Clinical Alarms Research Articles

Developing a Clinical Alarms Management Committee at an Academic Medical Center.

Developing a Clinical Alarms Management Committee at an Academic Medical Center.

A Roundtable Discussion: Navigating the Noise with Clinical Alarm Management.

A Roundtable Discussion: Navigating the Noise with Clinical Alarm Management.

중환자실에서 사용되는 의료장비의 경보음 발생과 관리 현황

Purpose: This study aimed to investigate the clinical alarm occurrence and management of nurses toward clinical alarms in the intensive care unit (ICU). Methods: This observational study was conducted with 40 patients and nurses cases in two ICUs of a university hospital. This study divided 24 hours into the unit of an hour and conducted two times of direct observation per unit hour for 48 hours targeting the medical devices applied to 40 patients. Data were analyzed using IBM SPSS Statistics 23. Results: On average, 3.8 units of medical devices were applied for each patient and the ranges of alarm settings were wide. During 48 hours, 184 cases of clinical alarm were occurred by four types of medical devices including physiological monitors, mechanical ventilators, infusion pumps, and continuous renal replacement therapy. Among them, false alarm was 110 cases (59.8%). As for the alarm management by ICU nurses, two-minute alarm mute took up most at 38.0% (70 cases), and no response was second most at 32.6% (60 cases). When valid alarm sounded, nurses showed no response at 43.2%. Conclusion: The findings suggest that a standard protocol for alarm management should be developed for Korean ICU settings. Based on the protocol, continuous training and education should be provided to nurses for appropriate alarm management. Key Words: Clinical alarm; Intensive care unit; Medical device; Observation Key Words: 경보음; 중환자실; 의료장비; 관찰

Assessment of Clinical Alarms Influencing Nurses' Perceptions of Alarm Fatigue.

Excessive clinical alarms have inundated health care for years. Multiple governing bodies, organizations, and facilities have deemed alarm management a priority. Alarm management is a multifaceted problem that affects all health care organizations and clinical staff, especially those in critical care units. Ultimately, the lack of knowledge regarding nurses' perceptions to alarm management and alarm fatigue creates patient safety chiasms. The purpose of this quality improvement project was to understand nurses' perceptions of alarm fatigue (utilizing the Healthcare Technology Foundation's Clinical Alarms Committee Survey) while implementing interventions that improve patient safety. The design of this qualitative study is an electronically distributed survey to 31 nurses who work in critical care. The Healthcare Technology Foundation clinical alarms survey has 36 questions with various answering strategies distributed (with permission) via e-mail access by BlueQ through Creighton University. Twenty-six respondents (n = 26) completed the survey, with 42% being intensive care unit nurses and 58% being progressive care unit nurses. The majority of nurses (n = 23, 88%) agreed that nuisance alarms occur frequently and disrupt patient care (n = 25, 96%). A lack of standardized method was noted to alarm management and parameter changes. Multiple patterns emerged that initiated the need for further examination and improvement. Following the survey, themes emerged, and changes were implemented including the following: an alarm management policy was created, tools were provided to staff for easy usage, staff were educated using hands-on practice at an annual training summit, and sustainability was created through continuation of alarm management assessment and improvement.

Data-Driven Implementation of Alarm Reduction Interventions in a Cardiovascular Surgical ICU

Alarm fatigue in the ICU setting has been well documented in the literature. The ICU's high-intensity environment requires staff's vigilant attention, and distraction from false and non-actionable alarms pulls staff away from important tasks, creates dissatisfaction, and is a potential patient safety risk if alarms are missed or ignored. This project was intended to improve patient safety by optimizing alarm systems in a cardiovascular surgical intensive care unit (CVSICU). Specific aims were to examine nurses' attitudes toward clinical alarm signals, assess nurses' ability to discriminate audible alarm signals, and implement a bundled set of best practices for monitor alarm reduction without undermining patient safety. CVSICU nurses completed an alarm perception survey and participated in alarm discriminability testing. Nurse survey data and baseline monitor alarm data were used to select targeted alarm reduction interventions, which were progressively phased in. Monitor alarm data and cardiorespiratory event data were trended over one year. Five of the most frequent CVSICU monitor alarm types-pulse oximetry, heart rate, systolic and diastolic blood pressure, pulse oximetry sensor, and ventricular tachycardia > 2-were targeted. After implementation, there was a 61% reduction in average alarms per monitored bed and a downward trend in cardiorespiratory events. To reduce alarm fatigue it is important to decrease alarm burden through targeted interventions. Methods to reduce non-actionable alarms include adding short delays to allow alarm self-correction, adjusting default alarm threshold limits, providing alarm notification through a secondary device, and teaching staff to optimize alarm settings for individual patients.

Wearable IMU-based real-time motion warning system for construction workers' musculoskeletal disorders prevention

Abstract The prevalent work-related musculoskeletal disorders (WMSDs) around lower back and neck amongst construction workers are precursors of operational injury in the construction industry. As a significant risk factor of WMSDs, time spent in insecure operational postures should be proactively prevented. This study developed a real-time motion warning personal protective equipment (PPE) that enables workers' self-awareness and self-management of ergonomically hazardous operational pattern for the prevention of WMSDs based on wearable Inertial Measurement Units (WIMUs). Data processing and real-time warning algorithms are proposed for automatically risk postures assessment and warning through a connected smartphone application as soon as dangerous operational patterns are detected. The system was tested and validated with robust clinical motion data output and effective alarm ringing in both laboratory and field experiments on a construction site in Hong Kong. The proposed PPE provides an alternative to help construction workers prevent WMSDs without disturbance and distraction in operations.

Role of Large Clinical Datasets From Physiologic Monitors in Improving the Safety of Clinical Alarm Systems and Methodological Considerations: A Case From Philips Monitors.

BackgroundLarge 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.ObjectiveThis 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.MethodsAt 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.ResultsBenefits 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.ConclusionsThe 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.

Defeating information overload in health surveillance using a metacognitive aid innovation from military combat systems

Modern sensors for health surveillance generate high volumes and rates of data that currently overwhelm operational decision-makers. These data are collected with the intention of enabling front-line clinicians to make effective clinical judgments. Ironically, prior human–systems integration (HSI) studies show that the flood of data degrades rather than aids decision-making performance. Health surveillance operations can focus on aggregate changes to population health or on the status of individual people. In the case of clinical monitoring, medical device alarms currently create an information overload situation for front-line clinical workers, such as hospital nurses. Consequently, alarms are often missed or ignored, and an impending patient adverse event may not be recognized in time to prevent crisis. One innovation used to improve decision making in areas of data-rich environments is the Human Alerting and Interruption Logistics (HAIL) technology, which was originally sponsored by the US Office of Naval Research. HAIL delivers metacognitive HSI services that empower end-users to quickly triage interruptions and dynamically manage their multitasking. HAIL informed our development of an experimental prototype that provides a set of context-enabled alarm notification services (without automated alarm filtering) to support users’ metacognition for information triage. This application is called HAIL Clinical Alarm Triage (HAIL-CAT) and was designed and implemented on a smartwatch to support the mobile multitasking of hospital nurses. An empirical study was conducted in a 20-bed virtual hospital with high-fidelity patient simulators. Four teams of four registered nurses (16 in total) participated in a 180-minute simulated patient care scenario. Each nurse was assigned responsibility to care for five simulated patients and high rates of simulated health surveillance data were available from patient monitors, infusion pumps, and a call light system. Thirty alarms per nurse were generated in each 90-minute segment of the data collection sessions, only three of which were clinically important alarms. The within-subjects experimental design included a treatment condition where the nurses used HAIL-CAT on a smartwatch to triage and manage alarms and a control condition without the smartwatch. The results show that, when using the smartwatch, nurses responded three times faster to clinically important and actionable alarms. An analysis of nurse performance also shows no negative effects on their other duties. Subjective results show favorable opinions about utility, usability, training requirement, and adoptability. These positive findings suggest the potential for the HAIL HSI system to be transferrable to the domain of health surveillance to achieve the currently unrealized potential utility of high-volume data.

False alarms during patient monitoring in clinical intensive care units are highly related to poor quality of the monitored electrocardiogram signals

Electrocardiograms (ECGs) recorded from patients in intensive care were investigated to quantify any relationship between ECG signal quality and false monitoring alarms. False alarms are a considerable problem for nursing and medical staff as they distract from clinical care, and are also a problem for patients as they disturb rest, which is important for clinical recovery. ECG and alarm data were obtained for 750 patient alarms from the PhysioNet database. The final 8 s period before the alarm was triggered was investigated. All but one ECG channel in 38 ECG recordings with out-of-range data were associated with false positive alarms (p < 0.0001). The frequency contributions for baseline (BL) instability, electromyogram (EMG) muscle noise, and high frequency (HF) noise were calculated. For all three frequency bands, the contributions associated with false positive alarms were very significantly greater than for true positive alarms (p < 0.0001). The greatest difference was for BL with a mean level for false positive alarms 4.0 times greater than for true positive alarms, followed by EMG and HF at 1.6 times and 1.4 times respectively. These results confirm that attention needs to be taken to improve ECG signal quality to reduce the frequency of clinical false alarms, and hence improve conditions for clinical staff and patients.

Analysis of the Clinicopathological Characteristics of Gastric Cancer in Extremely Old Patients.

PurposeGastric cancer is the third-leading cause of cancer-related death in Korea. As the Korean population is ageing, the number of extremely old patients with this disease is increasing. This study examined the clinicopathological characteristics of gastric cancer in extremely old (over 85 years) patients who received treatment or conservative observations and compared the treatment outcomes according to the treatment modality.Materials and MethodsA total of 170 patients over 85 years of age were diagnosed with gastric cancer. Of these, 81 underwent treatment for gastric cancer and 89 received conservative observations. The clinicopathological characteristics of the treatment and conservative groupswere compared.ResultsThe mean age of the patients was 86.5 years. The conservative group included significantly more patients with older ages, macroscopically advanced cancer and upper-middle located cancer. The overall survival rate of the treatment group was significantly higher than that of the conservative group. The disease-specific mortality rate was significantly lower in the treatment group than in the conservative group. Multivariate analysis revealed the clinical course, alarm sign, and macroscopic classification to be independent prognosis factors.ConclusionBy itself, the chronological age should not be used as a strategy to determine whether treatmentwill be administered for gastric cancer. Patients who have early gastric cancer or lower-risk preexisting comorbidities should not be discouraged from treatment, even if they are older than 85 years.

Alarme noturno e enurese: uma revisão baseada na evidência

Introduction: Nocturnal enuresis is a common problem, affecting about 15% of children between the ages of five and six years. Different treatments have been studied in order to diminish the potentially stigmatizing impact of NE, both for the child and the family. These include nocturnal alarms and behavior modification affecting sleep. Aim: The aim of this review was to assess the evidence for the effectiveness of nocturnal alarms in the treatment of nocturnal enuresis. Methods: A bibliographic review of international databases was conducted, using the MeSH terms ‘Nocturnal enuresis’ AND ‘Clinical alarms’. We also consulted the Index RMP database using the search terms Enurese noturna and Alarme. We selected meta-analyses, systematic reviews, randomized controlled trials, observational studies, and clinical guidelines written in Portuguese and English that were published between January 2005 and January 2015. The Oxford Centre for Evidence-Based Medicine criteria were used to establish the Level of Evidence (LE). Results: From a total of 52 articles found, nine met the inclusion criteria. These included three systematic reviews, three clinical trials, and three guidelines. Most studies found that NA is more beneficial than other non-pharmacologic options. When compared to desmopressin, the use of NA has shown equivalent effectiveness. Its use is associated with less risk of relapse and a better response when NE occurs due to diminished nocturnal bladder capacity. However, beneficial results take longer to appear with NA, parental collaboration is needed, and there is a risk of decreased adherence to this treatment. Clinical guidelines agree with the results of published trials. Discussion: Given the potential benefits of nocturnal alarms in the treatment of nocturnal enuresis (Level of Evidence 1, Strength of Recommendation A), the family doctor should consider this treatment for NE resistant to initial measures, thus avoiding the need for pharmacologic intervention or premature referral.

Death by alarm: An error model of hospital alarms

On any given day in the United States, there are about 480,000 patients in hospital for reasons other than psychiatric care or rehabilitation, each generating, on average, about 135 clinical alarms per day. Studies have shown that over 90% of these alarms result in no action being taken. Alarm errors, either alarms that sound and receive no response or alarms that fail to sound when they should, number roughly 8 million per day yet data on adverse alarm impacts indicate about 200 alarm-related deaths per year and a total of a little more than 500 adverse impacts per year. A compelling conclusion from this data is that clinical alarms in hospital are very inefficient and ineffective tools for monitoring medical emergencies. Much attention has been dedicated to alarms recently, with the general goal of improving response to alarms in order to ensure no medical emergency is missed. While this work is of immediate use and is vitally important to the operation of the modern hospital, it focuses on minor changes to the existing systems rather than on trying to design the optimum system for the future. It is future alarm systems that we consider here, with an aim of designing a more effective and efficient system for use in hospitals in roughly 20 years.

Room acoustic design, measurement, and simulation techniques to reduce hospital noises within patients' environment

Hospitalized patients and clinical staff identify noise as a major stressor. Environmental hospital noise raises ambient noise levels significantly above ideal levels. Options to reduce hospital noise include methods to modify noise, such as closing doors, adjusting hospital equipment, hospital personnel behaviors, and clinical alarms such as wireless communication devices for staff and future “smart” algorithms for patient-specific alarm thresholds. This study utilizes the beamforming techniques to localize and examines basic characteristic of sound field through measurements and simulation of noise in an environment that affects the patient’s audio perception, and collects evidence for impact of noise intensity on patient hearing toward reduction of the noise sources in hospital rooms. The profiles of noise levels for their time and frequency domain as being reflected, absorbed, or refracted within typical patient’s room are determined. The difference in applications of various architectural solutions to mitigate noise in hospitals within patient environment is estimated. The results contribute toward architectural room acoustic design solution(s) to reduce acoustic disruption of sleep or rest with adequate information and reproducible data to accelerate design decision-making process while providing practical solutions such as geometric modification to room architectural elements as compared to theoretical offerings by the research community.

NURSES’ KNOWLEDGE IN THE MANAGEMENT OF CLINICAL ALARMS IN THE CRITICAL CARE UNIT OF A TERTIARY HOSPITAL, A CROSS-SECTIONAL STUDY

Background: In low and middle income countries like Kenya, nurses are overworked as the nurse to patient ratio is not as stipulated by the World Health Organization (WHO). In this sense clinical alarms are important as they are able to alert the nurses in the critical care units or other areas of the hospital on the change in the patient’s condition. Nurses therefore need to be knowledgeable about alarms so as to manage patients effectively. &#x0D; Methods: A descriptive cross-sectional study was carried out in the month of June 2014 where 87 nurses were recruited as study participants. A structured self-administered questionnaire was used to collect data. Chi square and Cramer’s V were used to calculate relationship between the variables. &#x0D; Results: Out of 87 respondents, 71.7% (62) were females and 27.6% (25) were males. The respondents responded to seven questions borrowed from an online Continuous Professional Development (CPD) program by the American Association for Respiratory Care (AACR) program on continuing education and scored 69% on average. There was a statistically significant association (p=0.049) between the question on knowledge, “Wiping electrodes with a rough washcloth or gauze and or using sandpaper on the electrode prevents spurious signals and helps to remove part of the stratum corneum allowing electrical signals to travel” and years worked in the critical care unit. The nurses who had worked in CCU for more than five years scored the highest (48.5%) whilst the ones who had worked in CCU for more than ten years scored the least (23.1%). &#x0D; Discussion: There is a deficit in knowledge on the management of clinical alarms, effective assessment and training on management of clinical alarms is necessary. Protocols and policies on alarm management need to be developed.

Clinical Issues—March 2016

This MonthIncreasing ambient room temperatureKey words: OR temperature, core temperature, unplanned hypothermia, ambient room temperature, thermoregulation.Clinical alarm managementKey words: alarm fatigue, clinical alarms, alert alarms.

Changes in Default Alarm Settings and Standard In-Service are Insufficient to Improve Alarm Fatigue in an Intensive Care Unit: A Pilot Project.

BackgroundClinical 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.ObjectiveTo 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.MethodsThis 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.ResultsAlarm 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.ConclusionsChanging 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.

Clinical Alarms in Intensive Care Units: Perceived Obstacles of Alarm Management and Alarm Fatigue in Nurses.

ObjectivesThe 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.MethodsSubjects 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.ResultsOverall 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".ConclusionsNurses 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.

Alarm fatigue: impacts on patient safety.

Electronic medical devices are an integral part of patient care. As new devices are introduced, the number of alarms to which a healthcare professional may be exposed may be as high as 1000 alarms per shift. The US Food and Drug Administration has reported over 500 alarm-related patient deaths in five years. The Joint Commission, recognizing the clinical significance of alarm fatigue, has made clinical alarm management a National Patient Safety Goal. Potential solutions to alarm fatigue include technical, organizational, and educational interventions. Selecting only the right monitors (i.e., avoiding overmonitoring), judicious selection of alarm limits, and multimodal alarms can all reduce the number of nuisance alarms to which a healthcare worker is exposed. Alarm fatigue can jeopardize safety, but some clinical solutions such as setting appropriate thresholds and avoiding overmonitoring are available.

A two-stage clinical decision support system for early recognition and stratification of patients with sepsis: an observational cohort study.

ObjectiveTo examine the diagnostic accuracy of a two-stage clinical decision support system for early recognition and stratification of patients with sepsis.DesignObservational cohort study employing a two-stage sepsis clinical decision support to recognise and stratify patients with sepsis. The stage one component was comprised of a cloud-based clinical decision support with 24/7 surveillance to detect patients at risk of sepsis. The cloud-based clinical decision support delivered notifications to the patients’ designated nurse, who then electronically contacted a provider. The second stage component comprised a sepsis screening and stratification form integrated into the patient electronic health record, essentially an evidence-based decision aid, used by providers to assess patients at bedside.SettingUrban, 284 acute bed community hospital in the USA; 16,000 hospitalisations annually.ParticipantsData on 2620 adult patients were collected retrospectively in 2014 after the clinical decision support was implemented.Main outcome measure‘Suspected infection’ was the established gold standard to assess clinical decision support clinimetric performance.ResultsA sepsis alert activated on 417 (16%) of 2620 adult patients hospitalised. Applying ‘suspected infection’ as standard, the patient population characteristics showed 72% sensitivity and 73% positive predictive value. A postalert screening conducted by providers at bedside of 417 patients achieved 81% sensitivity and 94% positive predictive value. Providers documented against 89% patients with an alert activated by clinical decision support and completed 75% of bedside screening and stratification of patients with sepsis within one hour from notification.ConclusionA clinical decision support binary alarm system with cross-checking functionality improves early recognition and facilitates stratification of patients with sepsis.

Nurses' Perspectives on Clinical Alarms

Alarm hazards are a critical issue in patient safety. Of all health care providers, nurses are the ones most directly affected by the multitude of clinical alarms. To qualitatively explore nurses' experiences with clinical alarms. The Krippendorff method for content analysis was used to analyze comments provided by 406 nurses in a national survey on perceptions of clinical alarms. Six interrelated themes emerged: dissonance and desensitization; pollution, panic, and pathology; calling for accountability; calling for authority of nurses; clinical alarm management is crucial but not a panacea; and hope for the future. Nurses are concerned about the impact of alarm fatigue on nurses and patients, recognize the importance of nurses' role in reducing noise pollution, and offer valuable insight into strategies that can mitigate alarm hazards.