Running head: ALARM FATIGUE 1

Reducing Monitor Alarm Fatigue in the Neonatal Intensive Care Unit

Mary Hefferan

Ferris State University

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Reducing Monitor Alarm Fatigue in the Neonatal Intensive Care Unit

A. Description of Quality Improvement Project

This quality improvement project will address the patient safety issue of monitor alarm

fatigue in the neonatal intensive care unit through staff education that addresses factors that

reduce unnecessary alarming. Oxygen saturation alarm limits for premature infants (less than 36

weeks) were 86%-96%; according to the Vermont Oxford Network (VON, 2014). For those

born at 36 weeks or later they are 92%-100%. Standard alarm parameters are necessary but act

only as a starting point for care. Currently, there is a lack of discussion regarding alarm

parameters during nurse to nurse report at the chosen site for this project. Individualized

parameters should be discussed during nurse handoff to further reduce unnecessary alarming.

Many factors weigh in for each infant when establishing alarm parameters such as

supplemental oxygen use, cardiac abnormalities, and acuity. To individualize this process, I plan

to increase awareness of customizing individual alarms to meet the specific needs of the patient

through staff education and on-site support and how it improves alarm safety. Also, proper

placement and changing of pulse ox/EKG leads and skin preparation has been shown to reduce

the number of false alarms. I also plan to establish a protocol and supportive education

regarding proper pulse ox/EKG placement and skin preparation based on the gestational age of

the patient and skin integrity. Staff education will be achieved through online courses, handout

materials, and on-site support.

B. Evidence Based Support

In 2013, The Joint Commission (JC) announced a national patient safety goal (NPSG) that

addressed alarm management and safety (JC, 2013). Phase I urged hospitals to “establish alarms

as an organizational priority” (JC, 2013, p. 1) and focus on management of the most important

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alarms. Phase II focused on policy development and education of staff regarding alarm safety.

The JC recognized alarm fatigue as a patient safety issue and stress the importance of

standardizing alarm management to reduce variations in care.

Alarm fatigue and desensitization to alarms can lead to a reduction in trust of the alarm,

disruption in patient care, and lead to disabling of the alarm posing a severe risk to patient safety

(Grahm & Cvach, 2014). Cvach (2012) states “from 2005 through 2008…[there were] 566

reports of patient deaths related to monitoring device alarms” (p. 269). The Emergency Care

Research Institute (ECRI, 2007) states excessive monitor alarms can distract clinicians and lead

to a “cry wolf” environment that can reduce response to real emergencies. Adding to the

problem, the American Association of Critical-Care Nurses (AACN, 2013) found “80% to 99%

of EKG monitor alarms are false or clinically insignificant” (p. 83)

The AACN (2013) found proper skin preparation enhances conductivity and reduces skin

impedance thereby reducing false monitor alarming. By properly preparing skin and

appropriately placing EKG leads, it can reduce false alarms due to rapid heart rate and

arrhythmia (ECRI, 2007). Also, Cvach, Biggs, Rothwell, and Charles-Hudson (2013) found that

after implementing a daily electrode change, monitor alarms decreased by 46% per bed per day.

Customizing alarm parameters to meet the specific needs of the patient showed a 43% reduction

in false alarms after staff was educated regarding the change (AACN, 2013).

C. Description of Unit

This project will take place in the Helen Devos Children’s Hospital (HDVCH) in the

neonatal intensive care unit (NICU). The unit consists of 8 ward-style rooms that hold

anywhere from 6 to 12 babies per room and in the new addition there are 40 private rooms

for a total of 103 beds. Each room can contain a combination of open cribs, warmer tables,

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or isolettes. The alarm noises can vary from monitor alarms, ventilator alarms, and IV pump

alarms. Parents are welcome and may sit by the bedside of their infant as well.

D. Stakeholder Involvement

Christina Schmoekel has agreed to be my preceptor for this project and is the clinical

informatics educator for HDVCH. I connected with her through another fellow MSN student

and was interested because she has a NICU background and is currently in an informatics role.

Christina has her MSN, RNC-NIC, and CPHIMS certification. She has connected me with the

NICU manager and Amy Atwater who will be involved for this project and will be my main

resources for this project. Amy is a registered nurse who coordinates special projects. She

linked me with Beth Huizinga, a clinical nurse specialist, who provided me with her input

regarding my project goals. Kari Luymes is a nurse technician who attended the recent meeting

who will assist me in collecting data and as a reference for current policies. I have also been

given the contact names of a biomedical engineer representative and the lead respiratory

therapist to be contacted for assistance in data collection.

E. QSEN Competencies

a. Safety:

i. Knowledge : “Describe best practices that promote patient and provider safety”

(QSEN Institute, 2012, “Safety”). The goal of this project is to educate staff

regarding best practice regarding alarm management. This will promote patient

safety by reducing unnecessary alarms that can result in alarm fatigue that

compromises patient safety.

ii. Skill : “Participate as a team member to design, promote, and model effective use

of technology and standardized practices that support safety and quality” (QSEN

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Institute, 2012, “Safety”). To develop the educational component that supports

best practice, my goal is to collaborate with the NICU team to establish how to

utilize monitor alarm technology to promote patient safety. Through educating

staff I hope to model the effective use these standardized practices.

b. Teamwork and Collaboration

i. Attitude : “Appreciate the importance of inter-professional collaboration. Value

collaboration with nurses and other members of the nursing team” (QSEN

Institute, 2012, “Teamwork and Collaboration”). Maintaining an attitude that

promotes collaboration is essential to implementing this quality and safety

program. I plan to elicit feedback from all members of the nursing team and

management.

F. ANA Scope & Standards of Practice for Nursing Informatics

a. Standard 1-Assessment : collecting information and data regarding current practice

and workflow to identify the potential effect of a solution to the current need (ANA,

2008). During the planning phase, information will be collected regarding current

standards for alarm parameters, establishment of parameters, and current practice

regarding skin preparation and changing of EKG leads. Assessment will include

prioritizing the data and analyzing the most crucial needs for the unit (ANA, 2008).

b. Standard 2-Problem and Issues Identification : identify the needs of the unit to

determine the desired outcomes and develop a plan for implementation (ANA, 2008).

Based on the needs of the unit determined from stakeholder involvement and

evidence based research, outcomes and specifics of the plan will be identified. The

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problem/need has been identified through the initiation of the NPSG and the data

regarding risks to patient safety.

c. Standard 5-Implementation : implement a plan in a “safe and timely manner”

implementation (ANA, 2008, p. 71) and collaborate with other stakeholders before,

during, and after. Implementation will include a documented plan and “evidence

based-actions” (ANA, 2008, p. 71) regarding the steps to achieve goals and desired

outcomes.

G. RCA

a. A meeting with the stakeholders, Christina, Amy, and Kari was held to identify

current barriers to safe alarm management. Some of the major barriers identified

were that often it is difficult to hear certain alarms when they alarm within the new

private rooms. Also discussed as a potential barrier, is that a physician order must be

obtained to change alarm parameters or discontinue them; reducing the likelihood that

parameters will be specified to the needs of each patient. I also discussed barriers

with my former NICU co-workers and they identified issues with the two minute

pause option being utilized too often versus the more brief silence option. See

Appendix A for a full listing of root causes that lead to alarm fatigue.

H. Change and Leadership Theory

a. Kurt Lewin’s Theory of Planned Change

i. Unfreezing : Recently the NICU staff and I participated in a webinar regarding

alarm fatigue and management. This served as a tool for “unfreezing” current

practice and raised awareness of the risk to patient safety. I will reinforce the

unfreezing by providing further evidence based research regarding alarm

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fatigue within the educational presentation. Data that will be collected from

the monitor alarms should represent a need for change and assist in the

unfreezing of old beliefs as well. Lewin’s unfreezing stage acts as a stimulus

to drive change and prepares the “organization to accept that change is

necessary” (MindTools, 2014, para. 8) by showing that the existing standard

cannot continue.

ii. Movement/Change : As a result of the unfreezing and raised awareness, my

project for improvement will guide the unit towards change and education

regarding safe alarm management will be established. (Manchester et al.,

2014; MindTools, 2014). I hope to facilitate this movement towards change

by eliciting feedback and adapting the change to meet the specific needs of the

unit. Educating staff and providing evidence based research should promote

the acceptance of the change.

iii. Refreezing : The new practice standards will be reinforced and a “refreezing”

is expected to occur within the unit. Manchester et al. (2014), state that

identifying “clinical champions” (p. 85) will drive the organization to

maintain this change. As I implement this project I will serve as a clinical

champion and connect with those interested to further carry on the proposed

change.

b. Transformational Leadership: This style of leadership is identified to empower others

and be a “visible role model” (Giltinane, 2013, p. 37) for others. Transformational

leadership is “positively associated with followers’ commitment to improvement and

change” (Marshall, 2010, p. 28). I hope to inspire others and express a clear vision

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for the project. Enabling open communication and establishing a presence will assist

in fostering a culture of team work and collaboration (Marshall, 2010). By

connecting with others and collaborating with the team, I hope to develop trust and

motivate others. Transformational leaders set specific goals and show commitment

(Marshall, 2010). I plan to develop an overall aim statement for this project based on

the specific goals of the project to support this characteristic of a transformational

leader. Also, I intend to show commitment by being on site when possible rather than

utilizing technology to communicate.

I. Outcome Measurement

To measure the outcomes of this project, with the help of biomedical engineering, I will

collect monitor alarm data that will evaluate the number of alarms per patient per day after the

proposed education is completed. This alarm data will be categorized into clinically significant

or non-significant (requires no clinical intervention). The goal will be to see a reduction in the

non-significant alarm data, which is a cause of alarm fatigue. I will also collect data at the

bedside with tally sheets for alarms that cannot be tracked electronically (ventilators, CPAP).

Cvach (2012) found after altering alarm limits “to actionable levels” and individualizing patient

parameter limits, there was a 43% reduction in duplicate alarms. The overall alarm management

improvement project resulted in a “46% reduction in total alarms/pt/day” (Cvach, 2012, p. 272).

Without the scheduled lead change component, I hope to show at least a 25% reduction in non-

clinically significant alarms.

J. Predicted Results

By utilizing evidence based research to develop standards for alarm parameters, my project

should support the JC NPSG of alarm management. After this project, the nurse to nurse report

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will include discussion of alarm parameters for each patient which will increase specificity of

alarms and reduce non-clinically significant alarms. I expect a reduction of at least 25% of

alarms per day. Also, by educating staff regarding proper EKG skin preparation and placement,

I expect this to reduce the number of false monitor alarms. Reducing the number of false

monitor alarms should reduce alarm fatigue and the associated risks to patient safety. I hope by

incorporating these improvements awareness of alarm safety will increase and clinically

significant events will not be missed due to alarm fatigue.

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Reducing Monitor Alarm Fatigue in the Neonatal Intensive Care Unit

Goals with QSEN/ANA Support Sub-Objectives to meet Goal

Activities to meet Each Sub-objective

Timeline for each

Goal 1: State GoalCreate an educational program that increases awareness of alarm safety and encourages nurse-hand off discussion of alarm parameters

Meets QSEN Competencies/KSA(s):Safety: Knowledge- “Describe best practices that promote patient and provider safety” (QSEN Institute, 2012, “Safety”).Safety: Skill: “Participate as a team member to design, promote, and model effective use of technology and standardized practices that support safety and quality” (QSEN Institute, 2012, “Safety”).Teamwork and Collaboration: Attitude-“Appreciate the importance of inter-professional collaboration. Value collaboration with nurses and other members of the nursing team” (QSEN Institute, 2012, “Teamwork and Collaboration”).

Meets ANA Scope & Standards for specialty role:Standard 1-Assessment: collecting information and data regarding current practice and workflow to identify the potential effect of a solution to the current need (ANA, 2008).Standard 2-Problem and Issues Identification: identify the needs of the unit to determine the desired outcomes and develop a plan for implementation (ANA, 2008).Standard 5-Implementation: implement a plan in a “safe and timely manner” and collaborate with other stakeholders before, during, and after implementation (ANA, 2008, p. 71).

1.1 Determine current causes of nuisance alarming and alarm fatigue through RCA

1.2 Develop standardized EKG lead/pulse ox changes and proper skin preparation based on gestational age of patient and skin integrity

1.3 Educate staff regarding alarm safety and benefits of alarm parameter customization

1.4 Evaluate effectiveness of educational program

1.1Meet with stakeholders then with staff to determine specific needs and requests of the unit staff

1.2 Survey nurses regarding current causes of alarm fatigue1.3 Gather monitor alarm data for baseline comparison

1.4 Create online presentation regarding alarm safety and benefits of customized parameters

1.5 Answer questions regarding alarm safety and evaluate effectiveness after education.

1.6 Gather monitor alarm data following

1.1 10/2014

1.2 1/2015

1.3 1/2014-2/2015

1.4 1/2015-2/2015

1.5 3/2015-4/2015

1.6 4/2015-5/2015

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educationGoal 2: State GoalCreate an EKG/pulse ox skin preparation protocol and supportive educational component based on evidence based research

Meets QSEN Competencies/KSA(s):Safety: Knowledge- “Describe best practices that promote patient and provider safety” (QSEN Institute, 2012, “Safety”).Safety: Skill: “Participate as a team member to design, promote, and model effective use of technology and standardized practices that support safety and quality” (QSEN Institute, 2012, “Safety”).Teamwork and Collaboration: Attitude-“Appreciate the importance of inter-professional collaboration. Value collaboration with nurses and other members of the nursing team”

Meets ANA Scope & Standards for specialty role:Standard 1-Assessment: collecting information and data regarding current practice and workflow to identify the potential effect of a solution to the current need (ANA, 2008).Standard 5-Implementation: implement a plan in a “safe and timely manner” and collaborate with other stakeholders before, during, and after implementation (ANA, 2008, p. 71).

2.1 Determine current causes of nuisance alarming and alarm fatigue through RCA

2.2 Develop standard skin preparation protocol based on evidence

2.3 Conduct education regarding new protocol to NICU staff

2.4 Evaluate effectiveness of new protocol

2.1 Meet with stakeholders then with staff to determine specific needs and requests of the unit staff

2.2 Meet with leadership to discuss protocol and specific needs of unit

2.3 Develop online educational presentation regarding protocol

2.4. Answer questions and elicit feedback regarding new process

2.5. Gather alarm data following education and new policy

2.1 10/2014

2.2 1/2015

2.3 2/2015-3/2015

2.4 3/2015-4/2015

2.5 4/2015-5/2015

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Appendix A

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33(2013), 83-86. Retrieved from www.cconline.org

American Association of Critical-Care Nurses. (2013). Strategies for managing alarm fatigue

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fatigue-final.ppt

Cvach, M. (2012). Monitor alarm fatigue: An integrative review. Biomedical Instrumentation

and Technology,46(4), 268-277. doi:10.2345/0899-8205-46.4.268

Cvach, M. , Biggs, M., Rothwell, J. K., & Charles-Hudson, C. (2013). Daily electrode change

and effect on cardiac monitor alarms: An evidence based approach. Journal of Nursing

Care Quality, 28(3), 265-271. doi:10.1097/NCQ.0b013e31827993bc

Emergency Care Research Institute. (2007). The hazards of alarm overload. Health Devices, 73-

83. Retrieved from www.ecri.org

Giltinane, L. C. (2013). Leadership styles and theories. Nursing Standard, 27(41), 35-39.

Retrieved from http://rcnpublishing.com/journal/ns

Graham C. K., & Cvach, M. (2010). Monitor alarm fatigue: Standardizing use of physiological

monitors and decreasing nuisance alarms. American Journal of Critical Care, 19(1), 28-

34. doi:10.4037/ajcc2010651

The Joint Commission. (2013). The Joint Commission announces 2014 national patient safety

goal. Retrieved from

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Manchester, J., Gray-Miceli, L. D., Metcalf, A. J., Paolini, A. C., Napier, H. A., Coogle, L. C., &

Owens, G. M. (2014). Facilitating Lewin’s change model with collaborative evaluation in

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Marshall, E.S. (2010). Transformational leadership in nursing: From expert clinician to

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Phillips, J., & Barnsteiner, H. J. (2005). Clinical alarms: Improving efficiency and effectiveness.

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Quality and Safety Education for Nurses Institute. (2012). Graduate KSAs. Retrieved from

http://qsen.org/competencies/graduate-ksas/#safety