What is your job title? Are you full-time, part-time, or PRN? Do you currently experience alarm fatigue? Yes/No4. What interventions can we do

Learning Goal: I’m working on a programming discussion question and need an explanation and answer to help me learn.

Give a peer review of the 4 groups presentations below.

Alarm fatigue is sensory overload when exposed to an excessive number
of alarms, which can result in desensitization to alarms and contribute to
patient harm, up to and including death (Winters, 2021)
● Key Objectives:
○ Alarm safety and the prevention of alarm fatigue
○ Develop policies and practice standards to improve awareness
○ Design interventions that reduce alarm fatigue
○ Increase patient safety

Why is this problem important?

● ICU nurses may receive 150-400 alarms per patient throughout their shift, totalling greater than
900 alarms per day, 80-99% of alarms are insignificant or “false” (Lewandowska et al., 2020)
● False alarms lead clinicians to reduce alarm volume to ineffective levels, silence alarms, set
inappropriate alarm parameters, or not check patients in a timely manner, ultimately jeopardizing
patient safety (Bach et al., 2018)
● MAUDE reports 566 patient deaths due to medical device alarms from 2005-2008 (Bach et al.,
2018)
● In 2010, over 2,500 adverse events were reported regarding mechanical ventilators, alarm
system error contributed to one third of the events (Bach et al, 2018)
● Developing policies and practice standards to improve awareness, and attempting to design
interventions can help reduce false alarms and alarm fatigue to ensure patient safety.

Contributing Factors

● Incorrect parameter thresholds, not considering patient needs when
adjusting parameters, EKG electrode malfunction, staff inability to hear or
decipher where an alarm stems from, poor staff training and response,
and alarm malfunction contribute to alarm fatigue (Gaines, 2019).
● Culture of safety is lacking

Theoretical Concept

● Data Information Knowledge Wisdom (DIKW) theory
● Assess the nurse’s perception of alarm fatigue
● Variables to consider
○ the frequency of alarms
○ accuracy of the alarm
○ events that trigger an alarm to sound
● Identification of causes of alarm fatigue will enable effective design of
interventions

Potential Solution

● Computerized provider order entry (CPOE)
● Clinical Decision Support Systems (CDS)
● SMART alarms (Appendix A)
● Use of Smartphones with smart apps
● Differentiating warning and severe alarms while considering more
● Provider education
○ personalized parameters
○ Tiering alert
○ Cost of ignoring alarms

Implementation

● Pilot investigation on the risk of alarm fatigue on a 28-bed telemetry
unit.
● All alarms, false or true, will be evaluated, investigating how often
they occur and the nurse’s response to them.
● Customized alarm systems with improvements in middleware
software to decrease false alarms and make them more specific to
the patient’s condition.
● Having an order set placed in the EHR by the provider that allows
the nurse to titrate the alarms based on the patient’s vitals trends.

SEVERE ALARM WARNING ALARM

● Life Threatening Arrhythmia
● SpO2 <90%
● HR >120
● HR<60
● MAP < 65
● Mechanical Ventilators
● Apnea
● EKG Electrode Placement
● Telemetry Artifact
● Feeding Tube Volume Low
● IVF Volume Low
● Chair Alarms
● Bed Alarms
● Battery Low

Implementation

● Communication during morning and evening rounds between the provider and
nurse is an important resource.
● Nurses, physicians, and other healthcare personnel can join committees on their
unit’s council team for changing and improving alarm systems to reduce the number
of false alarms that occur.
● These unit-led meetings could also allow staff to provide feedback on the alarm
fatigue.
● After conducting our research project, our goal is to be able to implement an
effective strategy/system to share with units within the hospital as well as other
hospitals to prevent patient harm due to false alarms.

Budget & Resources
● This operation will involve the implementation of SMART alarms and
smartphones that are specific to the patient’s condition.
● Initial consultation, service and consulting proposal, flat or hourly rates,
client approved data set, outlined results, expectations, and detailed
requirements in order to build a system for processing and analyzing
data.
● Minimum estimated budget $150,000
● Seek Accountable care organization such as Kaiser Permanente for
financial assistance and grants once study is established

Evaluation
● Longitudinal employee survey: prior to use of CPOE, CDS system, and
SMART alarms and six months post implementation
● Trend occurrence of alarms and frequency of false alarms
● Goal: Alarm prioritization and decrease desensitization
● Reduction of employee reported alarm fatigue by 15-20% within six
months

Pre-Implementation Staff Survey

1. What is your job title?
2. Are you full-time, part-time, or PRN?
2. Do you currently experience alarm fatigue? Yes/No
4. What interventions can we do to lessen the alarm fatigue?
5. What medical equipment do you believe produces the most false alarms?
6. How does alarm fatigue affect patient care?

Post-Implementation Staff Survey
1. What is your job title?
2. Are you full-time, part-time, or PRN?
3. Did you experience alarm fatigue prior to CPOE/CDS system and SMART alarm implementation? Yes/No
4. Do you currently experience alarm fatigue? Yes/No
5. Do you find CPOE/CDS systems and SMART alarms effective in reducing alarm fatigue? Yes/No

Evaluation: Project timeline

References

Alert fatigue. Patient Safety Network. (2019, September 7). Retrieved June 25, 2022, from
https://psnet.ahrq.gov/primer/alert-fatigue
Bach, T. A., Berglund, L.-M., & Turk, E. (2018). Managing alarm systems for quality and safety in the hospital
setting. BMJ Open Quality, 7(3). https://doi.org/10.1136/bmjoq-2017-000202
Casey, S., Avalos, G., & Dowling, M. (2018). Critical care nurses’ knowledge of alarm fatigue and practices
towards alarms: A multicentre study. Intensive and Critical Care Nursing, 48, 36–41.
https://doi.org/10.1016/j.iccn.2018.05.004

References
Emergency Care Research Institute. (2019, June 14). Culture of safety: An overview. ECRI. Retrieved July 11,
2022, from https://www.ecri.org/components/HRC/Pages/RiskQual…
Fernandes, C., Miles, S., & Lucena, C. J. (2020). Detecting false alarms by analyzing alarm-context information:
Algorithm development and validation. JMIR Medical Informatics, 8(5). https://doi.org/10.2196/15407
Gaines, K. (2019, August 19). Alarm fatigue is way too real (and scary) for Nurses. Nurse.org. Retrieved June 27,
2022, from https://nurse.org/articles/alarm-fatigue-statistic… References
Emergency Care Research Institute. (2019, June 14). Culture of safety: An overview. ECRI. Retrieved July 11,
2022, from https://www.ecri.org/components/HRC/Pages/RiskQual…
Fernandes, C., Miles, S., & Lucena, C. J. (2020). Detecting false alarms by analyzing alarm-context information:
Algorithm development and validation. JMIR Medical Informatics, 8(5). https://doi.org/10.2196/15407
Gaines, K. (2019, August 19). Alarm fatigue is way too real (and scary) for Nurses. Nurse.org. Retrieved June 27,

Answer preview for What is your job title? Are you full-time, part-time, or PRN? Do you currently experience alarm fatigue? Yes/No4. What interventions can we do

940 Words