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Nurses Current Roles in Alarm Fatigue
The AACN (American Association of Critical Care Nurses) Practice Alert summarizes evidence based practice on ways bedside nurses can aid in reducing false alarms including:

Provide proper skin preparation for and placement of ECG electrodes.

Customize delay and threshold settings on oxygen saturation via pulse oximetry (SpO2) monitors.

Check alarm settings at the start of every shift, with any change in patient condition and with any change in caregiver.

Customize alarm parameter settings for individual patients in accordance with unit or hospital policy.

Provide initial and ongoing education about devices with alarms.

(AACN, 2015)

Is this improving or worsening the issue?

Following the parameters outlined by the AACN, the overall occurrence of false alarms in the critical care setting has decreased. These parameters have improved the issue as shown in Sentara hospitals. At Sentara Princess Anne Hospital (SPAH), nurses provide care utilizing the new model. Nurses initially learn about the model in orientation and it is reinforced with their nurse preceptors. In SPAH's ICU, total monthly alarms went down by 10,000 in just one month
(Sentara Healthcare, 2015).

Attached below is a copy of the current AACN practice alert on alarm fatigue:

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"Alarm fatigue is sensory overload when clinicians are exposed to an excessive number of alarms, which can result in desensitization to alarms and missed alarms" (Sendelbach & Funk, 2014, p. 378).

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The problem with this issue is that life-threatening events in patient care are being missed due to sensory overload. Up to 85% of alarms sounding on hospital units are false alarms signaling no real danger to patients. These false alarms can lead to alarm fatigue and may distract health care providers attention away from significant alarms indicating actual or impending harm (Sendelbach & Funk, 2014).

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Critical care patients hooked up to continuous monitoring systems including: telemetry leads, pulse oximetry, temperature, BIPAP machines, ventilators, and feeding tubes.

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Alarm fatigue can happen to any health care provider who works in a medical institution (hospitals, rehabilitation facilities, nursing homes, outpatient clinics) which handles critical patients.

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These patients are affected as they are medically unstable and in need of close monitoring care.

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After being exposed to alarms for an extended period of time, alarm fatigue can happen to any worker at any point in their career.

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In some hospital units, more than 85% of alarms are false. The large number of false alarms has caused nurses to turn down the volume of audible alarm signals, adjust the alarm settings outside limits that are safe and appropriate for the patient, ignore alarm signals, or even deactivate alarms, which has resulted in drastic events and patient deaths (Sendelbach & Funk, 2014).

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Problems Leading to Alarm Fatigue
-Inappropriate alarm settings

-Persistant A-fib
-Non-actionable events such as PVC's and brief spikes in ST segments

-Patient's bending arms where IV's are inserted
-Wide QRS complexes due to bundle branch block or ventricular pacemaker rhythm
-Vital sign parameter threshold
(Harris et al., 2014)

False Alarms vs. True Alarms
-48 hour study done observing alarm occurrences in 56 ICU beds
-Overall 2,184 clinical alarms were counted for 48 hours of observation. Of these, 1,394 alarms were categorized as false alarms.
- Questionnaires were provided to all nurses regarding alarms on the unit, 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"
(Cho, Kim, Lee, & Cho, 2016)

Nurse's Perception on Alarms
-A quality improvement project was conducted on a 26-bed ICU with 69 full- and part-time nurses to determine nurse's perceptions and attitudes toward alarms.
-Almost all nurses (95%-98%) believed that false alarms are frequent, disrupt care, and reduce trust in alarm systems, causing nurses to inappropriately disable them.
(Sowan, Terriela, Gomez, Reed, & Rapp, 2014).

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Nurses Involvement
The critical care nurse can help decrease the occurrence of alarm fatigue in many ways. The nurse can help by not only following the AACN rules when receiving patients, but also by listening and responding to each patient needs. At the bedside the nurse can change EKG electrodes daily, provide proper skin preparation for all devices connected to the monitor, and use proper oxygen saturation probes and placement. Nurses feeling affected by alarm fatigue need to speak up to let managers know that not enough actions are in place to reduce this concern.

Barriers/Challenges

Time: Asking nurses to change electrodes/pulse ox every shift is another task to add to their already long list of assignments for the day.

Financial: The unit may have to buy extra supplies to meet the needs of daily rotating, establishing new interprofessional teams to dive into the issue means more money for the healthcare company to provide for their employees.

Ethical: The AACN recommends establishing a policy where patient alarms are catered to their condition. Not having every patient hooked up to the same parameters could cause an ethical dilemma as with critical patients you never know when something could go wrong.

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1- Alarm Adjustments
The occurrence of false alarms results from the fact that the parameters are uniform throughout the unit. False alarms could be reduced if the patient's condition was took into perspective when being set up for continuous monitoring. Individualized alarm ranges can help reflect that patient's specific diagnosis and would refrain from alerting the nursing staff with unnecessary information.

2- Secondary Alarm Systems
This incorporates setting up an alarm system that notifies the right health care employee based on the situation. For example, when battery changes are needed this alert could go to the nursing care partner rather than the nurse. This would help reduce the total number of alarms going directly to a single staff member each day.

3- Should They Still Be Monitored?
Avoiding unnecessary monitoring and discontinuing monitoring when it is no longer clinically necessary is a great way to reduce alarm fatigue. The more patients who are being monitored, the more alarms signaling off. Just because we have the technology does not mean we need to use it on every patient. Nurses should question physician orders of monitoring when the patient no longer meets the criteria. Sentara follows the "American Heart Association Practice Standards for ECG Monitoring" to determine the eligibility of each patient. These guidelines are included below and outlined in Table 7 of the following article:

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“The number of alarm signals per patient per day can reach several hundred depending on the unit… translating to thousands of alarm[s] [for each] unit and tens of thousands of alarm[s] throughout the hospital every day.”
-The Joint Commission on Patient Safety

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In my time at SCOHS, I have learned these concepts that will help me take a leadership role transitioning into practice:
1- Listening and Responding
One of the basic nursing skills learned is the importance of listening to each of your patients and taking action in a timely manner. Listening to both verbal concern and equipment alerts should set a trigger off in your mind that further action needs to be taken. Responding to each alarm in a timely manner is important as there is always a reason alarms are going off that must be addressed. I will take this skill with me into practice as a leadership role as I will not only respond to my patient's alarms and concerns, but will make any alarm going off in the unit my top priority.
2-  Attention to Detail
Paying attention to every single detail when providing care to patients is important as the smallest of things can make a big difference in outcome. Whether it is a slight increase in temperature or slight decrease in heart rate, every trend has an explanation in the end. When alarms are going off and the patient is "just one number below the range" or "in A-fib for only 10 seconds", these cannot be ignored. As the nurse you are there to monitor your patients extensively, and that includes noticing slight changes in baselines. In practice, I will use attention to detail to enhance a leadership role as I will not be hesitant to notify my provider if I see a sepsis trend or inform my charge nurse if I suspect an UTI. Not silencing any alarm is important as these alerts are the ones helping you pay attention to every single detail.