Abstract
This evidence-based research project provides an appraisal of current research on how an alarm management program impacts alarm fatigue among registered nurses (RNs) in both intensive care units (ICUs) and telemetry units. Alarm fatigue is a major problem recognized by both the American Association of Critical-Care Nurses (AACN) and the Joint Commission. RNs are the primary caretakers of critically ill patients in ICUs and telemetry units and therefore are at the greatest risk for alarm fatigue.
The researchers performed an evidence synthesis to determine the impact of an alarm management program on alarm fatigue among ICU and telemetry RNs. A literature search was conducted using scientific databases such as PubMed, CINAHL, Trip, Cochrane Review, and Google Scholar. Our search strategy included the following terms: adult registered nurse, inpatient registered nurse, ICU registered nurses, RNs, Nurse Practitioners, alarm fatigue, alarm management strategy, education, cardiac monitor alarm, alarm strategies, alarm bundle, telemetry alarm, and cardiac monitor. Any studies involving the pediatric population, pulse oximeter alarms, and ventilator alarms were excluded. Due to the lack of available randomized control trials and cohort studies, the authors included two quality improvement (QI) projects. Finally, six studies were taken into consideration for review. The authors appraised each of the six articles using the Critical Appraisal Skills Programme Checklist (CASP) Tool. This tool allowed the authors to synthesize information based on the outcomes and determine the level of the evidence of each article in order to make evidence-based practice recommendations on implementing alarm management programs.
Introduction
Full physical examination by medical providers has always been the primary method of patient assessment. Throughout the 21st century, medical technology has provided healthcare workers with an abundance of real-time information and continuous physiological monitoring to alert health care providers when a serious problem occurs. Walking onto any hospital floor, it is easy to quickly become overwhelmed by the hums of ventilators and the blaring of alarms. These devices are designed to inform healthcare providers of critical medical situations, but can actually be hazardous and create alarm fatigue. This in turn, can hinder medical care and lead to adverse patient outcomes (Bach et al., 2018).
Research has suggested that approximately 80–99% of alarms are falsely activated due to a combination of human, organizational, and technical factors (Bach et al., 2018). Per the Joint Commission, 85–99% of alarm signals do not actually require clinical intervention (Seifert et al., 2021). Siebig et al. (2010), analyzed real-time data in an ICU to establish the clinical validity of the monitoring devices used in their specific institution and found that only 16.9% of monitoring alarms were appropriately set off to either identify a patient's change in status or identify a problem with the machine. On the other hand, 43.6% of these alarms were set off as a false positive, and 44.2% were set off as a result of patient movement or manipulation by the medical providers.
Alarm fatigue is defined as desensitization and apathy of healthcare providers to the sound of an overwhelming number of repetitive or simultaneous alarms (Lewis & Oster, 2019). This is a major problem recognized by both the AACN and the Joint Commission. Between 2009 and 2012, the Joint Commission received 98 alarm-related adverse patient event reports, 80 of which were fatal and 13 caused permanent loss of function (Lewis & Oster, 2019). A retrospective study was published in 2011, which determined that 216 inpatient deaths between 2005 and 2010 across the US were linked to either delayed or absent responses to activated alarms. Additionally, between 2005 and 2008, the United States Food and Drug Administration database received 566 reports of inpatient deaths related to alarm fatigue (Bach et al., 2018). These studies demonstrate an unreasonably high prevalence of adverse events in hospitalized patients. Therefore, in 2014, the Joint Commission made alarm management a national patient safety goal, aiming to reduce the prevalence of alarm fatigue in nurses to ultimately prevent adverse patient events.
In addition to adverse events, desensitization to healthcare alarms is costly to health care systems. Nurses are the primary healthcare provider responsible for close patient monitoring and therefore are at the forefront for developing alarm fatigue. The primary intervention to reduce alarm fatigue is through alarm management (Lewis & Oster, 2019). According to Turmell et al. (2017), implementing an alarm management strategy has the potential to save hundreds of thousands of healthcare dollars. Additionally, it can collectively save RNs hundreds of hours of time, so they may focus more on direct patient care.
Alarm management can be accomplished through a combination of evidence-based interventions, including educational programs, development of policies and procedures, reducing over-monitoring of patients, and customizing alarm parameters. Literature suggests that implementing alarm management programs decreases the likelihood of alarm fatigue in nurses in the inpatient setting. These programs may include daily reassessment of need for each monitoring alarm, proper skin preparation prior to applying adhesive-based monitoring technology, and frequency of changing or recalibrating monitoring devices (Lewis & Oster, 2019) This has the potential to improve patient safety and significantly reduce sentinel events in the inpatient population.
Method
A literature search was conducted using databases such as PubMed, CINAHL, Trip, Cochrane Review, and Google Scholar. Our search strategy included the following terms: (adult registered nurse OR inpatient registered nurse OR ICU registered nurses OR RNs OR Nurse Practitioners) AND (alarm fatigue OR alarm management strategy OR education OR telemetry alarm OR cardiac monitor alarm OR alarm strategy OR alarm bundle OR telemetry alarm OR cardiac monitor). The authors excluded any studies involving the pediatric population, pulse oximeter alarms, and ventilator alarms. The authors also planned to exclude articles that were QI projects, but due to the lack of recent higher-quality studies, two QI projects were included.
Of the 79 studies found, 13 duplicates were removed. Of the remaining 66 articles, all four authors reviewed titles and abstracts for relevance, but only two of the four authors were required to include or exclude each article by title and abstract. After excluding 44 irrelevant articles based on their titles and abstracts, all four authors performed a full-text review of the remaining 21 articles; however, only two of the four authors were required to include or exclude each article during this stage. Of these 21 articles, two authors reached a consensus to include six studies according to the criteria listed above. Of the six articles, each author reviewed two articles independently and two articles collaboratively in pairs and critiqued them based on study purpose, sample size, statistical data analysis, conclusions, limitations, and implications for future practice. Due to the lack of available randomized control trials and cohort studies, the authors included two QI projects. Using this data, we determined the level of evidence and the quality of these articles.
Please see the Prisma Flow Diagram (Figure 1) for reference.
Prisma flow diagram generated by Covidence software highlighting the process for including and excluding articles in this literature review. Note: Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia. Available at www.covidence.org.
Results
The authors used the CASP tool to characterize the articles based on their individual quality, strength, and limitations. Each CASP tool was chosen based on the design of the corresponding study. The tool has ten to twelve questions that each highlight a different aspect of the study. Each question considers whether the methods used were appropriate, if their findings were significant, and if the results can be applied locally.
Of the six articles, each author reviewed two articles independently using the necessary CASP tool and created a table of evidence. Each author then reviewed two articles that another author independently reviewed, and the paired authors compared their findings. The paired authors determined the qualities and levels of the studies they reviewed and summarized their findings in the table of evidence. After grading each study based on the above criteria, the authors synthesized the evidence to make best-practice recommendations. Please see Table of Evidence (Table 1) for reference.
Table of Evidence.
Discussion
Six articles were reviewed by the authors to determine the impact of alarm management programs on alarm fatigue among RNs. All articles indicated that alarm fatigue causes a significant impact on ICU and telemetry RNs and is the biggest contributor to alarm-related adverse events (Bach et al., 2018). Nurses from all around the world agree that alarms disturb patient care, are burdensome, and diminish trust in alarm systems (Lewandowska, et al., 2020). Lewandowska, et al. (2020), highlights the negative impact of alarm fatigue and points to the importance of an alarm management system to alleviate this burden. This qualitative systematic review does not show the impact of an alarm management system, it only assumes that implementing one would lessen alarm fatigue in RNs based on the negative perceptions of nurses about alarm fatigue.
Bach et al. (2018) identified a gap between knowledge of alarm standards and their translation into practice. After performing a literature review, the researchers defined alarm standards as an umbrella term that encompassess three domains: machine learning, alarm configuration, and alarm designs. Machine learning refers to utilizing “smart” alarms that use specific algorithms to determine if the alarms were alerting RNs of critical information or if they were falsely activated prior to generating a sound. Alarm configuration refers to the ability of RNs to alter the alarm parameters to meet patient-specific needs to reduce the number of unnecessary alarms. Finally, alarm design refers to the standardization of alarm sounds based on the machine's perception of urgency, so each sound correlates with a different level of urgency. They emphasize that it is not enough to simply know the domains of alarm standards, but it is crucial for RNs to actually apply this knowledge into their practice to effectively reduce alarm fatigue. The researchers suggest that this gap is due to the lack of collaboration among technical, human, and organizational factors in alarm management programs. However, this study does not propose an alarm management program that may bridge this gap, so it is not feasible to predict what the impact of such a program would have on alarm fatigue in RNs.
One QI project suggested that implementing educational programs to improve the nursing staff's understanding of cardiac telemetry nuisance alarms will positively impact alarm fatigue (Karapas & Bobay, 2021). After the nursing staff completed the educational intervention, there was a statistically significant increase in nursing knowledge about alarm management; however, there were no statistically significant differences in the number of nuisance alarms. Evidently this educational program was beneficial in providing the nursing staff with knowledge about the concept of alarm fatigue. Although, it is possible that it was not clear in teaching them how to apply this knowledge to practice which may be responsible for why there was no statistically significant reduction in nuisance alarms. Graham and Cvach’s (2010) QI project suggests that combining an RN education program with technology-based interventions will decrease the number of unnecessary and/or duplicate cardiac alarms. Unfortunately, they did not perform any statistical analysis to determine significance or which intervention applied was the most influential. Although both QI projects showed promise in providing a positive impact on alarm fatigue, they lacked statistical significance, generalizability, and the rigor required to be considered strong, reliable evidence.
Only two of the six studies demonstrated a statistically significant reduction of alarm fatigue in RNs by implementing an alarm management program. Bi et al. (2020), implemented an alarm management education program using a single-blind, randomized controlled trial with two parallel groups. They created a 4-week training program based on both the “Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings’’ published by the American College of Cardiology (ACC) and “Managing alarms in acute care across the life span: electrocardiography and pulse oximetry” published by the AACN. This training program was implemented specifically for RNs in the ICU. After the RNs completed it, there was a statistically significant reduction in inactionable telemetry alarms. Using a Likert scale, these nurses reported an overall decrease in their alarm fatigue after experiencing this structured training program. Lewis and Oster (2019) created the Communication, Electrodes, Appropriateness Setup Alarm Parameters and Education (CEASE) bundle based on the 2013 AACN Alert for Alarm Management recommendations. They implemented this patient-specific monitoring bundle in a quasi-experimental study in the ICU which significantly decreased alarm fatigue among those RNs (Lewis & Oster, 2019). Both of these studies showed a high level of evidence, good reliability, and strength of evidence thereby supporting the authors’ evidence-based practice recommendations.
Please see the Level of Evidence Table (Table 2) and the Outcome Synthesis Table (Table 3) for reference.
Levels and Types of Evidence of Relevant Studies.
Outcome Synthesis Table
↑improvement.
↓no affect.
*statistically significant.
°statistical significances not reported, clinical significance.
Implications for Practice
Alarm fatigue is a major problem recognized by both the AACN and the Joint Commission (Lewis & Oster, 2019). Based on the literature review, critical appraisal, and synthesis of evidence it is clear that implementing an alarm management program shows clinical significance in decreasing alarm fatigue among ICU and telemetry RNs. Both of the higher quality studies utilized experimental research designs to assess their educational interventions. Both of their training programs significantly reduced nurses’ alarm fatigue (Bi et al., 2020 & Lewis & Oster, 2019). Additionally, Bi et al. (2020) educational program did not interfere with the nurses’ judgment of true crisis alarms while simultaneously building their alarm management skills. Overall, both educational programs showed promising results that a structured alarm management program reduces inefficient or invalid behaviors.
Please see the Evidence-Based Practice Recommendation Table (Table 4) for reference.
Evidence Based Practice Recommendation Table.
Limitations
Unfortunately, the available literature is extremely limited. For example, coming across only one randomized control trial and one quasi-experimental study is disheartening because it is unclear if their results are generalizable. Future research must replicate these educational interventions in the desired population to make a more comprehensive practice recommendation. These studies also do not show if their specific alarm management programs apply to both ICU and telemetry RNs. The authors also may have been limited by their strict exclusion criteria and narrow PICO question which focused only on telemetry alarms.
Outcome Recommendations/Conclusion
Many studies have shown that the presence of excessive alarms is a significant issue among RNs; however, there have been limited high-quality studies documenting the impact of alarm management programs on alarm fatigue (Bach et al., 2018). Although limited, the evidence supports that alarm management programs positively impact alarm fatigue in ICU and telemetry RNs. However, the lack of knowledge, skills, and mentors are key barriers to implementing evidence-based practice (Melnyk & Fineout-Overholt, 2018). Specialized clinical training and education would provide RNs with an opportunity to not only augment their knowledge but also to transform their practice (Bi et al., 2020). Lewis and Oster (2019) suggest training RNs to become expert clinical leaders called “champions.” This is a strategy to expand knowledge related to alarm management throughout the various shifts and departments within the hospital. This allows the champions to mentor the RNs in ICUs and telemetry units who are experiencing the burden of alarm fatigue. On the other hand, too much training can be burdensome and therefore utilizing the theory of planned behavior, an alarm management program can also focus on “reshaping behaviors” by training RNs’ attitudes, subjective norms, perceived behavioral control, and awareness (Bi et al., 2020).
It is imperative for hospitals to develop evidence-based alarm management programs that are tailored to bridging the gap of simply knowing alarm management standards and actually applying them into practice (Bach et al., 2018). Applying the ACC and AACN alarm management practice recommendations enables a hospital to mold a specific alarm management program to their own organization (Lewis and Oster, 2019). The greatest barrier in the implementation of an alarm management program is the lack of an existing evidence-based standardized program due to insufficient high-quality evidence. Therefore, it is not possible to implement a specific alarm management program at this time. The John Hopkins Nursing Evidence-Based Practice Model (JHNEBP) is a circular conceptual model which, since there is no standardized alarm management program, would allow organizations to review relevant sources of new evidence and allow for their further investigation before determining what is truly the best practice.
The primary outcome in decreasing alarm fatigue can be quantitatively measured using a Likert scale pre- and post-intervention. Secondary outcomes include the overall decrease in nuisance telemetry alarms. Obtaining baseline data prior to implementation will allow the organization to see if the implementation of their customized alarm management program impacts overall alarm numbers on their desired units.
Conclusions
Despite extensive literature highlighting the astronomical prevalence of alarm fatigue in RNs, there was a lack of data related to implementing alarm management programs. Therefore, more research is needed to support the utilization of alarm management programs in ICUs and telemetry units to improve alarm fatigue among RNs.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Hofstra Northwell School of Nursing and Physician Studies paid for the open access for the article.
