Recommended
Recommended
More Related Content
Similar to Assignment Steps Resources Tutorial help on Excel® and Word fun.docx
Similar to Assignment Steps Resources Tutorial help on Excel® and Word fun.docx (17)
More from lynettearnold46882
More from lynettearnold46882 (20)
Recently uploaded
Recently uploaded (20)
Assignment Steps Resources Tutorial help on Excel® and Word fun.docx
- 1. Assignment Steps Resources: Tutorial help on Excel® and Word functions can be found on the Microsoft® Office website. There are also additional tutorials via the web offering support for Office products. Scenario: Imagine you are a business consultant to a firm of your choice. You have been asked to analyze, advise, and create recommendations on how the firm can ensure its future success in its current market. Work with your instructor to choose a firm that matches the following criteria: a publicly-traded company operating in the U.S. market. Note: A publicly-traded company is a private- sector firm owned by its shareholders/stock holders. Prepare a minimum 1,050-word analysis of economic data and business data to explain how the core economic principles impact the sustainability of the firm and what actions the firm can take to ensure success. Address the following: · Identify the market structure your chosen firm operates in, analyze your chosen firm's current market share, and identify the firm's local/global competitors. Analyze the barriers to entry in this market to illustrate the potential for new competition and its impact on your firm's future in the market. Hints: Be sure you review the barriers to entry discussed in the course text. You might consider presenting the data graphically. · Identify and explain trends in current macroeconomic indicators for last three years including: · Current stage of the business cycle. · Real gross domestic product (GDP). · Inflation as measured by the consumer price index (CPI). · Unemployment rate. · Federal funds rate. · Current rate for borrowing funds such as the so-called "prime rate." Note: A requirement of the Week 1 Influence of
- 2. Economics on Household Decision Making report was to gather data on the CPI, GDP, and interest rates, so you should consider reviewing the feedback you received on the Week 1 report. · Evaluate trends in demand over last three years and explain their impact on the industry and the firm. Include quarterly (last two quarters) and annual sales (last three years) figures for the product your firm sells. Create business strategies by analyzing information and data related to the demand for and supply of your firm's product(s) to support your recommendation for the firm's actions. Remember to include a graphical representation of the data and information used in your analysis. · Examine available, current data and information, such as pricing and the availability of substitutes, and explain how you could determine the price elasticity of demand for your firm's product. Assess how the price elasticity of demand impacts the firm's pricing decisions and revenue growth. · Apply the concepts of variable and fixed costs to your firm for informing its output decisions. For instance, analyze how different kinds of costs (labor, research and development, raw materials) affect the firm's level of output. · Based on the data gathered and analysis performed for this report write a conclusion in which you: · Create business strategies, including price and non-price strategies, based on your market structure to ensure the market share and potential market expansions and explore global opportunities for your business in a dynamic business environment and provide recommendations. · Develop a recommendation for how the firm can manage its future production by synthesizing the macroeconomic and microeconomic data presented. · Propose how the firm's position within the market and among its competitors will allow it to take your recommended action. · Recommend strategies for the firm to sustain its success going forward by evaluating the findings from demand trends, price elasticity, current stage of the business cycle, and government policies.
- 3. Cite a minimum of three peer-reviewed references and a minimum of two government economic data sources/references. REVIEWS Systematic Review of Physiologic Monitor Alarm Characteristics and Pragmatic Interventions to Reduce Alarm Frequency Christine Weirich Paine, MPH1,2, Veena V. Goel, MD3,4,5,6, Elizabeth Ely, PhD, RN7, Christopher D. Stave, MLS8, Shannon Stemler, BA1, Miriam Zander, BA1, Christopher P. Bonafide, MD, MSCE1,9,10,11* 1Division of General Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; 2 PolicyLab, The Children’s Hospital of Philadel- phia, Philadelphia, Pennsylvania; 3 Department of Pediatrics, Stanford University School of Medicine, Stanford, California; 4 Division of Systems Medi- cine, Stanford University School of Medicine, Stanford, California; 5 Department of Clinical Informatics, Stanford Children’s Health, Stanford, California; 6 Division of Pediatric Hospital Medicine, Lucile Packard Children’s Hospital Stanford, Palo Alto, California; 7 Center for Pediatric Nursing Research and Evidence-Based Practice, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; 8 Lane Medical Library, Stanford Univer- sity School of Medicine, Stanford, California; 9 Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadel- phia, Pennsylvania; 10 Center for Pediatric Clinical
- 4. Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; 11Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania. BACKGROUND: Alarm fatigue from frequent nonactionable physiologic monitor alarms is frequently named as a threat to patient safety. PURPOSE: To critically examine the available literature rele- vant to alarm fatigue. DATA SOURCES: Articles published in English, Spanish, or French between January 1980 and April 2015 indexed in PubMed, Cumulative Index to Nursing and Allied Health Lit- erature, Scopus, Cochrane Library, Google Scholar, and ClinicalTrials.gov. STUDY SELECTION: Articles focused on hospital physio- logic monitor alarms addressing any of the following: (1) the proportion of alarms that are actionable, (2) the relationship between alarm exposure and nurse response time, and (3) the effectiveness of interventions in reducing alarm frequency. DATA EXTRACTION: We extracted data on setting, collec- tion methods, proportion of alarms determined to be action- able, nurse response time, and associations between interventions and alarm rates. DATA SYNTHESIS: Our search produced 24 observational studies focused on alarm characteristics and response time and 8 studies evaluating interventions. Actionable alarm proportion ranged from <1% to 36% across a range of hos- pital settings. Two studies showed relationships between high alarm exposure and longer nurse response time. Most
- 5. intervention studies included multiple components imple- mented simultaneously. Although studies varied widely, and many had high risk of bias, promising but still unproven interventions include widening alarm parameters, instituting alarm delays, and using disposable electrocardiographic wires or frequently changed electrocardiographic electrodes. CONCLUSIONS: Physiologic monitor alarms are commonly nonactionable, and evidence supporting the concept of alarm fatigue is emerging. Several interventions have the potential to reduce alarms safely, but more rigorously designed studies with attention to possible unintended con- sequences are needed. Journal of Hospital Medicine 2016;11:136–144. VC 2015 Society of Hospital Medicine Clinical alarm safety has become a recent target for improvement in many hospitals. In 2013, The Joint Commission released a National Patient Safety Goal prompting accredited hospitals to establish alarm safety as a hospital priority, identify the most impor- tant alarm signals to manage, and, by 2016, develop policies and procedures that address alarm manage- ment.1 In addition, the Emergency Care Research Institute has named alarm hazards the top health tech- nology hazard each year since 2012.2 The primary arguments supporting the elevation of alarm management to a national hospital priority in the United States include the following: (1) clinicians rely on alarms to notify them of important physiologic changes, (2) alarms occur frequently and usually do not warrant clinical intervention, and (3) alarm over- load renders clinicians unable to respond to all alarms, resulting in alarm fatigue: responding more slowly or ignoring alarms that may represent actual
- 6. clinical deterioration.3,4 These arguments are built largely on anecdotal data, reported safety event data- bases, and small studies that have not previously been systematically analyzed. Despite the national focus on alarms, we still know very little about fundamental questions key to improv- ing alarm safety. In this systematic review, we aimed to answer 3 key questions about physiologic monitor alarms: (1) What proportion of alarms warrant atten- tion or clinical intervention (ie, “actionable” alarms), and how does this proportion vary between adult and *Address for correspondence and reprint requests: Christopher P. Bonafide, MD, MSCE, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104; Telephone: 267-426- 2901; E-mail: [email protected] Additional Supporting Information may be found in the online version of this article. Received: July 18, 2015; Revised: October 1, 2015; Accepted: October 6, 2015 2015 Society of Hospital Medicine DOI 10.1002/jhm.2520 Published online in Wiley Online Library (Wileyonlinelibrary.com). 136 An Official Publication of the Society of Hospital Medicine Journal of Hospital Medicine Vol 11 | No 2 | February 2016
- 7. pediatric populations and between intensive care unit (ICU) and ward settings? (2) What is the relationship between alarm exposure and clinician response time? (3) What interventions are effective in reducing the frequency of alarms? We limited our scope to monitor alarms because few studies have evaluated the characteristics of alarms from other medical devices, and because miss- ing relevant monitor alarms could adversely impact patient safety. METHODS We performed a systematic review of the literature in accordance with the Meta-Analysis of Observational Studies in Epidemiology guidelines5 and developed this manuscript using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.6 Eligibility Criteria With help from an experienced biomedical librarian (C.D.S.), we searched PubMed, the Cumulative Index to Nursing and Allied Health Literature, Scopus, Cochrane Library, ClinicalTrials.gov, and Google Scholar from January 1980 through April 2015 (see Supporting Information in the online version of this article for the search terms and queries). We hand searched the reference lists of included articles and reviewed our personal libraries to identify additional relevant studies. We included peer-reviewed, original research studies published in English, Spanish, or French that addressed the questions outlined above. Eligible patient populations were children and adults admitted
- 8. to hospital inpatient units and emergency departments (EDs). We excluded alarms in procedural suites or operating rooms (typically responded to by anesthesi- ologists already with the patient) because of the differ- ences in environment of care, staff-to-patient ratio, and equipment. We included observational studies reporting the actionability of physiologic monitor alarms (ie, alarms warranting special attention or clin- ical intervention), as well as nurse responses to these alarms. We excluded studies focused on the effects of alarms unrelated to patient safety, such as families’ and patients’ stress, noise, or sleep disturbance. We included only intervention studies evaluating prag- matic interventions ready for clinical implementation (ie, not experimental devices or software algorithms). Selection Process and Data Extraction First, 2 authors screened the titles and abstracts of articles for eligibility. To maximize sensitivity, if at least 1 author considered the article relevant, the arti- cle proceeded to full-text review. Second, the full texts of articles screened were independently reviewed by 2 authors in an unblinded fashion to determine their eli- gibility. Any disagreements concerning eligibility were resolved by team consensus. To assure consistency in eligibility determinations across the team, a core group of the authors (C.W.P, C.P.B., E.E., and V.V.G.) held a series of meetings to review and dis- cuss each potentially eligible article and reach consen- sus on the final list of included articles. Two authors independently extracted the following characteristics from included studies: alarm review methods, analytic design, fidelity measurement, consideration of unin- tended adverse safety consequences, and key results. Reviewers were not blinded to journal, authors, or
- 9. affiliations. Synthesis of Results and Risk Assessment Given the high degree of heterogeneity in methodol- ogy, we were unable to generate summary proportions of the observational studies or perform a meta- analysis of the intervention studies. Thus, we organ- ized the studies into clinically relevant categories and presented key aspects in tables. Due to the heterogene- ity of the studies and the controversy surrounding quality scores,5 we did not generate summary scores of study quality. Instead, we evaluated and reported key design elements that had the potential to bias the results. To recognize the more comprehensive studies in the field, we developed by consensus a set of char- acteristics that distinguished studies with lower risk of bias. These characteristics are shown and defined in Table 1. For the purposes of this review, we defined nonac- tionable alarms as including both invalid (“false”) alarms that do not that accurately represent the physi- ologic status of the patient and alarms that are valid but do not warrant special attention or clinical inter- vention (“nuisance” alarms). We did not separate out invalid alarms due to the tremendous variation between studies in how validity was measured. RESULTS Study Selection Search results produced 4629 articles (see the flow diagram in the Supporting Information in the online version of this article), of which 32 articles were eligi- ble: 24 observational studies describing alarm charac- teristics and 8 studies describing interventions to reduce alarm frequency.
- 10. Observational Study Characteristics Characteristics of included studies are shown in Table 1. Of the 24 observational studies,7–30 15 included adult patients,7–21 7 included pediatric patients,22–28 and 2 included both adult and pediatric patients.29,30 All were single-hospital studies, except for 1 study by Chambrin and colleagues10 that included 5 sites. The number of patient-hours examined in each study ranged from 60 to 113,880.7–11,13–16,18–27,29,30 Hospital settings included ICUs (n 5 16),9–11,13,14,16–19,22–27,29 general wards (n 5 5),12,15,20,22,28 EDs (n 5 2),7,21 postanesthesia care unit Review of Physiologic Monitor Alarms | Paine et al An Official Publication of the Society of Hospital Medicine Journal of Hospital Medicine Vol 11 | No 2 | February 2016 137 T A B L E 1 . G e n e ra
- 82. te d us in g st at ist ic al pr oc es s co nt ro lc ha rts . Paine et al | Review of Physiologic Monitor Alarms 138 An Official Publication of the Society of Hospital Medicine
- 83. Journal of Hospital Medicine Vol 11 | No 2 | February 2016 (PACU) (n 5 1),30 and cardiac care unit (CCU) (n 5 1).8 Studies varied in the type of physiologic signals recorded and data collection methods, ranging from direct observation by a nurse who was simultaneously caring for patients29 to video recording with expert review.14,19,22 Four observational studies met the criteria for lower risk of bias.11,14,15,22 Intervention Study Characteristics Of the 8 intervention studies, 7 included adult patients,31–37 and 1 included pediatric patients.38 All were single-hospital studies; 6 were quasi- experimental31,33–35,37,38 and 2 were experimental.32,36 Settings included progressive care units (n 5 3),33–35 CCUs (n 5 3),32,33,37 wards (n 5 2),31,38 PACU (n 5 1),36 and a step-down unit (n 5 1).32 All except 1 study32 used the monitoring system to record alarm data. Several studies evaluated multicomponent inter- ventions that included combinations of the following: widening alarm parameters,31,35–38 instituting alarm delays,31,34,36,38 reconfiguring alarm acuity,35,37 use of secondary notifications,34 daily change of electro- cardiographic electrodes or use of disposable electro- cardiographic wires,32,33,38 universal monitoring in high-risk populations,31 and timely discontinuation of monitoring in low-risk populations.38 Four interven- tion studies met our prespecified lower risk of bias criteria.31,32,36,38
- 84. Proportion of Alarms Considered Actionable Results of the observational studies are provided in Table 2. The proportion of alarms that were action- able was <1% to 26% in adult ICU set- tings,9–11,13,14,16,17,19 20% to 36% in adult ward settings,12,15,20 17% in a mixed adult and pediatric PACU setting,30 3% to 13% in pediatric ICU set- tings,22–26 and 1% in a pediatric ward setting.22 Relationship Between Alarm Exposure and Response Time Whereas 9 studies addressed response time,8,12,17,18,20–22,27,28 only 2 evaluated the relation- ship between alarm burden and nurse response time.20,22 Voepel-Lewis and colleagues found that nurse responses were slower to patients with the high- est quartile of alarms (57.6 seconds) compared to those with the lowest (45.4 seconds) or medium (42.3 seconds) quartiles of alarms on an adult ward (P 5 0.046). They did not find an association between false alarm exposure and response time.20 Bonafide and colleagues found incremental increases in response time as the number of nonactionable alarms in the preceding 120 minutes increased (P < 0.001 in the pediatric ICU, P 5 0.009 on the pediatric ward).22 Interventions Effective in Reducing Alarms Results of the 8 intervention studies are provided in Table 3. Three studies evaluated single interven- tions;32,33,36 the remainder of the studies tested inter- ventions with multiple components such that it was impossible to separate the effect of each component. Below, we have summarized study results, arranged by component. Because only 1 study focused on pedi- atric patients,38 results from pediatric and adult set-
- 85. tings are combined. Widening alarm parameter default settings was evaluated in 5 studies:31,35–38 1 single intervention randomized controlled trial (RCT),36 and 4 multiple- intervention, quasi-experimental studies.31,35,37,38 In the RCT, using a lower SpO2 limit of 85% instead of the standard 90% resulted in 61% fewer alarms. In the 4 multiple intervention studies, 1 study reported significant reductions in alarm rates (P < 0.001),37 1 study did not report preintervention alarm rates but reported a postintervention alarm rate of 4 alarms per patient-day,31 and 2 studies reported reductions in alarm rates but did not report any statistical test- ing.35,38 Of the 3 studies examining patient safety, 1 study with universal monitoring reported fewer rescue events and transfers to the ICU postimplementation,31 1 study reported no missed acute decompensations,38 and 1 study (the RCT) reported significantly more true hypoxemia events (P 5 0.001).36 Alarm delays were evaluated in 4 studies:31,34,36,38 3 multiple-intervention, quasi-experimental stud- ies31,34,38 and 1 retrospective analysis of data from an RCT.36 One study combined alarm delays with wid- ening defaults in a universal monitoring strategy and reported a postintervention alarm rate of 4 alarms per patient.31 Another study evaluated delays as part of a secondary notification pager system and found a nega- tively sloping regression line that suggested a decreas- ing alarm rate, but did not report statistical testing.34 The third study reported a reduction in alarm rates
- 86. but did not report statistical testing.38 The RCT com- pared the impact of a hypothetical 15-second alarm delay to that of a lower SpO2 limit reduction and reported a similar reduction in alarms.36 Of the 4 studies examining patient safety, 1 study with univer- sal monitoring reported improvements,31 2 studies reported no adverse outcomes,35,38 and the retrospec- tive analysis of data from the RCT reported the theo- retical adverse outcome of delayed detection of sudden, severe desaturations.36 Reconfiguring alarm acuity was evaluated in 2 stud- ies, both of which were multiple-intervention quasi- experimental studies.35,37 Both showed reductions in alarm rates: 1 was significant without increasing adverse events (P < 0.001),37 and the other did not report statistical testing or safety outcomes.35 Secondary notification of nurses using pagers was the main intervention component of 1 study incorpo- rating delays between the alarms and the alarm pages.34 As mentioned above, a negatively sloping regression line was displayed, but no statistical testing or safety outcomes were reported. Review of Physiologic Monitor Alarms | Paine et al An Official Publication of the Society of Hospital Medicine Journal of Hospital Medicine Vol 11 | No 2 | February 2016 139 T A B
- 137. sc rip tio n of da ta co lle ct io n m et ho ds . Paine et al | Review of Physiologic Monitor Alarms 140 An Official Publication of the Society of Hospital Medicine Journal of Hospital Medicine Vol 11 | No 2 | February 2016 T A
- 179. ta tio n co un tn ot re po rte d. Review of Physiologic Monitor Alarms | Paine et al An Official Publication of the Society of Hospital Medicine Journal of Hospital Medicine Vol 11 | No 2 | February 2016 141 Disposable electrocardiographic lead wires or daily electrode changes were evaluated in 3 studies:32,33,38 1 single intervention cluster-randomized trial32 and 2 quasi-experimental studies.33,38 In the cluster- randomized trial, disposable lead wires were com- pared to reusable lead wires, with disposable lead wires having significantly fewer technical alarms for lead signal failures (P 5 0.03) but a similar number of monitoring artifact alarms (P 5 0.44).32 In a single-intervention, quasi-experimental study, daily electrode change showed a reduction in alarms, but no statistical testing was reported.33 One multiple-
- 180. intervention, quasi-experimental study incorporating daily electrode change showed fewer alarms without statistical testing.38 Of the 2 studies examining patient safety, both reported no adverse outcomes.32,38 DISCUSSION This systematic review of physiologic monitor alarms in the hospital yielded the following main findings: (1) between 74% and 99% of physiologic monitor alarms were not actionable, (2) a significant relationship between alarm exposure and nurse response time was demonstrated in 2 small observational studies, and (3) although interventions were most often studied in combination, results from the studies with lower risk of bias suggest that widening alarm parameters, implementing alarm delays, and using disposable elec- trocardiographic lead wires and/or changing electrodes daily are the most promising interventions for reduc- ing alarms. Only 5 of 8 intervention studies measured intervention safety and found that widening alarm parameters and implementing alarm delays had mixed safety outcomes, whereas disposable electrocardio- graphic lead wires and daily electrode changes had no adverse safety outcomes.29,30,34–36 Safety measures are crucial to ensuring the highest level of patient safety is met; interventions are rendered useless without ensur- ing actionable alarms are not disabled. The variation in results across studies likely reflects the wide range of care settings as well as differences in design and quality. This field is still in its infancy, with 18 of the 32 articles published in the past 5 years. We anticipate improvements in quality and rigor as the field matures, as well as clinically tested interventions that incorporate smart alarms. Smart alarms integrate data
- 181. from multiple physiologic signals and the patient’s his- tory to better detect physiologic changes in the patient and improve the positive predictive value of alarms. Academic–industry partnerships will be required to implement and rigorously test smart alarms and other emerging technologies in the hospital. To our knowledge, this is the first systematic review focused on monitor alarms with specific review ques- tions relevant to alarm fatigue. Cvach recently pub- lished an integrative review of alarm fatigue using research published through 2011.39 Our review builds upon her work by contributing a more extensive and systematic search strategy with databases spanning nursing, medicine, and engineering, including addi- tional languages, and including newer studies pub- lished through April 2015. In addition, we included multiple cross-team checks in our eligibility review to ensure high sensitivity and specificity of the resulting set of studies. Although we focused on interventions aiming to reduce alarms, there has also been important recent work focused on reducing telemetry utilization in adult hospital populations as well as work focused on reduc- ing pulse oximetry utilization in children admitted with respiratory conditions. Dressler and colleagues reported an immediate and sustained reduction in telemetry utili- zation in hospitalized adults upon redesign of cardiac telemetry order sets to include the clinical indication, which defaulted to the American Heart Association guideline-recommended telemetry duration.40 Instruc- tions for bedside nurses were also included in the order set to facilitate appropriate telemetry discontinuation. Schondelmeyer and colleagues reported reductions in
- 182. continuous pulse oximetry utilization in hospitalized children with asthma and bronchiolitis upon introduc- tion of a multifaceted quality improvement program that included provider education, a nurse handoff checklist, and discontinuation criteria incorporated into order sets.41 Limitations of This Review and the Underlying Body of Work There are limitations to this systematic review and its underlying body of work. With respect to our approach to this systematic review, we focused only on monitor alarms. Numerous other medical devices generate alarms in the patient-care environment that also can contribute to alarm fatigue and deserve equally rigorous evaluation. With respect to the underlying body of work, the quality of individual studies was generally low. For example, determina- tions of alarm actionability were often made by a sin- gle rater without evaluation of the reliability or validity of these determinations, and statistical testing was often missing. There were also limitations specific to intervention studies, including evaluation of nonge- neralizable patient populations, failure to measure the fidelity of the interventions, inadequate measures of intervention safety, and failure to statistically evaluate alarm reductions. Finally, though not necessarily a limitation, several studies were conducted by authors involved in or funded by the medical device indus- try.11,15,19,31,32 This has the potential to introduce bias, although we have no indication that the quality of the science was adversely impacted. Moving forward, the research agenda for physio- logic monitor alarms should include the following: (1) more intensive focus on evaluating the relationship
- 183. between alarm exposure and response time with Paine et al | Review of Physiologic Monitor Alarms 142 An Official Publication of the Society of Hospital Medicine Journal of Hospital Medicine Vol 11 | No 2 | February 2016 analysis of important mediating factors that may pro- mote or prevent alarm fatigue, (2) emphasis on study- ing interventions aimed at improving alarm management using rigorous designs such as cluster- randomized trials and trials randomized by individual participant, (3) monitoring and reporting clinically meaningful balancing measures that represent unin- tended consequences of disabling or delaying poten- tially important alarms and possibly reducing the clinicians’ ability to detect true patient deterioration and intervene in a timely manner, and (4) support for transparent academic–industry partnerships to evalu- ate new alarm technology in real-world settings. As evidence-based interventions emerge, there will be new opportunities to study different implementa- tion strategies of these interventions to optimize effectiveness. CONCLUSIONS The body of literature relevant to physiologic moni- tor alarm characteristics and alarm fatigue is limited but growing rapidly. Although we know that most alarms are not actionable and that there appears to be a relationship between alarm exposure and response time that could be caused by alarm fatigue, we cannot yet say with certainty that we know which interventions are most effective in safely reducing
- 184. unnecessary alarms. Interventions that appear most promising and should be prioritized for intensive evaluation include widening alarm parameters, imple- menting alarm delays, and using disposable electro- cardiographic lead wires and changing electrodes daily. Careful evaluation of these interventions must include systematically examining adverse patient safety consequences. Acknowledgements: The authors thank Amogh Karnik and Micheal Sell- ars for their technical assistance during the review and extraction process. Disclosures: Ms. Zander is supported by the Society of Hospital Medi- cine Student Hospitalist Scholar Grant. Dr. Bonafide and Ms. Stemler are supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number K23HL116427. The content is solely the responsibility of the authors and does not necessar- ily represent the official views of the National Institutes of Health. The authors report no conflicts of interest. References 1. National Patient Safety Goals Effective January 1, 2015. The Joint Commission Web site. http://www.jointcommission.org/assets/1/6/ 2015_NPSG_HAP.pdf. Accessed July 17, 2015.
- 185. 2. ECRI Institute. 2015 Top 10 Health Technology Hazards. Available at: https://www.ecri.org/Pages/2015-Hazards.aspx. Accessed June 23, 2015. 3. Sendelbach S, Funk M. Alarm fatigue: a patient safety concern. AACN Adv Crit Care. 2013;24(4):378–386. 4. Chopra V, McMahon LF Jr. Redesigning hospital alarms for patient safety: alarmed and potentially dangerous. JAMA. 2014;311(12): 1199–1200. 5. Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observatio- nal studies in epidemiology: a proposal for reporting. Meta- analysis Of Observational Studies in Epidemiology (MOOSE) Group. JAMA. 2000;283(15):2008–2012. 6. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta- analyses: the PRISMA statement. Ann Intern Med. 2009;151(4):264– 269, W64. 7. Atzema C, Schull MJ, Borgundvaag B, Slaughter GRD, Lee CK. ALARMED: adverse events in low-risk patients with chest pain receiving continuous electrocardiographic monitoring in the emer-
- 186. gency department. A pilot study. Am J Emerg Med. 2006;24:62– 67. 8. Billinghurst F, Morgan B, Arthur HM. Patient and nurse- related implications of remote cardiac telemetry. Clin Nurs Res. 2003;12(4): 356–370. 9. Biot L, Carry PY, Perdrix JP, Eberhard A, Baconnier P. Clinical evalu- ation of alarm efficiency in intensive care [in French]. Ann Fr Anesth Reanim. 2000;19:459–466. 10. Chambrin MC, Ravaux P, Calvelo-Aros D, Jaborska A, Chopin C, Boniface B. Multicentric study of monitoring alarms in the adult intensive care unit (ICU): a descriptive analysis. Intensive Care Med. 1999;25:1360–1366. 11. Drew BJ, Harris P, Zègre-Hemsey JK, et al. Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational study of consecutive intensive care unit patients. PloS One. 2014;9(10):e110274. 12. Gazarian PK. Nurses’ response to frequency and types of electrocardi- ography alarms in a non- critical care setting: a descriptive study. Int J Nurs Stud. 2014;51(2):190–197.
- 187. 13. G€orges M, Markewitz BA, Westenskow DR. Improving alarm per- formance in the medical intensive care unit using delays and clinical context. Anesth Analg. 2009;108:1546–1552. 14. Inokuchi R, Sato H, Nanjo Y, et al. The proportion of clinically relevant alarms decreases as patient clinical severity decreases in inten- sive care units: a pilot study. BMJ Open. 2013;3(9):e003354– e003354. 15. Gross B, Dahl D, Nielsen L. Physiologic monitoring alarm load on medical/surgical floors of a community hospital. Biomed Instrum Technol. 2011;45:29–36. 16. Koski EM, M€akivirta A, Sukuvaara T, Kari A. Frequency and reliabil- ity of alarms in the monitoring of cardiac postoperative patients. Int J Clin Monit Comput. 1990;7(2):129–133. 17. Morales S"anchez C, Murillo P"erez MA, Torrente Vela S, et al. Audit of the bedside monitor alarms in a critical care unit [in Spanish]. Enferm Intensiva. 2014;25(3):83–90. 18. Pergher AK, da Silva RCL. Stimulus-response time to invasive blood pressure alarms: implications for the safety of critical-care patients.
- 188. Rev Ga"ucha Enferm. 2014;35(2):135–141. 19. Siebig S, Kuhls S, Imhoff M, Gather U, Scholmerich J, Wrede CE. Intensive care unit alarms— how many do we need? Crit Care Med. 2010;38:451–456. 20. Voepel-Lewis T, Parker ML, Burke CN, et al. Pulse oximetry desatu- ration alarms on a general postoperative adult unit: a prospective observational study of nurse response time. Int J Nurs Stud. 2013; 50(10):1351–1358. 21. Way RB, Beer SA, Wilson SJ. Whats that noise? Bedside monitoring in the Emergency Department. Int Emerg Nurs. 2014;22(4):197– 201. 22. Bonafide CP, Lin R, Zander M, et al. Association between exposure to nonactionable physiologic monitor alarms and response time in a children’s hospital. J Hosp Med. 2015;10(6):345–351. 23. Lawless ST. Crying wolf: false alarms in a pediatric intensive care unit. Crit Care Med. 1994;22(6):981–985. 24. Rosman EC, Blaufox AD, Menco A, Trope R, Seiden HS. What are we missing? Arrhythmia detection in the pediatric intensive care unit. J Pediatr. 2013;163(2):511–514.
- 189. 25. Talley LB, Hooper J, Jacobs B, et al. Cardiopulmonary monitors and clinically significant events in critically ill children. Biomed Instrum Technol. 2011;45(s1):38–45. 26. Tsien CL, Fackler JC. Poor prognosis for existing monitors in the intensive care unit. Crit Care Med. 1997;25:614–619. 27. van Pul C, VD Mortel H, VD Bogaart J, Mohns T, Andriessen P. Safe patient monitoring is challenging but still feasible in a neonatal inten- sive care unit with single family rooms. Acta Paediatr Oslo Nor 1992. 2015;104(6):e247–e254. 28. Varpio L, Kuziemsky C, Macdonald C, King WJ. The helpful or hindering effects of in-hospital patient monitor alarms on nurses: a qualitative analysis. CIN Comput Inform Nurs. 2012;30(4):210– 217. 29. O’Carroll T. Survey of alarms in an intensive therapy unit. Anaesthe- sia. 1986;41(7):742–744. 30. Wiklund L, H€ok B, Ståhl K, Jordeby-J€onsson A. Postanesthesia moni- toring revisited: frequency of true and false alarms from different monitoring devices. J Clin Anesth. 1994;6(3):182–188.
- 190. 31. Taenzer AH, Pyke JB, McGrath SP, Blike GT. Impact of pulse oxime- try surveillance on rescue events and intensive care unit transfers: a before-and-after concurrence study. Anesthesiology. 2010;112(2): 282–287. 32. Albert NM, Murray T, Bena JF, et al. Differences in alarm events between disposable and reusable electrocardiography lead wires. Am J Crit Care. 2015;24(1):67–74. Review of Physiologic Monitor Alarms | Paine et al An Official Publication of the Society of Hospital Medicine Journal of Hospital Medicine Vol 11 | No 2 | February 2016 143 33. Cvach MM, Biggs M, Rothwell KJ, Charles-Hudson C. Daily elec- trode change and effect on cardiac monitor alarms: an evidence- based practice approach. J Nurs Care Qual. 2013;28:265–271. 34. Cvach MM, Frank RJ, Doyle P, Stevens ZK. Use of pagers with an alarm escalation system to reduce cardiac monitor alarm signals. J Nurs Care Qual. 2014;29(1):9–18. 35. Graham KC, Cvach M. Monitor alarm fatigue: standardizing use of
- 191. physiological monitors and decreasing nuisance alarms. Am J Crit Care. 2010;19:28–34. 36. Rheineck-Leyssius AT, Kalkman CJ. Influence of pulse oximeter lower alarm limit on the incidence of hypoxaemia in the recovery room. Br J Anaesth. 1997;79(4):460–464. 37. Whalen DA, Covelle PM, Piepenbrink JC, Villanova KL, Cuneo CL, Awtry EH. Novel approach to cardiac alarm management on teleme- try units. J Cardiovasc Nurs. 2014;29(5):E13–E22. 38. Dandoy CE, Davies SM, Flesch L, et al. A team-based approach to reducing cardiac monitor alarms. Pediatrics. 2014;134(6):e1686–e1694. 39. Cvach M. Monitor alarm fatigue: an integrative review. Biomed Ins- trum Technol. 2012;46(4):268–277. 40. Dressler R, Dryer MM, Coletti C, Mahoney D, Doorey AJ. Altering overuse of cardiac telemetry in non-intensive care unit settings by hardwiring the use of American Heart Association guidelines. JAMA Intern Med. 2014;174(11):1852–1854. 41. Schondelmeyer AC, Simmons JM, Statile AM, et al. Using quality improvement to reduce continuous pulse oximetry use in
- 192. children with wheezing. Pediatrics. 2015;135(4):e1044–e1051. 42. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52(6):377–384. Paine et al | Review of Physiologic Monitor Alarms 144 An Official Publication of the Society of Hospital Medicine Journal of Hospital Medicine Vol 11 | No 2 | February 2016 AACN Advanced Critical Care Volume 27, Number 3, pp. 283-289 © 2016 AACN DOI: http://dx.doi.org/10.4037/aacnacc2016110 Clinical Trial of an Educational Program to Decrease Monitor Alarms in a Medical Intensive Care Unit Arian Brantley, APRN, MS, NP-C, ACCNS-AG Sandra Collins-Brown, RN, BSN Jasmine Kirkland, RN, BSN Meghan Knapp, RN, BSN
- 193. Arian Brantley is Staff Nurse, 71 Intensive Care Unit, Emory University Hospital Midtown, Atlanta, Georgia. Sandra Collins-Brown is Staff Nurse, 71 Intensive Care Unit, Emory University Hospital Midtown, Atlanta, Georgia. Jasmine Kirkland is Staff Nurse, 71 Intensive Care Unit, Emory University Hospital Midtown, Atlanta, Georgia. Meghan Knapp is Staff Nurse, 71 Intensive Care Unit, Emory University Hospital Midtown, Atlanta, Georgia. Jackie Pressley is Staff Nurse, 71 Intensive Care Unit, Emory University Hospital Midtown, Atlanta, Georgia. Melinda Higgins is Associate Research Professor, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia. James P. McMurtry is Clinical Nurse Specialist, 71 Intensive Care Unit, Emory University Hospital Midtown, Atlanta, 550 Peachtree St, NE, Atlanta GA 30308 ([email protected] emoryhealthcare.org). The authors declare no conflicts of interest. Alarm signal events from medical equip-ment are an audible signal designed to alert nursing staff to a physiological change in a patient’s condition, a technical problem requiring investigation, and/or a situation requiring intervention. Some alarm signal events also occur when there are no actual clinical problems with the patient but because of artifact or small physiological
- 194. changes that exceed the upper or lower alarm limits. High frequency of the latter alarms, often called nuisance or nonaction- able alarms, can desensitize staff’s reaction to alarms. This situation, called “alarm fatigue,” may cause staff to react more slowly to alarm signal events or ignore them altogether.1-4 283 A B S T R A C T Clinical research to identify effective interven- tions for decreasing nonactionable alarms has been limited. The objective of this study was to determine if a staff educational pro- gram on customizing alarm settings on bed- side monitors decreased alarms in a medical intensive care unit (MICU). A preintervention, postintervention, nonequivalent group design was used to evaluate an educational program on alarm management in a convenience sample of MICU nurses. A 15-minute session was provided in a 1-week period. The outcome variable (number of alarms for low oxygen saturation via pulse oximetry [SpO2]) was determined from monitor log files adjusted by patient census. Data were collected for 15 days before and after the intervention. 2 analysis was used, with P less than .05 considered sig- nificant. After 1 week of education, low SpO2 alarms decreased from 502 to 306 alarms per patient monitored per day, a 39% reduc- tion (P < .001). Instructions for nurses in the medical intensive care unit on individualizing
- 195. alarm settings to patients’ clinical condition decreased common monitor alarms by 39%. Keywords: alarm fatigue, alarm avoidance, nonactionable alarms, nuisance alarms, false alarms Jackie Pressley, RN, BSN Melinda Higgins, PhD James P. McMurtry, APRN, MSN, CNS-BC, CCRN by AACN on September 6, 2016http://acc.aacnjournals.org/Downloaded from http://acc.aacnjournals.org/ WWW.AACNACCONLINE.ORGBRANTLEY ET AL 284 Alarm fatigue can be a dangerous phenom- enon because staff may not intervene quickly enough to alarms that occur when a patient’s condition has changed, jeopardizing patient safety with the potential to result in adverse events and even death.5-13 In addition to staff fatigue from large numbers of bedside alarm signal events, the audible alarm signal events can disturb patients and prevent sleep/rest and patients’ recovery.2,14,15 Lack of sleep/rest during hospitalization is a major dissatisfier for patients.16,17
- 196. Background The frequency of monitor alarm signal events is high in critical care units,10,18 with experts estimating that more than 300 physio- logical monitor alarm signal events occur each day for each patient.18 Although the percentage of those alarm signal events that are nonaction- able varies, experts10,18 and clinicians4,11 believe that the frequency of nonactionable alarm sig- nal events is high. In the past decade, clinicians have continued to rate nonactionable alarm signal events as the largest issue related to monitor alarms at their institutions.11 Clinicians believe that a primary underlying cause of nonactionable alarm signal events with physiological monitoring is inappropriately set alarm limits, which leads to the triggering of alarm signal events even when physiological fluctuations are normal and/or small.4 Monitor technology experts concur,8,19-21 but recognize that until technological advancements in moni- toring equipment allow the technology to auto- matically set alarm settings that are customized for each patient, the key to decreasing many nonactionable alarm signal events lies in get- ting clinicians to individualize or customize monitor alarms for each patient.8 One approach sometimes used by hospi- tals, including our own facility in 2013, to decrease nonactionable alarm signal events is to change the monitor’s default settings (low and high rates; response priority level) for alarms.22,23 Although this approach decreases
- 197. the frequency of some alarms, it does not eliminate the underlying problem that for individual patients, the default alarm settings may not be appropriate. National regulatory groups,13,18 professional associations,3,5,19-21 and critical care experts1,11,23-26 have urged clinicians to intervene to decrease nonactionable alarm signal events. Aside from studies to improve the hardware and/or programming of physiological monitors, lim- ited clinical evaluations have been done on other approaches to decrease nonactionable alarm signal events.12,27-30 Prior evaluations were quality improvement or performance improvement projects focused almost exclu- sively on electrocardiographic (ECG) moni- tor alarms, all of which evaluated a “bundle” of different interventions to decrease non- actionable ECG alarm signal events. Those approaches included improving the quality of the ECG signal (skin preparations before electrode placement; frequent ECG electrode changes), elimination of duplicative ECG alarms, changes in default alarm settings in the computer software, and staff education on customizing ECG alarm signal event limits to each patient’s clinical condition. Although all of the projects found substantial decreases in ECG alarm signal events following implemen- tation of practice changes, the impact of each individual intervention of the bundle is not known. Only one of the quality improvement projects included non-ECG physiological mon- itor alarm signal events (low Spo2; high and
- 198. low respiratory rates).28 To date, no research has been published on interventions designed to increase clinicians’ use of customization for high and low alarm signal events for physio- logical monitor parameters as an attempt to decrease nonactionable alarm signal events. Review of alarm history data in our medi- cal intensive care unit (MICU) in late 2012 indicated that more than 1500 alarm signal events per patient per day were occurring, with approximately 70% of those alarm signals coming from non-ECG physiological parameters. The vast majority of those non- ECG alarm signal events were from low satu- rated oxygen level shown by pulse oximetry (Spo2). The hospital’s default setting for low Spo2 alarm signal events was 90%, based on an assumption of a relatively normal respira- tory function for adult patients in the hospi- tal’s ICUs. Many of the MICU patients had moderate to severe respiratory insufficiency, so their Spo2 levels were often at or below the default settings. Similar to prior surveys of nursing practice,3,11 anecdotal observation in our MICU indicated that nursing staff did not routinely customize their alarm signal event limits to each patient’s clinical condition. We believed that this lack of customization of alarm settings was contributing to the high number of Spo2 alarm signal events. by AACN on September 6, 2016http://acc.aacnjournals.org/Downloaded from http://acc.aacnjournals.org/
- 199. VOLUME 27 • NUMBER 3 • JULY-SEPTEMBER 2016 ICU ALARMS 285 The purpose of this study was to determine if a brief educational program for nurses on alarm management for non-ECG physiological parameters could decrease the number of low Spo2 alarm signal events per patient per day. Methods Study approval was obtained from the institution’s investigational review board before data collection. Data collection was completed during a 5-week period. Study Design A pretest, posttest, nonequivalent group design was used to evaluate the effect of a staff educational program on alarm management. The dependent variable for the study was the number of low Spo2 alarm signal events per patient per day during a 15-day period. Study Setting The study was conducted in a 20-bed MICU, with a total of 54 registered nurses employed in 0.2 to 1.0 full-time-equivalent (FTE) positions. Monitoring capabilities at each bedside included a range of physiologi-
- 200. cal parameters, with all patients monitored for ECG rhythm, blood pressure, respira- tory rate, and Spo2 (Solar 8000M/I V5, GE Healthcare). Oxygen saturation monitoring was done with a finger probe (Oxysensor MAXN, Covidien) connected to an Spo2 module using Nellcor pulse oximetry technol- ogy (OxiMax Technology, GE Healthcare) within the bedside monitoring system. Each monitor physiological parameter was pro- grammed with default values for alarm set- tings common to all monitored beds in the ICUs and intermediate care units for the facility. The default values were based on the monitor manufacturer’s suggestions and consensus opinion of expert nursing and medical clinicians in the ICUs and intermedi- ate care units. Bedside alarm settings could be customized by bedside clinicians on the basis of individual patient care situations. When alarm settings were exceeded, audible alarms occurred at the bedside and at the unit’s central monitoring station. Sample Selection Participants in this study were registered nurses working as bedside clinicians on the MICU. Inclusion criteria included being a permanent employee on the study unit, at a minimum of 0.2 FTE each week, and comple- tion of new-employee unit orientation. A mini- mum sample size of 21 staff members (40% of MICU staff) was required for this study to ensure that an adequate number of staff par-
- 201. ticipated in the alarm management education. Study Intervention The educational program on alarm man- agement was a 15-minute session designed to review the rationale for minimizing alarms and provide strategies for reducing nonactionable alarms by customizing the low and high alarm settings for the non-ECG parameters to each patient’s current condition and/or situation (Table 1). Content of the educational class was developed by the study investigators and was based on the monitor manufacturer’s educa- tional materials and expert advice on minimiz- ing nonactionable alarms.12,22,24,26 Classes were taught by 1 of 5 study investigators, all of whom were registered nurses experienced with the MICU patients and monitoring equipment. Investigators were trained to provide the educational intervention following a stan- dard curriculum and use of pocket-card guides for customizing alarm parameters. During a 1-week period, educational sessions were provided at the beginning or end of the nurses’ patient care shifts in a unit room used for staff education and meetings. Although a number of non-ECG physiological parameters were discussed, the major focus was on low Spo2 because it represented the highest number of alarm event signals in previous quality data monitoring. Examples of patients with normal and abnormal Spo2 values were provided, with suggestions for appropriate alarm signal event limits. Appropriate alarm signal event limits were determined a priori and were based on
- 202. manufacturers’ suggested parameters in educa- tional materials and review by expert clinicians familiar with the MICU patient population. Because the vast majority of the MICU patients had usual Spo2 values on the steep portion of the oxygen saturation curve, the lower alarm signal event limit recommendation was conser- vatively set (1% below the lowest value in the previous 2-hour period). Participants were provided with a pocket card summarizing key information for setting alarm limits indi- vidualized to each patient. Pocket cards were also attached to all bedside monitors for easy reference when caring for patients. The edu- cational program was provided for 1 week. by AACN on September 6, 2016http://acc.aacnjournals.org/Downloaded from http://acc.aacnjournals.org/ WWW.AACNACCONLINE.ORGBRANTLEY ET AL 286 Outcome Variable For the purposes of this study, the low Spo2 alarm signal event was selected for outcome monitoring because it had the highest rate of occurrence on the study unit and accounted for more than 50% of all non-ECG dysrhyth- mia alarm events. The number of low Spo2 alarm signal events was obtained through review of existing bedside monitor computer
- 203. alarm history for each monitored patient on the unit with a software program developed by the monitor manufacturer (Alarm Report- ing Tool, GE Healthcare).31 Alarm data were extracted from existing computer log files, which occurred whenever an audible monitor alarm signal event occurred. The number of alarm signal events was adjusted by the number of patients being monitored during the study period each day and was reported as low Spo2 alarm signal events per patient per day. Alarm data were collected for 15 days immediately before and 15 days after implementation of the study educational intervention. Data Analysis Data were summarized by using descriptive statistics. 2 analysis was used to compare prein- tervention and postintervention frequency of low Spo2 alarms per day and the number of patients monitored during each study period. The level of significance was set at P less than .05. Results A total of 22 nurses completed the 15-minute educational intervention during a 1-week period. All but 2 nurses were female, with a mean age of 37.9 (SD, 14.8) years (age data available for only 17 nurses). Years of experi- ence in nursing and in critical care nursing varied, with the majority of nurses having 5 or more years of experience in nursing and critical care nursing (Table 2).
- 204. 1. Rationale for keeping nonactionable alarm signal events (eg, nuisance alarms) at a minimum A. Staff alarm fatigue B. Noise disruptions affect patients’ rest/sleep and satisfaction 2. Management of alarms with high rates of occurrence on the unit A. Parameter alarms with highest occurrence are either from low oxygen saturation shown by pulse oximetry (SpO2) or high respiratory rate (> 50% of alarms), causing more than 300 000 alarms on the unit in a 1-month period. Many are nonactionable alarms. B. Nursing strategies to decrease nonactionable alarm signal events: (1) During assessment of patient at the beginning of the shift, and periodically during the shift, set realistic high and low alarm levels for SpO2 and high respiration parameters on the bedside monitor: (a) SpO2 low alarms—Set the patient’s SpO2 to 1 percentage point below the lowest value for the past 2-hour trend (excluding isolated spikes). (b) Respiration high alarms—Set the patient’s high respiration rate alarm to 10 breaths per minute above the highest value for the past 2-hour trend. (2) Check the skin adherence and placement of electrocardiography chest electrodes on admission and every 24 hours. Respirations are detected by measuring thoracic impedance in lead configurations I, II, and RL-LL. The monitor “learns” the patient’s respiration patterns according to these configurations for 8 breaths. Changing the leads automatically starts the relearning process, or relearning can be selected from the monitor menu. Periodically, the relearning process is necessary if the patient’s breathing pattern has
- 205. changed and the monitor is no longer calculating the respiratory rate. The lead configurations are as follows: (a) Lead I for upper chest breathers (b) Lead II for abdominal breathers (c) RL-LL lead for abnormal breathers (3) Check SpO2 finger probe adherence each shift and replace as necessary 3. Question and answer period 4. Provide each participant with a pocket card summarizing key information for setting individualized patient’s alarm limits and lead locations for optimal respiratory monitoring. Participants should also be told that cards will be attached to all bedside monitors for easy reference when caring for patients. Table 1: Content Outline for a Staff Educational Intervention on Oxygen Saturation and Respiratory Alarm Management by AACN on September 6, 2016http://acc.aacnjournals.org/Downloaded from http://acc.aacnjournals.org/ VOLUME 27 • NUMBER 3 • JULY-SEPTEMBER 2016 ICU ALARMS 287 Before the intervention, low Spo2 alarms made up 50% of all alarms; after the inter- vention, they made up 44% of all alarms.
- 206. The total number of low Spo2 alarm signal events during the 15-day baseline period was 128 186 or 503 alarm signal events per patient per day for 17 patients. Following the educa- tional intervention, the total number of low Spo2 alarm signal events during the 15-day postintervention period was 78 267 or 307 alarm signal events per patient per day for 17 patients. The 39% reduction in Spo2 alarms after the educational intervention was statistically significant (P < .001). Discussion This study was the first study in which an intervention to decrease non-ECG physiologi- cal alarm signal events in critically ill patients was analyzed. After the 40% of MICU staff received a brief educational intervention on alarm management, the highest number of non-ECG monitor alarms (low Spo2) decreased 39%. The 15-minute alarm management edu- cation provided at change of shift emphasized the importance of avoiding nonactionable alarm signal events by customizing alarms limits to be appropriate for each patient’s current physiological situation rather than accepting the monitor’s default values. Prior published reports of approaches to alarm management were descriptive designs or quality or performance improvement proj- ects.12,27-30 Practice changes that were imple- mented focused almost exclusively on ECG alarms, and each included multiple interven-
- 207. tions to decrease nonactionable alarm signal events, making it difficult to understand the contribution of individual strategies to the overall outcomes. For example, strategies used by Graham and Cvach28 included com- puter software adjustments to default alarm settings for selective ECG and physiological parameters, elimination of duplicate alarm signal events, and staff education about the importance of setting patient-specific alarm limits as a way to decrease nonactionable alarm signal events. Although this bundle of strategies resulted in a 43% decrease in total alarms during the 1-year period of the quality improvement project, it is not known which interventions were most important and/or if other changes on the unit during the long study period could account for the decrease in the number of alarms. Our results show that a single, brief educational intervention focused on customizing alarm limits to each patient’s condition can significantly reduce the number of non-ECG physiological alarm signal events. Limitations This study evaluated only a single, brief educational intervention for MICU nursing staff focused on non-ECG alarm settings. Different results may occur with more extensive education, when applied to ECG alarm settings, and/or with noneducational interventions. Another limitation of the study is that we evaluated only 1 time point shortly after completion of the educational interven-
- 208. tion. Whether the alarm decreases were main- tained over time is not known. In this study, we evaluated only the number of alarms and were not able to quantify the number of alarms that were actionable and nonactionable. Researchers in future studies should quantify the source of the alarms (eg, alarms for arti- fact, alarms for clinically significant physio- logical changes, alarms for nonactionable physiological changes). Although other fac- tors could have contributed to the decrease in low Spo2 alarm signal events, the conduct of the study during a short period of time (5 weeks) helped to reduce some factors such as changes in practice routines and/or types of MICU patients. Clinical Implications Emphasizing the importance of customiz- ing alarm limits to a patient’s physiological condition, rather than relying on a monitor Characteristic Nursing experience, y < 1 1-5 > 5 to 10 > 10 to 20 > 20 Progressive and critical care experience, y < 1
- 209. 1-3 > 3 to 5 > 5 No. of nurses 1 10 2 4 5 3 7 1 11 Table 2: Experience of 22 Nurse Participants by AACN on September 6, 2016http://acc.aacnjournals.org/Downloaded from http://acc.aacnjournals.org/ WWW.AACNACCONLINE.ORGBRANTLEY ET AL 288 system’s default settings, can decrease some of the non-ECG physiological alarms. Such customization is especially important in units with large numbers of patients who have usual physiological values that are close to the monitor’s default alarm settings. Until smarter monitor technology is available that can cus-
- 210. tomize the upper and lower alarm limits to the patient’s individual physiological status, it falls to the nurse clinician to customize alarm limits to decrease the number of nonactionable alarms. Because customizing alarm limits resulted in only a 39% decrease in alarm signal events, clinicians should continue to implement other strategies for alarm reduction. Future Research The limited number of studies on how best to reduce nonactionable alarm signal events emphasizes the need for additional research in this area. Because this study is the first study in which a single, clinician- initiated intervention to decrease alarm sig- nal events was examined, replication of this study is important. Researchers in future studies should also attempt to quantify the frequency and appropriateness of custom- ized alarms for individual patients. To better understand the impact of interventions to decrease monitor alarm signal events, studies should be designed to evaluate outcomes of individual interventions rather than solely bundling several interventions together. Conclusions This study demonstrated that a simple, brief educational program for MICU nursing staff on customizing alarm settings to each patient’s physiological condition, rather than using default alarm values, significantly decreased the most common bedside monitor
- 211. alarm signal event by 39%. Ideally, reduc- tions in inappropriate clinical alarms will reduce the chance of alarm fatigue of staff nurses, which can be a patient safety risk factor. In addition, noise reduction from fewer bedside alarms may facilitate patients’ rest/sleep and improve patient satisfaction. Acknowledgments Special thanks to Stephen Treacy for assis- tance with electronic alarm data extraction and Marianne Chulay, RN, PhD, FAAN, for assistance with study design, data analysis, and manu- script preparation. REFERENCES 1. Sendelbach S. Alarm fatigue. Nurs Clin North Am. 2012; 47:375-382. 2. Cvach M. Monitor alarm fatigue: an integrative review. Biomed Instrum Tech. 2012;July/Aug:269-277. 3. ECRI Institute. Top 10 health technology hazards for 2013. Health Devices. 2013;42(11):1-15. 4. Christensen M, Dodd A, Sauer J, Watts N. Alarm setting for the critically ill patient: a descriptive pilot survey of nurses’ perceptions of current practice in an Australian Regional Critical Care Unit. Intensive Crit Care Nurs. 2014;30(4):204-210. 5. ECRI Institute. The hazards of alarm overload: keeping excessive physiologic monitoring alarms from impeding
- 212. care. Health Devices. 2007;36(3):27. 6. Kowalczyk L. “Alarm fatigue” a factor in 2nd death: UMass hospital cited for violation. Boston Globe. Sep- tember 21, 2011. https://www.bostonglobe.com/2011 /09/20/umass/qSOhm8dYmmaq4uTHZb7FNM/story.html. Accessed May 25, 2016. 7. Anonymous. Alert fatigue leads to OR fatalities. Same Day Surg. 2010;34(12):136-138. 8. Konkani A, Oakley B, Bauld T. Reducing hospital noise: a review of medical device alarm management. Biomed Instrum Tech. 2012;Nov:478-487. 9. Bonafide C, Lin R, Zander M, et al. Association between exposure to nonactionable physiologic monitor alarms and response time in a children’s hospital. J Hosp Med. 2015;10(6):345-351. 10. Edworthy J. Medical audible alarms: a review. J Am Med Inform Assoc. 2013;20(3):584-589. 11. Funk M, Clark T, Bauld T, Ott J, Coss P. Attitudes and practices related to clinical alarms. Am J Crit Care. 2014;23(3):e9-e18. 12. Sendelbach S, Wahl S, Anthony A, Shotts P. Stop the noise: a quality improvement project to decrease elec- trocardiographic nuisance alarms. Crit Care Nurse. 2015;35(4):15-22. 13. The Joint Commission. The Joint Commision announces 2014 national patient safety goals. Jt Comm Perspect. 2013;33(7):1-4.
- 213. 14. Akansel N, Kaymakci S. Effects of intensive care unit noise on patients: a study on coronary artery bypass graft surgery patients. J Clin Nurs. 2008;17(12):1581-1590. 15. Elliott R, McKinley S, Cistulli P, Fien M. Characterization of sleep in intensive care using 24 hr polysomnogra- phy: an observations study. Crit Care. 2013;17:R46. 16. Kelly C. In a hospital stay, no time to rest. The New York Times. August 7, 2007:F5. http://www.nytimes.com /2007/08/07/health/07case.html. Accessed May 16, 2016. 17. Frisk U, Nordstrom G. Patients’ sleep in an intensive care unit: patients’ and nurses’ perception. Int Crit Care Nurs. 2003;19:342-349. 18. Mitka M. Joint Commission warns of alarm fatigue: multitude of alarms from monitoring devices problem- atic. JAMA. 2013;22:2315-2316. 19. AACE Healthcare Technology Foundation. Impact of clinical alarms on patient safety: a report from the American College of Clinical Engineering Healthcare Technology Foundation. J Clin Eng. 2007;32:22-33. 20. Association for the Advancement of Medical Instru- mentation. A siren call for action: priority issues from the medical device alarms summit. Arlingon, VA: Associ- ation for the Advancement of Medical Instrumentation; 2011. http://s3.amazonaws.com/rdcms-aami/files/pro- duction /public/FileDownloads/Summits/2011_Alarms _Summit_publication.pdf. Accessed May 16, 2016. 21. Association for the Advancement of Medical Instru- mentation: 2011 Alarm Summit Attendees. Alarm
- 214. by AACN on September 6, 2016http://acc.aacnjournals.org/Downloaded from http://acc.aacnjournals.org/ VOLUME 27 • NUMBER 3 • JULY-SEPTEMBER 2016 ICU ALARMS 289 management: research gaps. Presented at: The Advanc- ing Safety In Medical Science Clinical Alarms 2011 Summit; October 4-5, 2011; Herndon, VA. 22. American Association of Critical-Care Nurses. AACN Prac- tice Alert: Alarm Management. http://www.aacn.org /wd /practice/content/practicealerts/alarm-management-practice -alert.pcms?menu=practice. Accessed May 16, 2016. 23. Welch J. An evidence-based approach to reduce nui- sance alarms and alarm fatigue. Biomed Instrum Tech- nol. 2011;Spring(suppl):46-52. 24. Phillips J. Clinical alarms: complexity and common sense. Crit Care Nurs Clin North Am. 2006;18:145-156. 25. Keller J. Clinical alarm hazards: a “top ten” health tech- nology safety concern. J Electrocard. 2012;45:588-591. 26. Purbaugh T. Alarm fatigue: a road map for mitigating the cacophony of beeps. Dimens Crit Care. 2014;33(1):4-7. 27. Whalen D, Covelle P, Piepenbrink J, Villanova K, Cuneo C, Awtry E. Novel approach to cardiac alarm management on telemetry units. J Cardio Nurs. 2014;
- 215. 29(5):E13-E22. 28. Graham K, Cvach M. Monitor alarm fatigue: standardiz- ing use of physiological monitors and decreasing nui- sance alarms. Am J Crit Care. 2010;19:28-34. 29. Cvach M, Biggs M, Rothwell K, Charles-Hudson C. Daily electrode change and effect on cardiac monitor alarms: an evidence-based practice approach. J Nurs Care Qual. 2013;28:265-271. 30. Dandoy C, Davies S, Flesch L, et al. A team-based approach to reducing cardiac monitor alarms. Pediat- rics. 2014;134(6):e1686-e1694. 31. GE Healthcare. Alarm Reporting Tool (ART). Milwaukee, WI: GE Healthcare; 2014. by AACN on September 6, 2016http://acc.aacnjournals.org/Downloaded from http://acc.aacnjournals.org/ Copyright of AACN Advanced Critical Care is the property of American Association of Critical-Care Nurses and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. EBP Annotated Bibliography Feedback Assignment Create an APA bibliographic entry. This assignment should not
- 216. exceed one double spaced page. Paragraph 1 (Summary): Briefly summarize the article using complete sentences. The following questions will guide you as you write your summary: · What is the article about? · What kind of study/review was done (i.e., RCT, descriptive, case study, or Systematic Review of similarly designed studies, etc.)? · What is the author’s purpose? · Is the text difficult to read or understand? · Does the author introduce the problem statement? · How and to whom (i.e. population of interest) was the study done? · What main findings are clinically relevant?