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Concept 1: This presentation has allowed me to fulfill course learning objective number 2: Apply quality improvement methods within the practice setting. Since my research is complete, I now have the knowledge to formulate a quality improvement project on my unit. I could take a leadership role within my unit and suggest that we use my research and design a plan to decrease alarm fatigue on my unit. The lassie faire culture on my unit has led to a reduction in compliance to all types of alarms. IV infusion pumps are constantly beeping, bed and chair alarms are going off, and heart monitors are dinging. Staff have become so desensitized to the urgency of alarms that they completely ignore them. It is causing a safety issue for patients because with multiple alarms always sounding no one alarm can be considered more critical than another and they all get ignored. A patient could exit out of bed and fall, and staff would not know. I plan to prepare this information as an elevator speech to propose some changes to our unit to decrease alarm fatigue. I plan to incorporate the various implementation strategies learned through my research to justify my proposal and advocate for safer patient care before we experience a sentient event. It is my hope that a committee can be formed to begin to devise strategies to implement my ideas.

For my own practice I can begin to monitor my response to alarms, learn more about default alarm settings and begin to customize alarms to fit the needs of my patients. I can also commit to being a superuser and teaching others about decreasing alarm fatigue. Sometimes taking on a leadership role doesn’t need to be through management or a quality improvement project. Leadership can be seen in one person who commits to making a difference, who inspires and encourages others to do the same.

Concept 2: This presentation allowed me to fulfill course learning objective number 6: Evaluate the effect of organizational design and culture of the health care system in the delivery of quality nursing care. This research allowed me to see that the environment in which the nurse works affects their performance and health as well as the care they deliver to others. Alarm fatigue is an increasingly important topic of discussion because monitoring equipment has increased in the last 20 years. As technology continues to advance, I know that as a nurse I must put it to the best use by learning how to adjust it to help me do my job instead of allowing it to dictate how I do my job. I must attempt to manage the environment in which I work to prevent myself from making mistakes and advocate for a safer work environment for myself and my patients. As a nurse leader I will apply the principles learned from professional nursing and evidence-based practice to uphold my position as a nurse who continues to learn, evaluate and apply the most current best practices to advance the nursing profession.

For my own practice I can become knowledgeable about new technologies and request further training from the educators and administration. I can research new ideas for the unit and present them to management. Nurses who are informed make better choices for their patients.

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1.)    To promote change the nurse first needs to be aware that alarm fatigue is harmful to their health. The nurses who work on units with high rates of alarms have worse sleep quality than those in other units and may experience mental health disorders such as depression, anxiety, fear and sleep disorders (Akturan et al., 2022). Qualitative interviews done by a study by Akturan et al. (2022) of nurses highlighted that alarm fatigue has effects on social life such as alarm sounds constantly in their ears, irregular sleep, intolerance to sounds and decreased social activities.

2.)    According to Akturan et al. (2022), the Joint Commission International has added a target for ‘Improvement of Clinical Alarm Systems’ to its international patient safety targets and offered recommendations.

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 (Dee, et al., 2022). Promoting these programs can inspire participations and superuser support.

3.)    Finally, the unit can become more attentive to the reduction of alarm fatigue by implementing minor changes such as readjusting alarm limits according to the patient's condition before each shift, changing the ECG electrodes and readjusting alarms according to the patient's condition when a new patient is hospitalized (Akturan et al., 2022).

In addition, development of different alarm sounds for different situations, joint monitoring screens, and easy access to technical support can also promote nurse participation.

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Hospital, Monitor - Vitals Monitor: Constant Beeps, Slow Rate, Heart Monitor Beeps, Hospital,...

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According to Sinno et al. (2022), implementing workshops and assigning monitor superusers (staff members that undergo training in and become experts in setting up monitoring devices) reduces the high rate of alarms. Superusers share their knowledge and expertise with other staff members and become the go to person to help problem solve equipment issues. They teach others how to better manage the equipment. These superusers are a valuable resource to the unit and the implementation of utilization of parameter controls.

Most alarms going off in the hospital are unintentional, but still add to the increasing noise level and cause fatigue. Being aware and mindful of alarms that are set and turning them off or pausing them when care like bathing, or turning, or repositioning is done, could help to minimize some of the unintentional alarms. Sinno et al. (2022) also suggests implementing the use of the pause function while examining or performing interventions on patients or to implement a delay between the deviation of the vital parameter and the sounding of the alarm.

Nurses can become informed and educated about the types of equipment they work with.  They can utilize the features of the equipment to set patient specific parameters that allow the nurse to know when the alarm is critical. Some hospitals offer special software to support nurses’ recognition of trends in patients’ alarms and facilitating changes to alarm settings may add value to alarm reduction initiatives (Ruppel et al., 2018). The challenge with customizing alarm settings for specific patients is that customization requires nurses’ ongoing assessment of and attention to alarm settings to ensure their continued relevance. Device manufacturers have been called on to help design technology that better supports alarm management. Smart alarm algorithms draw attention to specific clinical conditions, rather than relying on nurses to recognize patterns in multiple alarms for different vital signs (Ruppel et al., 2018). Implementing smart algorithm software was found to significantly reduce the mean alarms per bed hour and alarm duration for medium priority heart rate, respiratory rate, and arterial pressure alarms (Ruppel et al., 2018).

According to a study done by Glover et al. (2018), nurses can reduce alarm fatigue by lowering the volume of non-life-threatening equipment like infusion pumps. Although alarms must be audible, decreasing the volume level on bed alarms, phones, and call bells could greatly impact the unit.

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Nurses are silencing alarms, turning monitoring equipment off, and ignoring alarms due to the overwhelming number of alarms that are sounding and the stress they feel when the alarms are going off.

Failure to respond to an alarm can harm the patient and potentially be life-threatening.  Nurse are not resolving the root problem associated with alarm issues. Their avoidant behavior increases the amount of alarm noises heard by others on the unit, which adds to the overall noise level. They are creating a more stressful environment for everyone and taking away from patient care.

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To conduct my research review I searched key words, “alarm fatigue” and “alarm management” in the Pub Med database, focusing on articles that were peer reviewed and published within the last 5 years. I did increase my search criteria to include articles from the last ten years because I found several that were original citations and had been cited by many other studies. My literature review revealed three areas of consideration when researching alarm fatigue. The first area is the nurse’s perception of the alarm. The second is the large amount of false alarms that are sounding because they are in the default setting. And third is that a training and education system needs to be in place to show nurses how to manage alarm settings.

Article 1: A Framework to Assess Alarm Fatigue Indicators in Critical Care Staff.

My first article indicates that different personality types respond differently to alarm fatigue. Recognizing that certain individuals may be more prone to alarm fatigue can help to put measures in place to prevent alarm fatigue.

This article examines work-related and personality factors that could influence health providers in experiencing alarm fatigue. The purpose of this study was to provide a basis to determine factors that may predict the potential of alarm fatigue in critical care staff.

This article suggested that the perception of alarms and the emotional response to alarms may be linked to certain personality traits because there has been previous links of information-processing, decision-making processing, stress management and job performance related to personality. The aim of this study was to understand the contributing factors to alarm fatigue so that hospital administrators and nurse leaders could target interventions toward those who were predicted to have alarm fatigue and implement strategies in reducing them.

The Study Details

The study was conducted at an eight-bed ICU in a mid-size hospital in Montana. Data was collected for six-day shifts and six-night shifts involving 24 critical care professionals. Within each 12-hour shift, six 15-minute intervals were randomly generated through work sampling for 6 days; a total of 1,080 observations were collected. Alarm fatigue was assessed with the subjective workload assessment technique and Boredom, Apathy, and Distrust Affects, which were measured through validated questionnaires. The Big Five Personality model was used to assess personality traits. Results determined work factors including task prioritization, nurse-to-patient ratio, and length of shifts were associated with indicators of alarm fatigue. Personality traits of openness, conscientiousness, and neuroticism were also associated. Assessing personality traits for critical care staff to be aware of how their individualities can affect their behavior towards alarm fatigue was the final recommendation.

Clinical Application

This study provided significant insight into personality and behavioral traits that contributed to Alarm Fatigue. Clinical alarms are intended to increase anxiety and indicate a possible change in the patient’s condition. Nurses who scored higher in neuroticism experienced an increase in Alarm Fatigue. Nurses who scored higher in conscientiousness had a negative association with apathy and distrust and were able to plan and organize more effectively to create a goal-orientation routine that resulted in decreased Alarm Fatigue. The conscious nurse does not view alarms as intrusive. Also nurses that score higher in agreeableness had more trust and empathy for other people which represent more cooperation with people and systems making them more likely to respond to alarms and check on patients to ensure they are safe.

This article provided me with insight into the psychological process of responding to alarms. It highlighted that all nurses have unique personalities and processing abilities that affect how they respond to alarms. These factors determine if they are more susceptible to fatigue or not. As a nurse I would use this article to demonstrate how personality contributes to a unit’s environment. It can be helpful to identify individuals upon hiring that would have the qualities needed to become more adjusted to alarm fatigue and it would also provide insight on how to help those who do not have those personality traits learn how to deal with alarm fatigue better.

Article 2: Alarm-Related Workload in Default and Modified Alarm Settings and the Relationship Between Alarm Workload, Alarm Response Rate, and Care Provider Experience: Quantification and Comparison Study

The second consideration regarding Alarm Fatigue is that large quantities of alarms are being used at the default settings. There are multiple research studies that demonstrated that changing the default settings on patient monitors and other equipment that alarms will decrease the number of alarms sounding. The second article suggests individualized alarms with patient specific parameters will decrease the number of false alarms and make nurses more attentive to prioritize actual alarms that represent decompensation and change of conditions.

The findings of this study show that removal of certain nonessential alarms based on patient condition can result in better care provider experience, reduced mental workload, and higher overall satisfaction. The number of managed alarms is directly proportional to workload and the number of errors (error rate) committed and inversely proportional to alarm response rate and care provider experience.

That is, allowing the physiological monitoring device to operate under a default setting based on normal textbook values resulted in more alarms, thereby leading to a higher mental workload while managing these alarms.

The Study Details

This study aimed to assess nurses' perceived workload index of providing care under different clinical alarm settings and establish the relationship between perceived workload, alarm response rate, and care provider experience. In a clinical simulator, 30 participants responded to alarms that occurred on a physiological monitor under 2 conditions (default and modified) for a given clinical condition. Participants completed a National Aeronautics and Space Administration-Task Load Index questionnaire and rated the demand experienced on a 20-point visual analog scale with low and high ratings. A correlational analysis was performed to assess the relationships between the perceived workload score, alarm response rate, and care provider experience. Participants experienced lower workloads when the clinical alarm threshold limits were modified according to patients' clinical conditions. The workload index was higher for the default alarm setting (57.60 [SD 2.59]) than for the modified alarm setting (52.39 [SD 2.29]), with a statistically significant difference of 5.21 (95% CI 3.38-7.04), t₂₈=5.838, P<.05. Significant correlations were found between the workload index and alarm response rate. There was a strong negative correlation between alarm response rate and perceived workload, ρ₂₈=-.54, P<.001 with workload explaining 29% of the variation in alarm response rate. There was a moderate negative correlation between the experience reported during patient care and the perceived workload, ρ₂₈=-.49, P<.05. The perceived workload index was comparatively lower with alarm settings modified for individual patient care than in an unmodified default clinical alarm setting. These findings demonstrate that the modification of clinical alarm limits positively affects the number of alarms accurately addressed, care providers' experience, and overall satisfaction. The findings support the removal of nonessential alarms based on patient conditions, which can help care providers address the remaining alarms accurately and provide better patient care.

Clinical Application

This article showed that participants were able to address almost all presented alarms when the alarm settings were modified according to patient conditions. This finding is consistent with those of similar alarm setting modification studies, which showed that a 43% reduction in alarms is possible through alarm setting customization. There was also more than a 50% reduction in the total rate of alarms per bed per day.  Changing the alarm parameters can decrease the total amount of alarms from 180 per patient per day to 40. Decreasing alarms is also directly linked to the proportion of number of errors committed. The decrease in the number of errors was associated with the decrease in the numbers of alarms that needed addressed. When nurses have fewer false alarm notifications, they can attend to the remaining alarms without errors.

This article showed insight into the number of alarms that a nurse is exposure to daily. It proved that there is a need for modification of the default settings and by applying patient specific parameters alarm fatigue could be decreased, the errors committed would be decreased and the patient would be safer. I will use this article in clinical practice as evidence that devices that emit alarms need to be specifically managed and tailored to each patient. By learning about alarm technology and how to set parameters I will prevent myself from burnout, alarm fatigue and decrease my errors.

Article 3 Effects of monitor alarm management training on nurses' alarm fatigue: A randomized controlled trial

The third area that affects alarm fatigue is the amount of training a nurse receives regarding how to set alarm parameters and recognize alarms. This third category offers solutions to alarm fatigue and includes education, awareness, and different sounds of alarms as solutions.  The third article suggests that implementing a quality alarm management education course can improve the unit’s attention to alarms and decrease fatigue by allowing the nurse to better use the technology. It offers a study done with a quality improvement project implementing cease.

The findings from this article indicate that monitor alarm training based on the theory of planned behavior is effective in reducing nonactionable alarms and lowering alarm fatigue. A training-based program is effective in rebuilding the nurses’ awareness and behavior of alarm management and when hospital administrators implement training programs alarm management ability improves and alarm fatigue decreases.

The Study Details

The aim of the study was to evaluate the effect of monitor alarm management training based on the theory of planned behavior for reducing alarm fatigue in intensive care unit nurses. It was a randomized, single-blind trial with participants in a tertiary A level hospital. 93 ICU clinical nurses were included and randomly assigned to two groups. Nurses in the experimental group (n = 47) received a 12-week alarm management training course based on the theory of planned behavior. Nurses in the control group (n = 46) received regular training. All nurses' alarm fatigue scores were measured with a questionnaire before and after the study period. Total number of alarms, nonactionable alarms and true crisis alarms were recorded continuously throughout the study period. The results indicated that for baseline comparisons, no significant differences were found. By the analysis of independent samples one-way ANCOVAs, the nurses' adjusted alarm fatigue scores at the post-test in the experimental group were significantly lower than those in the control group (p < .001). After the study period, adjusted total number of alarms and nonactionable alarms recorded in the experimental group were both significantly lower than those recorded in the control group (p < .001). After the study period, no significant difference between the two groups was noted in the adjusted number of true crisis alarms (p > .05).

Clinical Application

This article showed that clinical training is an important way for clinical nurses to update their knowledge and promote the transformation of knowledge into clinical behaviors. It utilized the theory of planned behavior and suggested that alarm management behaviors could be reshaped through training of attitudes, norms, perceived control, and awareness. The educational program was identified to enhance the nurse’s skill and knowledge and was a practical economical intervention for alarm management. After the training program, the alarm fatigue scores of nurses decreased in the experimental group.

I will apply this article to clinical practice by advocating for alarm management training. I will promote awareness of programs that can be used to increase my skills of utilization of the alarm features and be more aware of how to change the settings.

Overall Reflection

While conducting research on the issue of Alarm Fatigue I realized that there is a large amount of research studies committed to the topic. I was able to select three articles to frame how I would approach the issue of Alarm Fatigue as a new nurse. The evidence recommends that knowing my personality type and how I handle alarms can contribute to my susceptibility of alarm fatigue. Another factor that contributes are the default alarm settings that alarm when the patient falls outside of the textbook parameters. Customizing these settings will decrease my alarms and errors. And finally, I need to look for a unit that offers a strong alarm management training course so I can learn how to adjust the features on the alarms. If the unit does not have one, I can recommend one citing the third article as evidence.

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What is Alarm Fatigue?

Alarm fatigue is a major problem recognized by both the AACN and the Joint Commission (Dee et al., 2022). 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). 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 (Dee et al., 2022).

According to Torabizadeh et al, (2017), the Emergency Care Research Institute (ECRI) defines alarm fatigue as the emotional pressure care-providers experience when they are exposed to too many alarm sounds. Consequently, the ECRI Institute listed alarm-related hazards among their Top 10 Health Technology Hazards for the year 2020 (Torabizadeh et al., 2017). In other words, alarm fatigue is a phenomenon that occurs when nurses work in a clinical environment where alarm sounds are heard frequently.

Why is it an issue?

In many hospitals, noise levels are above the limits recommended by World Health Organization of 30 decibels (Torabizadeh et al., 2017). Clinical alarms in ICUs were estimated to be more than 80 decibels, which is close to the noise level generated by a pneumatic drill in an operating room (Sinno, et al., 2022).

According to a study by Sinno et al. (2022), medical staff members were repeatedly exposed to an average of 771 patient monitor alarms per patient per day. Medical staff overexposed to alarms may experience a decrease in concentration, become careless, and commit mistakes. Moreover, overexposure may make medical staff less sensitive to alarms and may cause them to cope improperly with significant alarms that can affect patients' safety (Sinno, et al., 2022).

Alarm Fatigue is bad for the nurse’s health.

Loud noises can increase stress, fatigue and tension headaches in medical staff and make concentrating more difficult. Ruettgers et al. (2022) found that high noise levels have also been found to cause tachycardia, with chronic exposure being linked to hypertension, heart disease, and stroke. Research showed that 91% of nurses reported being negatively affected by the noise in their work environment, resulting in irritation, fatigue, concentration problems, tension headache, and burnout (Ruettgers et al., 2022).

Alarm Fatigue is bad for patient’s health.

The psychological pressure caused by frequent exposure to alarm sounds can desensitize nurses to alarm signals, which can in turn lead to negligence of important clinical alarms. As a result of alarm fatigue, nurses may not only become dilatory in responding to clinical alarms, but they may readjust the alarms and adopt settings that are not safe for patients and practically turn the alarm systems silent or off. If doctors or nurses deactivate the alarm sounds, put them on silent, or ignore them, patients’ safety is potentially threatened, and adverse events can occur.

Sinno et al. (2022) also found that alarm fatigue in patients lead to sleep disturbances, higher rate of delirium and delayed recovery. Sivakumaran et al. (2022) stated that exposure to acute noise can cause biological stress reactions, including those marked by changes in the hypothalamic–pituitary–adrenal axis, and immune system. Additionally, exposure to higher levels of noise may increase the risk of short- and long-term cardiovascular events.

Why so many alarms?

Cho et al. (2016), found that according to previous studies, there were no more than 6 types of alarms from one critically ill patient in 1983; however, there were at least 40 types of clinical alarms in 2011.The increased use of patient monitors and alarms and default alarm-setting ranges are principal factors that cause alarm fatigue.

Frequent false alarms may produce the 'cry wolf' effect and cause nurses to regard significant alarms as false and thus fail to respond properly (Cho et al., 2016). It can also make an alarm system less reliable and cause nurses not to use alarm devices. Moreover, false alarms can interfere with nurses’ efficient planning and performance and distract them.

Sinno et al., (2022) also note that false positive alarms can be caused by patient movement or poor skin contact of electrodes and are often clinically non-actionable. Most of these false alarms require no clinical intervention but cause disruption in the healthcare providers’ workflow.

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Beeping IV Pumps | POV: what the beeping IV pump sees... | By Nurse Blake | Facebook

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559K views, 4.9K likes, 347 loves, 2.3K comments, 2.6K shares, Facebook Watch Videos from Nurse Blake: POV: what the beeping IV pump sees...

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Dee et al. (2022) found that approximately 80–99% of alarms are falsely activated due to a combination of human, organizational, and technical factors. Per the Joint Commission, 85–99% of alarm signals do not actually require clinical intervention. When the staff feels the alarms are not accurate, they will not respond. If an alarm system is perceived to be 90% reliable, the response rate will be about 90%; if the alarm system is perceived to be 10% reliable, the response rate will be about 10%. Nurses adjust the order of their activities by evaluating alarm urgency in relation to the patient’s condition.

Overcoming nursing culture is a barrier to alarm fatigue. According to Rodziewicz et al. (2022) nurses should maintain a culture that works toward recognizing safety challenges and implementing viable solutions rather than harboring a culture of blame, shame, and punishment. Healthcare organizations need to establish a culture of safety that focuses on system improvement by viewing medical errors as challenges that must be overcome. All individuals on the healthcare team must play a role in making the provision of healthcare safer for patients and healthcare workers. If the consensus on the unit is to silence, turn off or ignore alarms, then eventually those who are left answering them for all others will stop as well and the patient’s safety is at risk.