This presentation is based on the December 2015 AHRQ WebMampM Spotlight Case See the full article at httpspsnetahrqgov webmm CME credit is available Commentary by Michele M Pelter RN PhD ID: 914915
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Slide1
Spotlight
Harm From Alarm Fatigue
Slide2This 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
Slide3Objectives
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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Slide4Case: 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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Slide5Case: 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
Slide6Background: 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
Slide7Background: 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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Slide8Misreading 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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Slide9Low-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
Slide10Case: 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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Slide11This 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
Slide12Alarms 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
Slide13Arrhythmia 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
Slide14Arrhythmia 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
Slide15A 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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Slide16Alarm 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
Slide17National 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
Slide18Dangers 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
Slide19Device 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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Slide20Device 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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Slide21Individual 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
Slide22Role 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
Slide23Take-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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