EDITOR'S NOTE: Heather Stringer is a freelance writer.
From 2009 to 2012, alarm-related sentinel events were associated with 80 patient deaths that were reported to the commission during those years. One widely reported case involved a 60-year-old man who was admitted to a hospital in Massachusetts after he suffered a head injury from a falling tree branch, according to the Boston Globe. Alarms signaled a rapid heart rate and falling blood oxygen levels, but an hour passed before staff responded. Federal investigators concluded alarm fatigue was a contributing factor in the man’s death.  Reducing the number of alarms in ICUs has become a national priority as entities like the Joint Commission have started requiring hospitals to prioritize alarm safety — or risk losing accreditation. In 2016, hospitals were expected to develop and implement specific components of policies and procedures to address the problem. But knowing which alarms to eliminate is a complex issue, and researcher Halley Ruppel, MS, RN, a doctoral student in the Yale School of Nursing, delved into this question in a recent article published in the American Journal of Critical Care. Ruppel, who worked in pediatric intensive care for seven years, reviewed studies from a 30-year period that classified alarms by accuracy and clinical relevance. The studies focused on physiologic alarms such as patient monitor alarms, ventilator alarms, infusion device alarms and continuous pulse oximetry alarms.

Her review showed measuring accuracy is somewhat straightforward, but assessing clinical relevance is “more subjective because it depends on the context of the patient,” she said, adding, “Both inaccurate and irrelevant alarms contribute to alarm fatigue.”
On any given day in certain hospital units, up to several hundred alarms may sound per patient, according to the Joint Commission. Yet 85% to 99% of these signals do not require clinical intervention, and as a result, nurses can become desensitized to the sounds. This alarm fatigue can ultimately put patient safety at risk.
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Anna Ver Hage, RN
For example, a ventricular tachycardia alarm may signal if a patient is simply moving, which means the alarm is inaccurate. One method that may help to eliminate inaccurate alarms in this scenario is to change electrodes regularly and ensure proper skin preparation for the electrodes, said Ruppel. An example of a clinically irrelevant alarm would be an accurate alert for a transient oxygen desaturation of 89% that does not require action on a nurse’s part, she said. “Nurses usually want to know if oxygen saturation drops below the default setting for a patient, but for patients with COPD, for example, the default may not be an important threshold,” Ruppel said. In these cases, the alarm settings could be customized by a nurse based on a patient’s needs, she said. Her review revealed that only 5% to 13% of the alarms in the studies were clinically relevant and she hopes this data will prompt more research about ways to reduce the number of alarms that are clinically irrelevant.  ECG alarms also are often clinically irrelevant, said Ruppel, and alarm settings can be tailored to address this problem. An athletic patient who has a low normal resting heart rate, for example, may need a different setting than the default configurations. Similarly, PVC [premature ventricular contraction] alarms often don’t require clinical intervention because PVCs are generally not treated, said Ruppel, and “these alarms can be configured to be inaudible in some cases.”  
Customizing monitor settings may be a logical strategy to reduce the number of clinically irrelevant alarms, but training new nurses to tailor settings for each patient requires education, said Ver Hage. For example, new critical care nurses should be taught how to silence arterial line alarms when they are drawing blood for labs, she said, and ideally this type of training should be started by the preceptor during orientation.  Reducing the number of alarms will not only decrease the risk of alarm fatigue, but help nurses avoid the tendency to become dependent on alarms more than their own assessments at the bedside, Ver Hage said. “In the acute care setting where nurses are monitoring multiple devices with alarm capabilities, we can begin to assume that more alarms is better,” she said. “But this is not the case. This can lead to unnecessary distractions and less time to focus on the patient.” Nurses like Ruppel and Ver Hage agree the goal is to create an environment in which the sound of an alarm means action is required, but more studies are needed that measure the clinical relevance of alarms, said Ruppel. Her article focused on physiological monitors for heart rate, oxygen saturation, respiratory rate, arrhythmias and blood pressure, and more research is needed that specifically addresses other device alarms, such as ventilator alarms, she said. “I think it is really important that we tackle this issue from multiple perspectives,” Ruppel said. “Excessive alarms are a patient safety problem, but they are often normalized in ICUs and other acute care environments because they seem like an inevitable part of care.”
Halley Ruppel, RN
In the acute care setting where nurses are monitoring multiple devices with alarm capabilities, we can begin to assume that more alarms is better. But this is not the case.”
— Anna Ver Hage, RN
Respiration alarms on the bedside monitor also could be silenced when patients are intubated, said Anna Ver Hage, AGACNP-BC, CNRN, CCRN, an acute care nurse practitioner at Banner Desert Medical Center in Arizona. “The ventilator alarm will go off if there is a problem, so the respiration alarm on the monitor is redundant,” she said. Irregular heart rate alarms also are frequently turned on for patients with atrial fibrillation, but this alarm is not necessary in a patient with known arrhythmia, said Ver Hage, who authored a continuing education course focused on alarm fatigue.
Stay alert to alarm fatigue triggers
Inaccurate or irrelevant alarms can unnecessarily add to the bells and whistles
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By Heather Stringer
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