Reducing False Alarms and Alarm Fatigue from Pulse Oximeters in a Neonatal Care Unit: A Quality Improvement Study

Abstract

Background: Pulse oximeters play a vital role in monitoring sick newborns, but majority of the times, their alarms are of little clinical significance. False alarms from pulse oximeters were frequent in our neonatal intensive care unit, causing desensitization of staff and inattention to clinically important alarms. Objectives: The objective of the study was to reduce the burden of false alarms and alarm fatigue. Methods: This was a quality improvement (QI) study. During the baseline phase, alarms for heart rate and SPO2 (percentage of oxygenated blood) were evaluated. Response to them within 30 s was checked. Major causes of false alarms were the movement of the newborns, inappropriate alarm limits, and loose probe. Fishbone chart was prepared, and Plan-Do-Study-Act (PDSA) model was designed using point of care quality improvement (POCQI) principles. During the first PDSA (implementation phase), the staff was trained to adjust alarm limits using the reference chart. A lecture on noise hazards, emphasis on muting the alarms, and advice to change probe site at beginning of their duty was given. In the second PDSA (sustenance phase), components of the first PDSA were strengthened by supportive supervision and guidance and the training of new staff. Results: Total 494, 329, and 162 alarms were observed during baseline, implementation, and sustenance phases, respectively. In the baseline phase majority, 364 (73.7%) were false alarms, which occurred at a frequency of 0.39 alarms/patient/h. More than one-third of the alarms were not responded timely. After QI, false alarms reduced to 214 (65%; 0.22 alarms/patient/h) and 100 (61.7%; 0.16 alarms/patient/h) in implementation and sustenance phases, respectively. Response to true alarms improved from 101 (77.7%) to 104 (90.4%) to 62 (100%) during the 3 phases consecutively. Conclusion: Frequent false alarms lead to desensitization of health care workers. POCQI principles can be a practical approach for reducing false alarms and improving alarm safety.