Understanding Clinical Alarm Safety

Assessment of Remote Vital Sign Monitoring and Alarms in a Real-World Healthcare at Home Dataset

The importance of vital sign monitoring to detect deterioration increases during healthcare at home. Continuous monitoring with wearables increases assessment frequency but may create information overload for clinicians. The goal of this work was to demonstrate the impact of vital sign observation frequency and alarm settings on alarms in a real-world dataset. Vital signs were collected from 76 patients admitted to healthcare at home programs using the Current Health (CH) platform; its wearable continuously measured respiratory rate (RR), pulse rate (PR), and oxygen saturation (SpO₂). Total alarms, alarm rate, patient rate, and detection time were calculated for three alarm rulesets to detect changes in SpO₂, PR, and RR under four vital sign observation frequencies and four window sizes for the alarm algorithms' median filter. Total alarms ranged from 65 to 3113. The alarm rate and early detection increased with the observation frequency for all alarm rulesets. Median filter windows reduced alarms triggered by normal fluctuations in vital signs without compromising the granularity of time between assessments. Frequent assessments enabled with continuous monitoring support early intervention but need to pair with settings that balance sensitivity, specificity, clinical risk, and provider capacity to respond when a patient is home to minimize clinician burden.

Reducing Cardiac Telemetry Nuisance Alarms Through Evidence-Based Interventions

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.

Frequency of Clinical Alarms in Intensive Care Units and Nurses' Sensitivity to Them: An Observational Study

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.

Impact of Hospital Nurses' Perception on Clinical Alarms and Patient Safety Culture on Alarm Management Practice

This study aimed to identify the impact of nurses' perception of clinical alarms and patient safety culture on alarm management. Additionally, we aimed to describe the importance of clinical alarm issues. The data were collected from 21 August to 10 September 2020. The study participants were 116 nurses working in a tertiary acute care hospital in Korea. The self-report questionnaire included general characteristics, clinical alarm issues, nurses' alarm perception, patient safety culture, and alarm management practice. The mean age of nurses was 28.04 ± 4.06 years, with 5.71 ± 4.35 years of total clinical experience. For the importance of alarm issues, frequent false alarms leading to reduced attention or response was the most important issue. Hierarchical linear regression analysis revealed that a higher level of nurses' perceived patient safety culture was the strongest predictor of better alarm management practice (p < 0.001), followed by their perception of clinical alarms (p = 0.034). In addition, female nurses (p = 0.004), charge nurses (p = 0.013), and nurses who work less than 40 h per week (p = 0.008) were more likely to work better in alarm management practice. Future studies are needed to develop standardized alarm management guidelines by improving nurses' positive perceptions of clinical alarms and patient safety culture.

Team-Based Intervention to Reduce the Impact of Nonactionable Alarms in an Adult Intensive Care Unit

BACKGROUND

Nonactionable alarms comprise over 70% of alarms and contribute a threat to patient safety. Few studies have reported approaches to translate and sustain these interventions in clinical settings.

PURPOSE

This study tested whether an interprofessional team-based approach can translate and implement effective alarm reduction interventions in the adult intensive care unit.

METHODS

The study was a prospective, cohort, pre- and postdesign with repeated measures at baseline (preintervention) and post-phase I and II intervention periods. The settings for the most prevalent nonactionable arrhythmia and bedside parameter alarms were adjusted during phases I and II, respectively.

RESULTS

The number of total alarms was reduced by 40% over a 14-day period after both intervention phases were implemented. The most prevalent nonactionable parameter alarms decreased by 47% and arrhythmia alarms decreased by 46%.

CONCLUSIONS

It is feasible to translate and sustain system-level alarm management interventions addressing alarm fatigue using an interprofessional team-based approach.

Rethinking Clinical Workflow

The concept of clinical workflow borrows from management and leadership principles outside of medicine. The only way to rethink clinical workflow is to understand the neuroscience principles that underlie attention and vigilance. With any implementation to improve practice, there are human factors that can promote or impede progress. Modulating the environment and working as a team to take care of patients is paramount. Clinicians must continually rethink clinical workflow, evaluate progress, and understand that other industries have something to offer. Then, novel approaches can be implemented to take the best care of patients.

Measurement of Physiological Monitor Alarm Accuracy and Clinical Relevance in Intensive Care Units

BACKGROUND

Alarm fatigue threatens patient safety by delaying or reducing clinician response to alarms, which can lead to missed critical events. Interventions to reduce alarms without jeopardizing patient safety target either inaccurate or clinically irrelevant alarms, so assessment of alarm accuracy and clinical relevance may enhance the rigor of alarm intervention studies done in clinical units.

OBJECTIVES

To (1) examine approaches used to measure accuracy and/or clinical relevance of physiological monitor alarms in intensive care units and (2) compare the proportions of inaccurate and clinically irrelevant alarms.

METHODS

An integrative review was used to systematically search the literature and synthesize resulting articles.

RESULTS

Twelve studies explicitly measuring alarm accuracy and/or clinical relevance on a clinical unit were identified. In the most rigorous studies, alarms were annotated retrospectively by obtaining alarm data and parameter waveforms rather than being annotated in real time. More than half of arrhythmia alarms in recent studies were inaccurate. However, contextual data were needed to determine alarms' clinical relevance. Proportions of clinically irrelevant alarms were high, but definitions of clinically irrelevant alarms often included inaccurate alarms.

CONCLUSIONS

Future studies testing interventions on clinical units should include alarm accuracy and/or clinical relevance as outcome measures. Arrhythmia alarm accuracy should improve with advances in technology. Clinical interventions should focus on reducing clinically irrelevant alarms, with careful consideration of how clinical relevance is defined and measured.

Research in Review: Driving Critical Care Practice Change

During the past year, studies were published that will lead to practice change, address challenges at the bedside, and introduce new care strategies. This article summarizes some of this important work and considers it in the context of previous research and practice. Examples of research-based practice changes include the performance and assessment of septic shock resuscitation, and the integration of tourniquets and massive transfusions in civilian trauma. Care challenges addressed include ethical considerations in light of the Ebola epidemic, infection prevention associated with chlorhexidine bathing, bedside alarm management, evidence to enhance moral courage, and interventions to mitigate thirst in critically ill patients. Research that portends future care includes a discussion of fecal microbiota transplant for patients with refractory infection with refractory infection with Clostridium difficile.