in Bioengineering, UCSF. Michele M. Pelter is an assistant professor, School of Nursing, and director, ECG Monitoring Research Lab, UCSF
| | - Xiao Hu
- Sukardi Suba is a doctoral student, Department of Physiological Nursing, School of Nursing, University of California, San Francisco (UCSF), San Francisco, California. Cass Piper Sandoval is an adult critical care clinical nurse specialist and clinical nurse coordinator, Interventional Cardiology, UCSF Heart and Vascular Center, UCSF Health, San Francisco, California. Jessica K. Zègre-Hemsey is an assistant professor, School of Nursing and an adjunct assistant professor, Department of Emergency Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. Xiao Hu is a professor, Department of Physiological Nursing, School of Nursing, and Department of Neurological Surgery, and a core member, Institute for Computational Health Sciences, UCSF-UC Berkeley Joint Graduate Program in Bioengineering, UCSF. Michele M. Pelter is an assistant professor, School of Nursing, and director, ECG Monitoring Research Lab, UCSF
| | - Michele M Pelter
- Sukardi Suba is a doctoral student, Department of Physiological Nursing, School of Nursing, University of California, San Francisco (UCSF), San Francisco, California. Cass Piper Sandoval is an adult critical care clinical nurse specialist and clinical nurse coordinator, Interventional Cardiology, UCSF Heart and Vascular Center, UCSF Health, San Francisco, California. Jessica K. Zègre-Hemsey is an assistant professor, School of Nursing and an adjunct assistant professor, Department of Emergency Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. Xiao Hu is a professor, Department of Physiological Nursing, School of Nursing, and Department of Neurological Surgery, and a core member, Institute for Computational Health Sciences, UCSF-UC Berkeley Joint Graduate Program in Bioengineering, UCSF. Michele M. Pelter is an assistant professor, School of Nursing, and director, ECG Monitoring Research Lab, UCSF
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17
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Ruppel H, Funk M, Whittemore R, Wung SF, Bonafide CP, Powell Kennedy H. Critical care nurses' clinical reasoning about physiologic monitor alarm customisation: An interpretive descriptive study. J Clin Nurs 2019; 28:3033-3041. [PMID: 30938915 DOI: 10.1111/jocn.14866] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/05/2019] [Accepted: 03/23/2019] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To explore clinical reasoning about alarm customisation among nurses in intensive care units. BACKGROUND Critical care nurses are responsible for detecting and rapidly acting upon changes in patients' clinical condition. Nurses use medical devices including bedside physiologic monitors to assist them in their practice. Customising alarm settings on these devices can help nurses better monitor their patients and reduce the number of clinically irrelevant alarms. As a result, customisation may also help address the problem of alarm fatigue. However, little is known about nurses' clinical reasoning with respect to customising physiologic monitor alarm settings. DESIGN This article is an in-depth report of the qualitative arm of a mixed methods study conducted using an interpretive descriptive methodological approach. METHODS Twenty-seven nurses were purposively sampled from three intensive care units in an academic medical centre. Semi-structured interviews were conducted by telephone and were analysed using thematic analysis. Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guidelines were used. RESULTS Four themes were identified from the interview data: unit alarm culture and context, nurse attributes, motivation to customise and customisation "know-how." A conceptual model demonstrating the relationship of these themes was developed to portray the factors that affect nurses' customisation of alarms. CONCLUSIONS In addition to drawing on clinical data, nurses customised physiologic monitor alarms based on their level of clinical expertise and comfort. Nurses were influenced by the alarm culture on their clinical unit and colleagues' and patients' responses to alarms, as well as their own technical understanding of the physiologic monitors. RELEVANCE TO CLINICAL PRACTICE The results of this study can be used to design strategies to support the application of clinical reasoning to alarm management, which may contribute to more appropriate alarm customisation practices and improvements in safety.
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Affiliation(s)
- Halley Ruppel
- School of Nursing, Yale University, West Haven, Connecticut
| | - Marjorie Funk
- School of Nursing, Yale University, West Haven, Connecticut
| | | | - Shu-Fen Wung
- College of Nursing, The University of Arizona, Tucson, Arizona
| | - Christopher P Bonafide
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
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18
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19
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Cameron HL, Little B. Nurses' Perceptions and Practices Related to Alarm Management: A Quality Improvement Initiative. J Contin Educ Nurs 2019; 49:207-215. [PMID: 29701862 DOI: 10.3928/00220124-20180417-05] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 02/09/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND The purpose of this quality improvement project was to develop, implement, and assess the effects of an alarm management policy and educational program on nurses' perceptions and practices of alarm management in an acute care hospital. METHOD Nurses from an acute care hospital in the southeastern United States attended a mandatory alarm management education program. The hospital implemented the evidence-based alarm management education to achieve the NPSG.06.01.01: Alarm Management. Pre- and posttests were administered to evaluate the education and the changes in nurses' perceptions and practices of clinical alarms. RESULTS A total of 417 nurses received the educational intervention. All participants completed the pretest, and 215 (51%) completed the voluntary posttest. Significant improvements were made in alarm perceptions and practices. Nurses suggested unit-specific alarm education, improved staffing, and updated equipment. CONCLUSION Findings support the benefits of continued education in alarm management for nurses. Bedside nurses are a critical member of a multidisciplinary alarm management team because they are at the forefront of patient safety and most at risk for experiencing alarm fatigue. J Contin Educ Nurs. 2018;49(5):207-215.
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20
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Freysdóttir GR, Björnsdóttir K, Svavarsdóttir MH. Nurses' use of monitors in patient surveillance: an ethnographic study on a coronary care unit. Eur J Cardiovasc Nurs 2018; 18:272-279. [PMID: 30497283 DOI: 10.1177/1474515118816930] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Physiological monitors are increasingly used for patient surveillance. Although nurses play a vital role in the observation, analysis and use of information obtained from these devices, difficulties in their use, coupled with the high frequency of false and nuisance monitor alarms, can lead to negative working conditions and threaten patient safety. AIM With the purpose of promoting effective monitor use and ensuring patient safety, the aim was to explore both how cardiovascular nurses use monitors in patient surveillance and the effect that the monitors have on the nurses' work. METHODS A qualitative ethnographic design with semi-structured interviews and a field observation conducted at a 35-bed coronary care unit. A purposive sample was used in selecting participants. Data were analysed using systematic text condensation. RESULTS Eight registered nurses, all women, aged 27-49 years, were participants. The themes helping device, competence development and distractions and strain reflected both the knowledge on which the nurses drew in working with monitors and their influence on the nurses' work. False security and collaboration and teamwork discussed how the nurses trust and depend on each other during monitor surveillance and how poor work conditions and unclear responsibility undermine surveillance. CONCLUSIONS Monitors enable nurses to observe critically ill cardiac patients closely and respond quickly to life-threatening changes in their condition. Current work arrangements and limited training diminish the reliability of monitor surveillance. It is imperative to revise the structure of the surveillance and improve education in monitor surveillance to enhance nurses' clinical competence and patients' safety.
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Affiliation(s)
| | | | - Margrét Hrönn Svavarsdóttir
- 3 School of Health Sciences, University of Akureyri, Iceland.,4 Department of Health Sciences, Norwegian University of Sciences and Technology, Norway
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21
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Lopez KD, Fahey L. Advocating for Greater Usability in Clinical Technologies: The Role of the Practicing Nurse. Crit Care Nurs Clin North Am 2018; 30:247-257. [PMID: 29724443 DOI: 10.1016/j.cnc.2018.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Health care, especially ICUs, rely on multiple types of technology to promote the best patient outcomes. Unfortunately, too often these technologies are poorly designed, causing errors, additional workload, and unnecessary frustration. The purpose of this article is to (1) empower nurses with the needed usability and usability testing vocabulary to identify and articulate clinical technology usability problems and (2) provide ideas on ways nurses can advocate to have an impact on positive change related to technology usability within a health care organization.
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Affiliation(s)
- Karen Dunn Lopez
- Health Systems Science, University of Illinois at Chicago College of Nursing, 845 South Damen Avenue MC 802, Chicago IL 60612, USA.
| | - Linda Fahey
- Decatur Memorial Hospital, 2300 N. Edward Street, Decatur, IL 62526, USA
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22
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Downey CL, Chapman S, Randell R, Brown JM, Jayne DG. The impact of continuous versus intermittent vital signs monitoring in hospitals: A systematic review and narrative synthesis. Int J Nurs Stud 2018; 84:19-27. [PMID: 29729558 DOI: 10.1016/j.ijnurstu.2018.04.013] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 04/17/2018] [Accepted: 04/17/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Continuous vital signs monitoring on general hospital wards may allow earlier detection of patient deterioration and improve patient outcomes. This systematic review will assess if continuous monitoring is practical outside of the critical care setting, and whether it confers any clinical benefit to patients. METHODS MEDLINE®, MEDLINE® In-Process, EMBASE, CINAHL and The Cochrane Library were searched for articles that evaluated the clinical or non-clinical outcomes of continuous vital signs monitoring in adults outside of the critical care setting. The protocol was registered with PROSPERO (CRD42017058098). FINDINGS Twenty-four studies met the inclusion criteria and reported outcomes on a total of 40,274 patients and 59 ward staff in nine countries. The majority of studies showed benefits in terms of critical care use and length of hospital stay. Larger studies were more likely to demonstrate clinical benefit, particularly critical care use and length of hospital stay. Three studies showed cost-effectiveness. Barriers to implementation included nursing and patient satisfaction and the burden of false alerts. CONCLUSIONS Continuous vital signs monitoring outside the critical care setting is feasible and may provide a benefit in terms of improved patient outcomes and cost efficiency. Large, well-controlled studies in high-risk populations are required to evaluate the clinical benefit of continuous monitoring systems.
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Affiliation(s)
- C L Downey
- Leeds Institute of Biomedical & Clinical Sciences, Clinical Sciences Building, St. James's University Hospital, University of Leeds, Leeds, LS9 7TF, United Kingdom.
| | - S Chapman
- Leeds Institute of Biomedical & Clinical Sciences, Clinical Sciences Building, St. James's University Hospital, University of Leeds, Leeds, LS9 7TF, United Kingdom
| | - R Randell
- School of Healthcare, Baines Wing, University of Leeds, Leeds, LS2 9JT, United Kingdom
| | - J M Brown
- Leeds Institute of Clinical Trials Research, Worsley Building, University of Leeds, Leeds, LS2 9NL, United Kingdom
| | - D G Jayne
- Leeds Institute of Biomedical & Clinical Sciences, Clinical Sciences Building, St. James's University Hospital, University of Leeds, Leeds, LS9 7TF, United Kingdom
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Dinis SMM, Rabiais ICM. Factors that interfere with the response of nurses in the monitoring of clinical alarms. Rev Bras Enferm 2017; 70:172-179. [PMID: 28226057 DOI: 10.1590/0034-7167-2015-0092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 08/14/2016] [Indexed: 11/22/2022] Open
Abstract
Objective: The objective of the present study was to identify and synthesize the best empirical evidence found on factors that influence the response of nurses regarding clinical alarms. Method: An integrative literature review was conducted with searches undertaken in ten electronic databases restricted to the period from 2005 to 2016. Results: Eight articles were included by cross-checking the descriptors selected. Conclusion: In the analysis of the studies, the following possible factors that might interfere with the response of nurses in the monitoring of clinical alarms were found: high number of false alarms, inaudibility of alarms due to the competition of sounds, difficulty in distinguishing the urgency of alarms, and increase in noise caused by the raise in the number of alarms.
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24
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Stokes JE, Manzoor SH, Cvach MM. Ventilator Alarms: Challenges and Opportunities for Improvement. Biomed Instrum Technol 2017; 51:390-397. [PMID: 28934585 DOI: 10.2345/0899-8205-51.5.390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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25
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Palchaudhuri S, Chen S, Clayton E, Accurso A, Zakaria S. Telemetry Monitor Watchers Reduce Bedside Nurses' Exposure to Alarms by Intercepting a High Number of Nonactionable Alarms. J Hosp Med 2017; 12:447-449. [PMID: 28574535 DOI: 10.12788/jhm.2754] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cardiac telemetry, designed to monitor hospitalized patients with active cardiac conditions, is highly utilized outside the intensive care unit but is also resource-intensive and produces many nonactionable alarms. In a hospital setting in which dedicated monitor watchers are set up to be the first responders to system-generated alerts, we conducted a retrospective study of the alerts produced over a continuous 2-month period to evaluate how many were intercepted before nurse notification for being nonactionable, and how many resulted in code team activations. Over the 2-month period, the system generated 20,775 alerts (5.1/patient-day, on average), of which 87% were intercepted by monitor watchers. None of the alerts for asystole, ventricular fibrillation, or ventricular tachycardia resulted in a code team activation. Our results highlight the high burden of alerts, the large majority of which are nonactionable, as well as the role of monitor watchers in decreasing the alarm burden on nurses. Measures are needed to decrease telemetry-related alerts in order to reduce alarm-related harms, such as alarm fatigue. Journal of Hospital Medicine 2017;12:447-449.
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Affiliation(s)
- Sonali Palchaudhuri
- Johns Hopkins Bayview Medical Center, Baltimore, Maryland; Providers for Responsible Ordering, Johns Hopkins Medicine, Baltimore, Maryland
| | - Stephanie Chen
- Johns Hopkins Bayview Medical Center, Baltimore, Maryland; Providers for Responsible Ordering, Johns Hopkins Medicine, Baltimore, Maryland; Kaiser Permanente San Francisco, San Francisco, California
| | - Elaine Clayton
- Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Anthony Accurso
- Providers for Responsible Ordering, Johns Hopkins Medicine, Baltimore, Maryland; New York University Population Health, New York, New York
| | - Sammy Zakaria
- Johns Hopkins Bayview Medical Center, Baltimore, Maryland; Providers for Responsible Ordering, Johns Hopkins Medicine, Baltimore, Maryland
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Using Supervised Machine Learning to Classify Real Alerts and Artifact in Online Multisignal Vital Sign Monitoring Data. Crit Care Med 2017; 44:e456-63. [PMID: 26992068 DOI: 10.1097/ccm.0000000000001660] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The use of machine-learning algorithms to classify alerts as real or artifacts in online noninvasive vital sign data streams to reduce alarm fatigue and missed true instability. DESIGN Observational cohort study. SETTING Twenty-four-bed trauma step-down unit. PATIENTS Two thousand one hundred fifty-three patients. INTERVENTION Noninvasive vital sign monitoring data (heart rate, respiratory rate, peripheral oximetry) recorded on all admissions at 1/20 Hz, and noninvasive blood pressure less frequently, and partitioned data into training/validation (294 admissions; 22,980 monitoring hours) and test sets (2,057 admissions; 156,177 monitoring hours). Alerts were vital sign deviations beyond stability thresholds. A four-member expert committee annotated a subset of alerts (576 in training/validation set, 397 in test set) as real or artifact selected by active learning, upon which we trained machine-learning algorithms. The best model was evaluated on test set alerts to enact online alert classification over time. MEASUREMENTS AND MAIN RESULTS The Random Forest model discriminated between real and artifact as the alerts evolved online in the test set with area under the curve performance of 0.79 (95% CI, 0.67-0.93) for peripheral oximetry at the instant the vital sign first crossed threshold and increased to 0.87 (95% CI, 0.71-0.95) at 3 minutes into the alerting period. Blood pressure area under the curve started at 0.77 (95% CI, 0.64-0.95) and increased to 0.87 (95% CI, 0.71-0.98), whereas respiratory rate area under the curve started at 0.85 (95% CI, 0.77-0.95) and increased to 0.97 (95% CI, 0.94-1.00). Heart rate alerts were too few for model development. CONCLUSIONS Machine-learning models can discern clinically relevant peripheral oximetry, blood pressure, and respiratory rate alerts from artifacts in an online monitoring dataset (area under the curve > 0.87).
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Yue L, Plummer V, Cross W. The effectiveness of nurse education and training for clinical alarm response and management: a systematic review. J Clin Nurs 2017; 26:2511-2526. [PMID: 27685951 DOI: 10.1111/jocn.13605] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2016] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES To identify the effectiveness of education interventions provided for nurses for clinical alarm response and management. BACKGROUND Some education has been undertaken to improve clinical alarm response, but the evidence for evaluating effectiveness for nurse education interventions is limited. DESIGN Systematic review. METHODS A systematic review of experimental studies published in English from 2005-2015 was conducted in four computerised databases (MEDLINE, EMBASE, CINAHL and Scopus). After identification, screening and appraisal using Joanna Briggs Institute instruments, quality research papers were selected, data extraction and analysis followed. RESULTS Five studies met the inclusion criteria for alarm response and no articles were concerned with clinical alarm education for management. All had different types and methods of interventions and statistical pooling was not possible. Response accuracy, response time and perceptions were consistent when different interventions were adopted. A positive effect was identified when learning about general alarms, single alarms, sequential alarms and medium-level alarms for learning as the primary task. Nurses who were musically trained had a faster and more accurate alarm response. Simulation interventions had a positive effect, but the effect of education provided in the care unit was greater. Overall, clinical alarm awareness was improved through education activities. CONCLUSIONS Nurses are the main users of healthcare alarms and work in complex environments with high numbers of alarms, including nuisance alarms and other factors. Alarm-related adverse events are common. The findings of a small number of experimental studies with diverse evidence included consideration of various factors when formulating education strategies. The factors which influence effectiveness of nurse education are nurse demographics, nurse participants with musical training, workload and characteristics of alarms. Education interventions based in clinical practice settings increase education effectiveness, although simulation can be effective. No study shows any type of intervention results in sustained improvement. RELEVANCE TO CLINICAL PRACTICE There are workload implications in education and the matching of load, number and type of alarms with nurse demographics which should be evaluated. There also needs to be a connection between education and the clinical setting to contribute to clinical alarm awareness for undergraduate nurses and practicing nurses. Education solely supported by employers is insufficient. Patient safety and long-term effects must be further explored.
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Affiliation(s)
- Liqing Yue
- Central South University Xiangya School of Public Health, Supervisor Nurse Xiangya Hospital of Central South University, China
| | - Virginia Plummer
- Faculty of Medicine, Nursing and Health Science, Monash University, Frankston, Vic., Australia.,Peninsula Health, Frankston, Vic., Australia
| | - Wendy Cross
- Nursing and Allied Health, Faculty of Medicine, Nursing and Health Science, Monash University, Clayton, Vic., Australia
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Sowan AK, Reed CC, Staggers N. Role of Large Clinical Datasets From Physiologic Monitors in Improving the Safety of Clinical Alarm Systems and Methodological Considerations: A Case From Philips Monitors. JMIR Hum Factors 2016; 3:e24. [PMID: 27694097 PMCID: PMC5065678 DOI: 10.2196/humanfactors.6427] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 08/22/2016] [Accepted: 09/10/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Large datasets of the audit log of modern physiologic monitoring devices have rarely been used for predictive modeling, capturing unsafe practices, or guiding initiatives on alarm systems safety. OBJECTIVE This paper (1) describes a large clinical dataset using the audit log of the physiologic monitors, (2) discusses benefits and challenges of using the audit log in identifying the most important alarm signals and improving the safety of clinical alarm systems, and (3) provides suggestions for presenting alarm data and improving the audit log of the physiologic monitors. METHODS At a 20-bed transplant cardiac intensive care unit, alarm data recorded via the audit log of bedside monitors were retrieved from the server of the central station monitor. RESULTS Benefits of the audit log are many. They include easily retrievable data at no cost, complete alarm records, easy capture of inconsistent and unsafe practices, and easy identification of bedside monitors missed from a unit change of alarm settings adjustments. Challenges in analyzing the audit log are related to the time-consuming processes of data cleaning and analysis, and limited storage and retrieval capabilities of the monitors. CONCLUSIONS The audit log is a function of current capabilities of the physiologic monitoring systems, monitor's configuration, and alarm management practices by clinicians. Despite current challenges in data retrieval and analysis, large digitalized clinical datasets hold great promise in performance, safety, and quality improvement. Vendors, clinicians, researchers, and professional organizations should work closely to identify the most useful format and type of clinical data to expand medical devices' log capacity.
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Affiliation(s)
- Azizeh Khaled Sowan
- School of Nursing, Department of Health Restoration & Care Systems Management, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States.
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Paine CW, Goel VV, Ely E, Stave CD, Stemler S, Zander M, Bonafide CP. Systematic Review of Physiologic Monitor Alarm Characteristics and Pragmatic Interventions to Reduce Alarm Frequency. J Hosp Med 2016; 11:136-44. [PMID: 26663904 PMCID: PMC4778561 DOI: 10.1002/jhm.2520] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Revised: 10/01/2015] [Accepted: 10/06/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Alarm fatigue from frequent nonactionable physiologic monitor alarms is frequently named as a threat to patient safety. PURPOSE To critically examine the available literature relevant to alarm fatigue. DATA SOURCES Articles published in English, Spanish, or French between January 1980 and April 2015 indexed in PubMed, Cumulative Index to Nursing and Allied Health Literature, Scopus, Cochrane Library, Google Scholar, and ClinicalTrials.gov. STUDY SELECTION Articles focused on hospital physiologic monitor alarms addressing any of the following: (1) the proportion of alarms that are actionable, (2) the relationship between alarm exposure and nurse response time, and (3) the effectiveness of interventions in reducing alarm frequency. DATA EXTRACTION We extracted data on setting, collection methods, proportion of alarms determined to be actionable, nurse response time, and associations between interventions and alarm rates. DATA SYNTHESIS Our search produced 24 observational studies focused on alarm characteristics and response time and 8 studies evaluating interventions. Actionable alarm proportion ranged from <1% to 36% across a range of hospital settings. Two studies showed relationships between high alarm exposure and longer nurse response time. Most intervention studies included multiple components implemented simultaneously. Although studies varied widely, and many had high risk of bias, promising but still unproven interventions include widening alarm parameters, instituting alarm delays, and using disposable electrocardiographic wires or frequently changed electrocardiographic electrodes. CONCLUSIONS Physiologic monitor alarms are commonly nonactionable, and evidence supporting the concept of alarm fatigue is emerging. Several interventions have the potential to reduce alarms safely, but more rigorously designed studies with attention to possible unintended consequences are needed.
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Affiliation(s)
- Christine Weirich Paine
- Division of General Pediatrics, The Children’s Hospital of
Philadelphia
- PolicyLab, The Children’s Hospital of Philadelphia
| | - Veena V. Goel
- Department of Pediatrics, Stanford University School of
Medicine
- Division of Systems Medicine, Stanford University School of
Medicine
- Department of Clinical Informatics, Stanford Children’s
Health
- Division of Pediatric Hospital Medicine, Lucile Packard
Children’s Hospital Stanford
| | - Elizabeth Ely
- Center for Pediatric Nursing Research and Evidence-Based Practice,
The Children’s Hospital of Philadelphia
| | | | - Shannon Stemler
- Division of General Pediatrics, The Children’s Hospital of
Philadelphia
| | - Miriam Zander
- Division of General Pediatrics, The Children’s Hospital of
Philadelphia
| | - Christopher P. Bonafide
- Division of General Pediatrics, The Children’s Hospital of
Philadelphia
- Department of Biomedical and Health Informatics, The
Children’s Hospital of Philadelphia
- Center for Pediatric Clinical Effectiveness, The Children’s
Hospital of Philadelphia
- Department of Pediatrics, Perelman School of Medicine at the
University of Pennsylvania
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Cho OM, Kim H, Lee YW, Cho I. Clinical Alarms in Intensive Care Units: Perceived Obstacles of Alarm Management and Alarm Fatigue in Nurses. Healthc Inform Res 2016; 22:46-53. [PMID: 26893950 PMCID: PMC4756058 DOI: 10.4258/hir.2016.22.1.46] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 12/17/2015] [Accepted: 12/19/2015] [Indexed: 11/23/2022] Open
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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Affiliation(s)
- Ok Min Cho
- Department of Nursing, Inha University, Incheon, Korea
| | - Hwasoon Kim
- Department of Nursing, Inha University, Incheon, Korea
| | | | - Insook Cho
- Department of Nursing, Inha University, Incheon, Korea
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Sowan AK, Gomez TM, Tarriela AF, Reed CC, Paper BM. Changes in Default Alarm Settings and Standard In-Service are Insufficient to Improve Alarm Fatigue in an Intensive Care Unit: A Pilot Project. JMIR Hum Factors 2016; 3:e1. [PMID: 27036170 PMCID: PMC4797663 DOI: 10.2196/humanfactors.5098] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 10/15/2015] [Accepted: 10/16/2015] [Indexed: 11/30/2022] Open
Abstract
Background Clinical alarm systems safety is a national concern, specifically in intensive care units (ICUs) where alarm rates are known to be the highest. Interventional projects that examined the effect of changing default alarm settings on overall alarm rate and on clinicians’ attitudes and practices toward clinical alarms and alarm fatigue are scarce. Objective To examine if (1) a change in default alarm settings of the cardiac monitors and (2) in-service nursing education on cardiac monitor use in an ICU would result in reducing alarm rate and in improving nurses’ attitudes and practices toward clinical alarms. Methods This quality improvement project took place in a 20-bed transplant/cardiac ICU with a total of 39 nurses. We implemented a unit-wide change of default alarm settings involving 17 parameters of the cardiac monitors. All nurses received an in-service education on monitor use. Alarm data were collected from the audit log of the cardiac monitors 10 weeks before and 10 weeks after the change in monitors’ parameters. Nurses’ attitudes and practices toward clinical alarms were measured using the Healthcare Technology Foundation National Clinical Alarms Survey, pre- and postintervention. Results Alarm rate was 87.86 alarms/patient day (a total of 64,500 alarms) at the preintervention period compared to 59.18 alarms/patient day (49,319 alarms) postintervention (P=.01). At baseline, Arterial Blood Pressure (ABP), Pair Premature Ventricular Contractions (PVCs), and Peripheral Capillary Oxygen Saturation (SpO2) alarms were the highest. ABP and SpO2 alarms remained among the top three at the postproject period. Out of the 39 ICU nurses, 24 (62%) provided complete pre- and postproject survey questionnaires. Compared to the preintervention survey, no remarkable changes in the postproject period were reported in nurses’ attitudes. Themes in the narrative data were related to poor usability of cardiac monitors and the frequent alarms. The data showed great variation among nurses in terms of changing alarm parameters and frequency of replacing patients' electrodes. Despite the in-service, 50% (12/24) of the nurses specified their need for more training on cardiac monitors in the postproject period. Conclusions Changing default alarm settings and standard in-service education on cardiac monitor use are insufficient to improve alarm systems safety. Alarm management in ICUs is very complex, involving alarm management practices by clinicians, availability of unit policies and procedures, unit layout, complexity and usability of monitoring devices, and adequacy of training on system use. The complexity of the newer monitoring systems requires urgent usability testing and multidimensional interventions to improve alarm systems safety and to attain the Joint Commission National Patient Safety Goal on alarm systems safety in critical care units.
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Affiliation(s)
- Azizeh Khaled Sowan
- Department of Health Restoration and Care Systems Management, School of Nursing, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States.
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Sendelbach S, Wahl S, Anthony A, Shotts P. Stop the Noise: A Quality Improvement Project to Decrease Electrocardiographic Nuisance Alarms. Crit Care Nurse 2015; 35:15-22; quiz 1p following 22. [DOI: 10.4037/ccn2015858] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUNDAs many as 99% of alarm signals may not need any intervention and can result in patients’ deaths. Alarm management is now a Joint Commission National Patient Safety Goal.OBJECTIVESTo reduce the number of nuisance electrocardiographic alarm signals in adult patients on the medical cardiovascular care unit.METHODSA quality improvement process was used that included eliminating duplicative alarms, customizing alarms, changing electrocardiography electrodes daily, standardizing skin preparation, and using disposable electrocardiography leads.RESULTSIn the cardiovascular care unit, the mean number of electrocardiographic alarm signals per day decreased from 28.5 (baseline) to 3.29, an 88.5% reduction.CONCLUSIONUse of a bundled approach to managing alarm signals decreased the mean number of alarm signals in a cardiovascular care unit. (Critical Care Nurse. 2015;35[4]:15–23)
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Affiliation(s)
- Sue Sendelbach
- Sue Sendelbach is director of nursing research at Abbott Northwestern Hospital, Minneapolis, Minnesota, and is on the Association of the Advancement of Medical Instrumentation’s committee on alarm management/alarm fatigue
| | - Sharon Wahl
- Sharon Wahl is a cardiovascular clinical nurse specialist at Abbott Northwestern Hospital and has facilitated several projects on alarm management within the critical care patient care units
| | - Anita Anthony
- Anita Anthony is a clinical nurse specialist and at the time of the project worked in the progressive care unit at Abbott Northwestern Hospital. She is now at University of Minnesota Medical Center in Minneapolis
| | - Pam Shotts
- Pamela Shotts is a quality specialist and manages the data for the alarm management project at Abbott Northwestern Hospital
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Bonafide CP, Lin R, Zander M, Graham CS, Paine CW, Rock W, Rich A, Roberts KE, Fortino M, Nadkarni VM, Localio AR, Keren R. Association between exposure to nonactionable physiologic monitor alarms and response time in a children's hospital. J Hosp Med 2015; 10:345-51. [PMID: 25873486 PMCID: PMC4456276 DOI: 10.1002/jhm.2331] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Revised: 11/25/2014] [Accepted: 12/07/2014] [Indexed: 01/17/2023]
Abstract
BACKGROUND Alarm fatigue is reported to be a major threat to patient safety, yet little empirical data support its existence in the hospital. OBJECTIVE To determine if nurses exposed to high rates of nonactionable physiologic monitor alarms respond more slowly to subsequent alarms that could represent life-threatening conditions. DESIGN Observational study using video. SETTING Freestanding children's hospital. PATIENTS Pediatric intensive care unit (PICU) patients requiring inotropic support and/or mechanical ventilation, and medical ward patients. INTERVENTION None. MEASUREMENTS Actionable alarms were defined as correctly identifying physiologic status and warranting clinical intervention or consultation. We measured response time to alarms occurring while there were no clinicians in the patient's room. We evaluated the association between the number of nonactionable alarms the patient had in the preceding 120 minutes (categorized as 0-29, 30-79, or 80+ alarms) and response time to subsequent alarms in the same patient using a log-rank test that accounts for within-nurse clustering. RESULTS We observed 36 nurses for 210 hours with 5070 alarms; 87.1% of PICU and 99.0% of ward clinical alarms were nonactionable. Kaplan-Meier plots showed incremental increases in response time as the number of nonactionable alarms in the preceding 120 minutes increased (log-rank test stratified by nurse P < 0.001 in PICU, P = 0.009 in the ward). CONCLUSIONS Most alarms were nonactionable, and response time increased as nonactionable alarm exposure increased. Alarm fatigue could explain these findings. Future studies should evaluate the simultaneous influence of workload and other factors that can impact response time.
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Affiliation(s)
- Christopher P. Bonafide
- Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Richard Lin
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Miriam Zander
- Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Christine W. Paine
- Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Whitney Rock
- Department of Biomedical Engineering, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Andrew Rich
- Department of Biomedical Engineering, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Kathryn E. Roberts
- Department of Nursing, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Margaret Fortino
- Department of Nursing, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Vinay M. Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - A. Russell Localio
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Ron Keren
- Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Rayo MF, Moffatt-Bruce SD. Alarm system management: evidence-based guidance encouraging direct measurement of informativeness to improve alarm response. BMJ Qual Saf 2015; 24:282-6. [PMID: 25734193 DOI: 10.1136/bmjqs-2014-003373] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Although there are powerful incentives for creating alarm management programmes to reduce 'alarm fatigue', they do not provide guidance on how to reduce the likelihood that clinicians will disregard critical alarms. The literature cites numerous phenomena that contribute to alarm fatigue, although many of these, including total rate of alarms, are not supported in the literature as factors that directly impact alarm response. The contributor that is most frequently associated with alarm response is informativeness, which is defined as the proportion of total alarms that successfully conveys a specific event, and the extent to which it is a hazard. Informativeness is low across all healthcare applications, consistently ranging from 1% to 20%. Because of its likelihood and strong evidential support, informativeness should be evaluated before other contributors are considered. Methods for measuring informativeness and alarm response are discussed. Design directions for potential interventions, as well as design alternatives to traditional alarms, are also discussed. With the increased attention and investment in alarm system management that alarm interventions are currently receiving, initiatives that focus on informativeness and the other evidence-based measures identified will allow us to more effectively, efficiently and reliably redirect clinician attention, ultimately improving alarm response.
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Affiliation(s)
- Michael F Rayo
- Department of Quality and Patient Safety, The Ohio State University, Columbus, Ohio, USA
| | - Susan D Moffatt-Bruce
- Department of Thoracic Surgery, College of Medicine, The Ohio State University, Columbus, Ohio, USA
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Jarvis S, Kovacs C, Briggs J, Meredith P, Schmidt PE, Featherstone PI, Prytherch DR, Smith GB. Aggregate National Early Warning Score (NEWS) values are more important than high scores for a single vital signs parameter for discriminating the risk of adverse outcomes. Resuscitation 2015; 87:75-80. [DOI: 10.1016/j.resuscitation.2014.11.014] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 11/11/2014] [Accepted: 11/19/2014] [Indexed: 01/19/2023]
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