EBP Annotated Bibliography Discussion EBP Annotated Bibliography Discussion
EBP Annotated Bibliography Discussion
EBP Annotated Bibliography Discussion
© 2016 AACN
DOI: http://dx.doi.org/10.4037/aacnacc2016110
Clinical Trial of an Educational Program to Decrease Monitor Alarms in a Medical Intensive Care Unit Arian Brantley, APRN, MS, NP-C, ACCNS-AG
Sandra Collins-Brown, RN, BSN
Jasmine Kirkland, RN, BSN
Meghan Knapp, RN, BSN
Arian Brantley is Staff Nurse, 71 Intensive Care Unit, Emory University Hospital Midtown, Atlanta, Georgia.
Sandra Collins-Brown is Staff Nurse, 71 Intensive Care Unit, Emory University Hospital Midtown, Atlanta, Georgia.
Jasmine Kirkland is Staff Nurse, 71 Intensive Care Unit, Emory University Hospital Midtown, Atlanta, Georgia.
Meghan Knapp is Staff Nurse, 71 Intensive Care Unit, Emory University Hospital Midtown, Atlanta, Georgia.
Jackie Pressley is Staff Nurse, 71 Intensive Care Unit, Emory University Hospital Midtown, Atlanta, Georgia.
Melinda Higgins is Associate Research Professor, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia.
James P. McMurtry is Clinical Nurse Specialist, 71 Intensive Care Unit, Emory University Hospital Midtown, Atlanta, 550 Peachtree St, NE, Atlanta GA 30308 (james.mcmurtry@ emoryhealthcare.org).
The authors declare no conflicts of interest.
Alarm signal events from medical equip-ment are an audible signal designed to alert nursing staff to a physiological change in a patient’s condition, a technical problem requiring investigation, and/or a situation requiring intervention. Some alarm signal events also occur when there are no actual clinical problems with the patient but because of artifact or small physiological changes that exceed the upper or lower alarm limits. High frequency of the latter alarms, often called nuisance or nonaction- able alarms, can desensitize staff’s reaction to alarms. This situation, called “alarm fatigue,” may cause staff to react more slowly to alarm signal events or ignore them altogether.1-4
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A B S T R A C T Clinical research to identify effective interven- tions for decreasing nonactionable alarms has been limited. The objective of this study was to determine if a staff educational pro- gram on customizing alarm settings on bed- side monitors decreased alarms in a medical intensive care unit (MICU). A preintervention, postintervention, nonequivalent group design was used to evaluate an educational program on alarm management in a convenience sample of MICU nurses. A 15-minute session was provided in a 1-week period. The outcome variable (number of alarms for low oxygen saturation via pulse oximetry [SpO2]) was
determined from monitor log files adjusted by patient census. Data were collected for 15 days before and after the intervention. 2 analysis was used, with P less than .05 considered sig- nificant. After 1 week of education, low SpO2 alarms decreased from 502 to 306 alarms per patient monitored per day, a 39% reduc- tion (P < .001). Instructions for nurses in the medical intensive care unit on individualizing alarm settings to patients’ clinical condition decreased common monitor alarms by 39%. Keywords: alarm fatigue, alarm avoidance, nonactionable alarms, nuisance alarms, false alarms
Jackie Pressley, RN, BSN
Melinda Higgins, PhD
James P. McMurtry, APRN, MSN, CNS-BC, CCRN
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Alarm fatigue can be a dangerous phenom- enon because staff may not intervene quickly enough to alarms that occur when a patient’s condition has changed, jeopardizing patient safety with the potential to result in adverse events and even death.5-13 In addition to staff fatigue from large numbers of bedside alarm signal events, the audible alarm signal events can disturb patients and prevent sleep/rest and patients’ recovery.2,14,15 Lack of sleep/rest during hospitalization is a major dissatisfier for patients.16,17
Background The frequency of monitor alarm signal
events is high in critical care units,10,18 with experts estimating that more than 300 physio- logical monitor alarm signal events occur each day for each patient.18 Although the percentage of those alarm signal events that are nonaction- able varies, experts10,18 and clinicians4,11 believe that the frequency of nonactionable alarm sig- nal events is high. In the past decade, clinicians have continued to rate nonactionable alarm signal events as the largest issue related to monitor alarms at their institutions.11
Clinicians believe that a primary underlying cause of nonactionable alarm signal events with physiological monitoring is inappropriately set alarm limits, which leads to the triggering of alarm signal events even when physiological fluctuations are normal and/or small.4 Monitor technology experts concur,8,19-21 but recognize that until technological advancements in moni- toring equipment allow the technology to auto- matically set alarm settings that are customized for each patient, the key to decreasing many nonactionable alarm signal events lies in get- ting clinicians to individualize or customize monitor alarms for each patient.8
One approach sometimes used by hospi- tals, including our own facility in 2013, to decrease nonactionable alarm signal events is to change the monitor’s default settings (low and high rates; response priority level) for alarms.22,23 Although this approach decreases the frequency of some alarms, it does not eliminate the underlying problem that for individual patients, the default alarm settings may not be appropriate.
National regulatory groups,13,18 professional associations,3,5,19-21 and critical care experts1,11,23-26 have urged clinicians to intervene to decrease nonactionable alarm signal events. Aside from studies to improve the hardware and/or
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programming of physiological monitors, lim- ited clinical evaluations have been done on other approaches to decrease nonactionable alarm signal events.12,27-30 Prior evaluations were quality improvement or performance improvement projects focused almost exclu- sively on electrocardiographic (ECG) moni- tor alarms, all of which evaluated a “bundle” of different interventions to decrease non- actionable ECG alarm signal events. Those approaches included improving the quality of the ECG signal (skin preparations before electrode placement; frequent ECG electrode changes), elimination of duplicative ECG alarms, changes in default alarm settings in the computer software, and staff education on customizing ECG alarm signal event limits to each patient’s clinical condition. Although all of the projects found substantial decreases in ECG alarm signal events following implemen- tation of practice changes, the impact of each individual intervention of the bundle is not known. Only one of the quality improvement projects included non-ECG physiological mon- itor alarm signal events (low Spo2; high and low respiratory rates).28 To date, no research has been published on interventions designed to increase clinicians’ use of customization for high and low alarm signal events for physio- logical monitor parameters as an attempt to decrease nonactionable alarm signal events.
Review of alarm history data in our medi- cal intensive care unit (MICU) in late 2012 indicated that more than 1500 alarm signal events per patient per day were occurring, with approximately 70% of those alarm signals coming from non-ECG physiological parameters. The vast majority of those non- ECG alarm signal events were from low satu- rated oxygen level shown by pulse oximetry (Spo2). The hospital’s default setting for low Spo2 alarm signal events was 90%, based on an assumption of a relatively normal respira- tory function for adult patients in the hospi- tal’s ICUs. Many of the MICU patients had moderate to severe respiratory insufficiency, so their Spo2 levels were often at or below the default settings. Similar to prior surveys of nursing practice,3,11 anecdotal observation in our MICU indicated that nursing staff did not routinely customize their alarm signal event limits to each patient’s clinical condition. We believed that this lack of customization of alarm settings was contributing to the high number of Spo2 alarm signal events.
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The purpose of this study was to determine if a brief educational program for nurses on alarm management for non-ECG physiological parameters could decrease the number of low Spo2 alarm signal events per patient per day.
Methods Study approval was obtained from the
institution’s investigational review board before data collection. Data collection was completed during a 5-week period.
Study Design A pretest, posttest, nonequivalent group
design was used to evaluate the effect of a staff educational program on alarm management. The dependent variable for the study was the number of low Spo2 alarm signal events per patient per day during a 15-day period.
Study Setting The study was conducted in a 20-bed
MICU, with a total of 54 registered nurses employed in 0.2 to 1.0 full-time-equivalent (FTE) positions. Monitoring capabilities at each bedside included a range of physiologi- cal parameters, with all patients monitored for ECG rhythm, blood pressure, respira- tory rate, and Spo2 (Solar 8000M/I V5, GE Healthcare). Oxygen saturation monitoring was done with a finger probe (Oxysensor MAXN, Covidien) connected to an Spo2 module using Nellcor pulse oximetry technol- ogy (OxiMax Technology, GE Healthcare) within the bedside monitoring system. Each monitor physiological parameter was pro- grammed with default values for alarm set- tings common to all monitored beds in the ICUs and intermediate care units for the facility. The default values were based on the monitor manufacturer’s suggestions and consensus opinion of expert nursing and medical clinicians in the ICUs and intermedi- ate care units. Bedside alarm settings could be customized by bedside clinicians on the basis of individual patient care situations. When alarm settings were exceeded, audible alarms occurred at the bedside and at the unit’s central monitoring station.
Sample Selection Participants in this study were registered
nurses working as bedside clinicians on the MICU. Inclusion criteria included being a permanent employee on the study unit, at a
minimum of 0.2 FTE each week, and comple- tion of new-employee unit orientation. A mini- mum sample size of 21 staff members (40% of MICU staff) was required for this study to ensure that an adequate number of staff par- ticipated in the alarm management education.
Study Intervention The educational program on alarm man-
agement was a 15-minute session designed to review the rationale for minimizing alarms and provide strategies for reducing nonactionable alarms by customizing the low and high alarm settings for the non-ECG parameters to each patient’s current condition and/or situation (Table 1). Content of the educational class was developed by the study investigators and was based on the monitor manufacturer’s educa- tional materials and expert advice on minimiz- ing nonactionable alarms.12,22,24,26 Classes were taught by 1 of 5 study investigators, all of whom were registered nurses experienced with the MICU patients and monitoring equipment. Investigators were trained to provide the educational intervention following a stan- dard curriculum and use of pocket-card guides for customizing alarm parameters. During a 1-week period, educational sessions were provided at the beginning or end of the nurses’ patient care shifts in a unit room used for staff education and meetings. Although a number of non-ECG physiological parameters were discussed, the major focus was on low Spo2 because it represented the highest number of alarm event signals in previous quality data monitoring. Examples of patients with normal and abnormal Spo2 values were provided, with suggestions for appropriate alarm signal event limits. Appropriate alarm signal event limits were determined a priori and were based on manufacturers’ suggested parameters in educa- tional materials and review by expert clinicians familiar with the MICU patient population. Because the vast majority of the MICU patients had usual Spo2 values on the steep portion of the oxygen saturation curve, the lower alarm signal event limit recommendation was conser- vatively set (1% below the lowest value in the previous 2-hour period). Participants were provided with a pocket card summarizing key information for setting alarm limits indi- vidualized to each patient. Pocket cards were also attached to all bedside monitors for easy reference when caring for patients. The edu- cational program was provided for 1 week.
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Outcome Variable For the purposes of this study, the low Spo2
alarm signal event was selected for outcome monitoring because it had the highest rate of occurrence on the study unit and accounted for more than 50% of all non-ECG dysrhyth- mia alarm events. The number of low Spo2 alarm signal events was obtained through review of existing bedside monitor computer alarm history for each monitored patient on the unit with a software program developed by the monitor manufacturer (Alarm Report- ing Tool, GE Healthcare).31 Alarm data were extracted from existing computer log files, which occurred whenever an audible monitor alarm signal event occurred. The number of alarm signal events was adjusted by the number of patients being monitored during the study period each day and was reported as low Spo2 alarm signal events per patient per day. Alarm data were collected for 15 days immediately
before and 15 days after implementation of the study educational intervention.
Data Analysis Data were summarized by using descriptive
statistics. 2 analysis was used to compare prein- tervention and postintervention frequency of low Spo2 alarms per day and the number of patients monitored during each study period. The level of significance was set at P less than .05.
Results A total of 22 nurses completed the 15-minute
educational intervention during a 1-week period. All but 2 nurses were female, with a mean age of 37.9 (SD, 14.8) years (age data available for only 17 nurses). Years of experi- ence in nursing and in critical care nursing varied, with the majority of nurses having 5 or more years of experience in nursing and critical care nursing (Table 2).
1. Rationale for keeping nonactionable alarm signal events (eg, nuisance alarms) at a minimum A. Staff alarm fatigue B. Noise disruptions affect patients’ rest/sleep and satisfaction
2. Management of alarms with high rates of occurrence on the unit A. Parameter alarms with highest occurrence are either from low oxygen saturation shown by pulse oximetry (SpO2) or high respiratory rate (> 50% of alarms), causing more than 300 000 alarms on the unit in a 1-month period. Many are nonactionable alarms. B. Nursing strategies to decrease nonactionable alarm signal events: (1) During assessment of patient at the beginning of the shift, and periodically during the shift, set realistic high and low alarm levels for SpO2 and high respiration parameters on the bedside monitor: (a) SpO2 low alarms—Set the patient’s SpO2 to 1 percentage point below the lowest value for the past 2-hour trend (excluding isolated spikes). (b) Respiration high alarms—Set the patient’s high respiration rate alarm to 10 breaths per minute above the highest value for the past 2-hour trend. (2) Check the skin adherence and placement of electrocardiography chest electrodes on admission and every 24 hours. Respirations are detected by measuring thoracic impedance in lead configurations I, II, and RL-LL. The monitor “learns” the patient’s respiration patterns according to these configurations for 8 breaths. Changing the leads automatically starts the relearning process, or relearning can be selected from the monitor menu. Periodically, the relearning process is necessary if the patient’s breathing pattern has changed and the monitor is no longer calculating the respiratory rate. The lead configurations are as follows: (a) Lead I for upper chest breathers (b) Lead II for abdominal breathers (c) RL-LL lead for abnormal breathers (3) Check SpO2 finger probe adherence each shift and replace as necessary
3. Question and answer period
4. Provide each participant with a pocket card summarizing key information for setting individualized patient’s alarm limits and lead locations for optimal respiratory monitoring. Participants should also be told that cards will be attached to all bedside monitors for easy reference when caring for patients.
Table 1: Content Outline for a Staff Educational Intervention on Oxygen Saturation and Respiratory Alarm Management
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Before the intervention, low Spo2 alarms made up 50% of all alarms; after the inter- vention, they made up 44% of all alarms.
The total number of low Spo2 alarm signal events during the 15-day baseline period was 128 186 or 503 alarm signal events per patient per day for 17 patients. Following the educa- tional intervention, the total number of low Spo2 alarm signal events during the 15-day postintervention period was 78 267 or 307 alarm signal events per patient per day for 17 patients. The 39% reduction in Spo2 alarms after the educational intervention was statistically significant (P < .001).
Discussion This study was the first study in which an
intervention to decrease non-ECG physiologi- cal alarm signal events in critically ill patients was analyzed. After the 40% of MICU staff received a brief educational intervention on alarm management, the highest number of non-ECG monitor alarms (low Spo2) decreased 39%. The 15-minute alarm management edu- cation provided at change of shift emphasized the importance of avoiding nonactionable alarm signal events by customizing alarms limits to be appropriate for each patient’s current physiological situation rather than accepting the monitor’s default values.
Prior published reports of approaches to alarm management were descriptive designs or quality or performance improvement proj- ects.12,27-30 Practice changes that were imple- mented focused almost exclusively on ECG alarms, and each included multiple interven- tions to decrease nonactionable alarm signal
events, making it difficult to understand the contribution of individual strategies to the overall outcomes. For example, strategies used by Graham and Cvach28 included com- puter software adjustments to default alarm settings for selective ECG and physiological parameters, elimination of duplicate alarm signal events, and staff education about the importance of setting patient-specific alarm limits as a way to decrease nonactionable alarm signal events. Although this bundle of strategies resulted in a 43% decrease in total alarms during the 1-year period of the quality improvement project, it is not known which interventions were most important and/or if other changes on the unit during the long study period could account for the decrease in the number of alarms. Our results show that a single, brief educational intervention focused on customizing alarm limits to each patient’s condition can significantly reduce the number of non-ECG physiological alarm signal events.
Limitations This study evaluated only a single, brief
educational intervention for MICU nursing staff focused on non-ECG alarm settings. Different results may occur with more extensive education, when applied to ECG alarm settings, and/or with noneducational interventions. Another limitation of the study is that we evaluated only 1 time point shortly after completion of the educational interven- tion. Whether the alarm decreases were main- tained over time is not known. In this study, we evaluated only the number of alarms and were not able to quantify the number of alarms that were actionable and nonactionable. Researchers in future studies should quantify the source of the alarms (eg, alarms for arti- fact, alarms for clinically significant physio- logical changes, alarms for nonactionable physiological changes). Although other fac- tors could have contributed to the decrease in low Spo2 alarm signal events, the conduct of the study during a short period of time (5 weeks) helped to reduce some factors such as changes in practice routines and/or types of MICU patients.
Clinical Implications Emphasizing the importance of customiz-
ing alarm limits to a patient’s physiological condition, rather than relying on a monitor
Characteristic
Nursing experience, y < 1 1-5 > 5 to 10 > 10 to 20 > 20
Progressive and critical care experience, y
< 1 1-3 > 3 to 5 > 5
No. of nurses
1 10 2 4 5
3 7 1 11
Table 2: Experience of 22 Nurse Participants
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system’s default settings, can decrease some of the non-ECG physiological alarms. Such customization is especially important in units with large numbers of patients who have usual physiological values that are close to the monitor’s default alarm settings. Until smarter monitor technology is available that can cus- tomize the upper and lower alarm limits to the patient’s individual physiological status, it falls to the nurse clinician to customize alarm limits to decrease the number of nonactionable alarms. Because customizing alarm limits resulted in only a 39% decrease in alarm signal events, clinicians should continue to implement other strategies for alarm reduction.
Future Research The limited number of studies on how
best to reduce nonactionable alarm signal events emphasizes the need for additional research in this area. Because this study is the first study in which a single, clinician- initiated intervention to decrease alarm sig- nal events was examined, replication of this study is important. Researchers in future studies should also attempt to quantify the frequency and appropriateness of custom- ized alarms for individual patients. To better understand the impact of interventions to decrease monitor alarm signal events, studies should be designed to evaluate outcomes of individual interventions rather than solely bundling several interventions together.
Conclusions This study demonstrated that a simple,
brief educational program for MICU nursing staff on customizing alarm settings to each patient’s physiological condition, rather than using default alarm values, significantly decreased the most common bedside monitor alarm signal event by 39%. Ideally, reduc- tions in inappropriate clinical alarms will reduce the chance of alarm fatigue of staff nurses, which can be a patient safety risk factor. In addition, noise reduction from fewer bedside alarms may facilitate patients’ rest/sleep and improve patient satisfaction.
Acknowledgments Special thanks to Stephen Treacy for assis-
tance with electronic alarm data extraction and Marianne Chulay, RN, PhD, FAAN, for assistance
with study design, data analysis, and manu- script preparation.
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