Spotlight Harm From Alarm Fatigue - PowerPoint Presentation

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Spotlight

Harm From Alarm Fatigue

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This presentation is based on the December 2015

AHRQ WebM&M Spotlight Case

See the full article at https://psnet.ahrq.gov/webmm CME credit is availableCommentary by: Michele M. Pelter, RN, PhD, and Barbara J. Drew, RN, PhD, University of California, San FranciscoEditor, AHRQ WebM&M: Robert Wachter, MDSpotlight Editor: Bradley A. Sharpe, MDManaging Editor: Erin Hartman, MS

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Source and Credits

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Objectives

At

the conclusion of this educational activity, participants should be able to:Define alarm fatigue and describe potential errors that can occur due to alarm fatigueIdentify federal and national agencies focusing on the issue of alarm fatigueList strategies that nurses and physicians can employ to address alarm fatigue

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Case: Harm From Alarm Fatigue

A 54-year-old man with hypertension, diabetes, and end-stage renal disease on hemodialysis was admitted to the hospital with chest pain. His initial electrocardiogram (ECG) showed no evidence of significant ischemia but cardiac biomarkers (troponin T) were slightly positive. He was admitted to the observation unit, placed on a telemetry monitor, and treated as having a NSTEMI (non-ST segment elevation myocardial infarction).

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Case: Harm From Alarm Fatigue (2)

Overnight, the

patient's telemetry monitor was constantly alarming with warnings of "low voltage" and "asystole." The bedside nurse initially responded to these alarms, checking on him several times and each time finding him to be well. The resident physician responsible for the patient overnight was also paged about the alarms. He came and checked the patient and the alarms and was not concerned. Both clinicians felt the alarms were misreading the telemetry tracings.5

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Background: This Case

The

scenario described is common: skilled and well-intentioned providers diligently respond to repeated false alarms However, excessive false alarms can lead to unintended harm6

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Background: Telemetry Monitoring

Hospitalized patients often monitored using telemetry

A standard electrocardiogram (ECG) acquires data from 12 different leadsTelemetry monitoring is a 5-electrode configurationAcquires 6 limb leads (I, II, III, aVR, aVL, aVF) and 1 chest lead (V)Telemetry display usually only shows 2 leads (often leads II and V)A computer algorithm then continuously analyzes

a limited number of leads (usually 1–2)The algorithm monitors for arrhythmias or other significant changes

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Misreading Asystole

Telemetry devices often misidentify heart rhythms as

asystoleMost common cause is failure to detect low-voltage QRS complexesIn this case, telemetry monitor was "misreading" the patient's heart rhythmTrue asystole would have been clinically apparentThe nurse appropriately checked on the patient and contacted the physicianHowever, the correct response should have been to search for another lead with a larger QRS complex

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Low-Voltage QRS Complex

In a recent study, low-voltage QRS complexes were a major cause of false cardiac monitor alarms

In that study, one patient contributed 5725 arrhythmia alarms due to a low-voltage QRS complex9

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Case: Harm From Alarm Fatigue (3)

The nurse and resident decided to silence all of the telemetry alarms

(this observation unit did not have constant or centralized monitoring of telemetry tracings). The patient was not checked for approximately 4 hours.When the bedside nurse went to perform morning vital signs, the patient was found unresponsive and cold with no pulse. A code blue was called but the patient had been dead for at least a few hours. The cause of death was unclear, but the providers felt the patient likely had a fatal arrhythmia related to his NSTEMI.

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This Case

Silencing all telemetry alarms in this patient was an error that contributed to his death

This patient was at risk for an arrhythmia due to his acute myocardial infarctionPresumably an arrhythmia would have triggered an appropriate alarm had the alarms been functioningThis adverse event reveals a clear hazard associated with hospital alarms11

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Alarms in the Hospital

In general, there are three types of clinical alarms in the hospital

Arrhythmia alarms: detect a change in cardiac rhythmParameter violation alarms: detect when a vital sign (e.g., heart rate, blood pressure, etc.) exceeds the alarm limit settingsTechnical alarms: indicate poor signal quality (e.g., low battery in a telemetry device)12

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Arrhythmia Alarms

Monitor manufacturers never want to miss an important arrhythmia

Thus, alarms are set to "err on the safe side"This results in a nearly 100% sensitivity but a poor specificity for detecting an arrhythmia That is, the devices rarely miss true arrhythmias but at the cost of triggering for many tracings that are not true arrhythmias13

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Arrhythmia Alarms (2)

In an analysis of 77 intensive care unit (ICU) beds over a 31-day period, there were 381,560 audible alarms (all kinds)

This is an average of 187 audible alarms per ICU bed each dayOf the 12,671 arrhythmia alarms, 88.8% were false alarms and not true arrhythmias14

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A Fatal Case of Alarm Fatigue

Patient safety concerns surrounding excessive alarm burden garnered

attention in 2010 after a highly publicized death at a well-known academic medical centerIn that case, there were repeated low heart rate alarms before the patient's cardiac arrestNo one working that day recalled hearing the alarmsIn the investigation, the Centers for Medicare and Medicaid Services (CMS) reported that alarm fatigue contributed to the patient's death

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Alarm Fatigue

Alarm fatigue occurs when clinicians are desensitized by numerous alarms

Many alarms are false or clinically irrelevantAlarm fatigue is not surprising given the frequency of alarmsNearly 190 audible alarms each day for each patient in the ICUIf only 10% are true alarms, then the nurse is responding to 170 false audible alarms each day, or more than 7 per hour16

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National Focus on Alarm Fatigue

Federal agencies and national organizations have disseminated alerts about alarm fatigue

Warnings have been issued about deaths due to silencing alarms on patient monitoring devicesAlarm fatigue was listed as the number one hazard of health technology in 2015 (4th year in a row)The Joint Commission established alarm safety as a National Patient Safety Goal in 201417

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Dangers of Excessive Alarms

The biggest harm from alert fatigue is that a patient develops a life-threatening problem that is missed because of excessive false alarms

Many factors result in excessive cardiac monitor alarms including:Alarm settings not tailored for the individual patientPresence of certain patient conditions like low ECG voltage, pacemaker, or a bundle branch blockDeficiencies in the computer algorithm18

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Device Settings to Combat Alarm Fatigue

Hospital alarm default settings can be reviewed to determine if some alarms that don't require intervention can be changed to inaudible text message alerts

Devices can be modified to maximize accuracy in identifying true clinical concernsFor example, in a patient with persistent atrial fibrillation triggering repeated alarms, the monitor could generate a prompt, "Do you want to continue to hear an atrial fibrillation alarm?"

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Device Settings to Combat Alarm Fatigue (2)

Creating algorithms that analyze all available ECG leads, rather than just a few, could minimize number of false alarms

Algorithms that integrate parameters (e.g., link heart rate and blood pressure) check to see if there was a physiologic response with the alarmFor instance, an algorithm-defined asystole event not associated with a simultaneous drop in blood pressure would be re-defined as false and would not trigger alarm

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Individual Strategies to Reduce Alarm Fatigue

Individual nurses and providers can take steps at the bedside to improve the usefulness of alarms

Nurses can tailor alarms to an individual patientDefault settings may not make sense for every patient21

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Role of Institutions in Reducing Alarm Fatigue

To

address alarm management, committees should be formed and include representatives from all levels of the organization All staff who interact with monitoring devices should receive education and training on how to use monitoring equipment22

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Take-Home Points

Alarms

should never be completely silenced; clinical staff should instead problem-solve why an alarm condition is occurring and work to resolve itCardiac monitor devices have a high sensitivity for detecting arrhythmias and vital sign changes but a low specificityTherefore, they generate many false positive alarms

Clinicians should learn to tailor alarm thresholds to individual patients to avoid

excessive alarms and alarm

fatigue

Alarm safety is a National Patient Safety Goal, highlighting the importance of developing institutional policies and

standards

to improve awareness

and design

interventions to reduce the burden

on clinicians

, while ensuring

patient safety

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