Alarm fatigue, caused by excessive numbers of alarms, is a national problem and patient safety issue. A quality improvement project was conducted on a medical telemetry unit to reduce alarm fatigue through various interventions such as individualizing patient alarm parameters, educating nursing staff, and improving communication. These interventions led to a significant decrease in the number of telemetry alarms and increased compliance with proper alarm management.

1. JUST GLANCE: Reducing Alarm Fatigue – 4NW
JENNIFER CRUZ RN, JOANNA DETROIA RN, JESSICA HATHAWAY RN &
BARBARA BIRD RN, MSN
Alarm fatigue is a national problem and the number one medical device technology
hazard in 2012. The problem of alarm desensitization is multifaceted and related to a
high false alarm rate, poor positive predictive values, lack of alarm standardization, and
the number of alarming medical devices in hospitals today (Cvach, 2012). The Joint
Commission is also taking the issue of clinical alarms seriously, as they are developing
a proposed National Patient Safety Goal for 2013 that addresses clinical alarm systems
(JCAHO, 2011). Small tests of change to improve alarm fatigue and management were
conducted on 4NW a medical telemetry unit. By individualizing patient alarm
parameters and educating both the Registered Nurses (RN) and Certified Nursing
Assistants (CNA) using current evidence-based practice, the goal is to decrease alarm
fatigue by thirty percent. The excessive numbers of monitor alarms and the fear that
nurses have become desensitized to these alarms was the purpose for this unit-based
quality improvement project. With the focus on telemetry alarms, this unit-based
quality improvement initiative will serve as a beneficial starting point for revamping
alarm management and decreasing alarm fatigue.
After educating the nursing staff and the unit secretary of the importance of managing
the nuisance telemetry alarms, a survey was conducted before and after implementation
of interventions. The post survey showed an increase in compliance with proper
electrode and battery management, including telemetry settings and maintaining
telemetry monitoring.
There was a significant decrease in the number of telemetry alarms on the unit as noted
by nursing staff and interdisciplinary team members.
We asked 4 North West staff to participate in our study and provide feedback based on the implementation of
daily lead and battery change, communication about patient transfers off the unit for testing and involved our
secretary, to ensure staff is aware that a patient has returned to the unit and has to be placed back on telemetry
immediately. Re-educating RN’s for telemetry setup, and alarm adherence and adjustment, based on the
current protocols set up by the Education Department at Kent using the current default settings that were
adjusted in 2013.
CNA's were educated on the importance of electrode adherence and asked to change electrodes daily with
morning care using proper skin preparation and change batteries as well. This was done during morning care
and if not able to be done on a particular patient, that information and task would be passed on to the next shift
for change of leads and batteries. We found this to be the best way to ensure that leads were getting changed,
skin was checked and being prepped appropriately and batteries were routinely getting changed.
Utilizing the “Ticket to Ride" as a communication tool to alert nursing staff and the unit secretary that the
patient is on telemetry when the patient returns from testing, the unit secretary will announce to the staff that
the patient has returned to ensure prompt re-application of the telemetry.
Placing the patient on the standby setting when a patient goes for testing can further decrease nuisance alarms.
The CNA's can assist in this process by alerting the RN when the patient is traveling off the unit. The RN can
then place telemetry on standby setting.
Reinforce with the RN's the life threatening red alarms, “Just Glance" is what needs to be done when hearing
the telemetry alarms. Red means stop everything and assess the patient immediately regardless of whose patient
it is.
What would it lead to in reality?
*Decreased frequency of Nuisance Alarms
*Decreased noise = Increased patient satisfaction
*Increased awareness of Critical Alarms
*Faster response time to a change in condition
*Clear multidisciplinary communication
*Increased awareness of alarm fatigue and desensitization
Updating the current policy to reflect:
*In an easier format to interpret, clarify alarm responsibility which includes the “Just
Glance” approach during critical alarms.
*Adding “Telemetry” to the Ticket to Ride which signals the unit secretary and transport
staff to notify the primary RN when a patient leaves/returns to unit for testing. The RN
will then change the monitor setting to or from “Standby” mode.
*Documentation by the RN when a change in parameters is made with the approval of
the Doctor, Nurse Practitioner or Physician’s Assistant to suit individual patient needs.
*Adjusting the time frame when electrodes and batteries are replaced
*Adding a Cardiac/Medical Telemetry Careset when the patient is assigned to a
cardiac/med surg telemetry unit.
Cardiac/Medical Telemetry Careset would include:
*The ordering Physician indicates reason for telemetry monitoring at initiation of
Careset.
*A task fired after 24 hours to:
*d/c monitoring
*continue monitoring due to change in condition or cardiology consult.
*Monitor strip during the eight hour shift timeframes
*Change batteries and electrodes during AM care.
What is alarm fatigue?
Alarm fatigue is the lack of response, due to the numbers of alarms, resulting in sensory
overload and desensitization, a national problem.
Medical devices generate enough false alarms to cause a reduction in responding
known as the "cry wolf" effect. Frequent alarms are distracting and interfere with
clinicians performing critical tasks and may lead to staff disabling alarm systems or
ignoring them.
The myriad of medical device alarms has created an environment that poses a
significant risk to patient safety. Device alarms are intended to alert clinicians of a
hazardous condition and potential problems. However, when a caregiver is subjected to
too many alarms, it disrupts his or her usual workflow and result in errors due to
omission, distraction or inattention.
From 2005-2008 the FDA and MAUDE (Manufacturer and User Facility Device
Experience) database received 566 reports of patient deaths related to monitoring
device alarms. A four month review of the MAUDE database between March 1, 2010
and June 30, 2010 revealed 73 alarm related deaths with 33 attributed to physiologic
monitors. The Joint Commissions sentinel event database includes reports of alarm
related deaths and 13 serious alarm related injuries in a similar period.
Our goal with this project is to change the nuisance alarms that seem to be the most
frustrating for staff and follow the guidelines set by education to decrease alarm fatigue
and minimize alarms that continually go off. By further educating staff about telemetry
alarms and how to minimize the frequency of the more frequent alarms, staff may have
a better understanding of the importance of alarm safety and best how to deal with
alarm fatigue.
ABSTRACT
INTRODUCTION
METHODS RESULTS
IMPLICATIONS
REFERENCES
JUST GLANCE
Cvach, M. (2012). Monitor alarm fatigue. Biomedical Instrumentation & Technology, 268-277.
Cvach, M., & Graham, K. (2010, January). Monitor alarm fatigue: standardizing use of physiological monitors and decreasing
nuisance alarms. American Journal of Critical Care, 19, 28-34.
Kent Hospital Education Fair 2013
Sendelbach, S. (2012). Alarm fatigue. The Nursing Clinics, 47, 375-382.
http://dx.doi.org/http://dx.doi.org/10.1016/j.cnur.2012.05.009
The Joint Commission Perspectives on Patient Safety, Dec 2011, Volume 11, Issue 12
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Roles of the CNA
During AM Care:
Change Batteries
Change Electrodes with proper skin
care
Notify RN if pt leaves/returns to unit.
Roles of the Unit Secretary
Add “Telemetry Monitoring” in Red to
Ticket to ride
Notify RN if pt leaves unit (either face
to face, via Vocera or overhead page)
(RN will then place pt monitor on
Standby mode)
Notify RN when pt returns to unit (RN
will then resume monitoring)
Roles of the RN
Initiate Telemetry monitoring per physician
orders.
Customize settings based on pt history
(pacer/chronic Afib/irregular hr)
Monitor Alarms
All RN’s stop what they are doing and “Just
Glance” when a critical alarm sounds.
Place monitor on Standby mode when pt
leaves unit for Testing/Procedures.
Remove from Standby mode and resume
monitoring when pt returns to unit.
Monitor strip q8hrs
Discontinue medical telemetry after 24hrs
based on orders and patient condition.
Communicate with CNA’s, and Unit Secretary
if pt is on Telemetry monitoring.
Roles of the Transport
Notify RN if pt leaves unit (either
face to face, via Vocera or overhead
page)(RN will then place pt monitor
on Standby mode)
Notify RN when pt returns to unit
(RN will then resume monitoring)