Chapter 53 - Sex differences in intensive care unit electrocardiographic alarms

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Multiparameter physiologic monitoring, including electrocardiographic (ECG) monitoring, in the intensive care unit (ICU) remains unsatisfactory as evidenced by the well-known alarm fatigue problem. For example, in one study, a single ICU patient generated over 700 alarms per day. At our institution, an average of 187 audible alarms were generated in our ICU per bed per day during a 1-month assessment. Of note, 88.8% of the audible ECG arrhythmia alarms were determined to be false. Alarm fatigue occurs when clinicians, mainly nurses since they are typically responsible for bedside ECG monitoring, are desensitized by frequent alarms, most of which are false or do not require a clinical action (i.e., “nuisance” alarms). In 2010, excessive alarm burden was identified as a significant patient safety concern in the public arena, following the death of a patient who was being monitored at a prestigious medical center. Despite multiple heart rate alarms for bradycardia that occurred prior to the patient's cardiac arrest, no one working on the unit that day recalled hearing the alarms. In the investigation that followed, the Centers for Medicare and Medicaid Services reported: “Nurses not recalling hearing low heart rate alarms and adjustments made to alarm volume was indicative was indicative of alarm fatigue, and contributed to the patient's death.”. The most recent data from the past 5years show that alarm fatigue was responsible for over 650 hospital deaths, a number believed to be a substantial underrepresentation because of non- or under-reporting. Over time, clinicians/nurses learn to deal with alarm fatigue by: (1) assimilating alarm noise into their workflow; which can lead to an alarm(s) being unintentionally missed; (2) silencing alarms without assessing the patient; (3) lowering the alarm volume; (4) permanently disabling alarms; and/or (5) delaying a response to an alarm. These actions place patients at risk for serious adverse events, including death, because true alarms are missed. While clinicians/nurses experience alarm fatigue from repeated exposure to alarms, patients are subjected to both psychological (i.e., fear, sleep deprivation, delirium) and physiological (i.e., increased heart rate, blood pressure) stresses from alarm noise. Patients also report being frightened by frequent alarms that often go unanswered.