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Research Outcomes of Implementing CEASE

An Innovative, Nurse-Driven, Evidence-Based, Patient-Customized Monitoring Bundle to Decrease Alarm Fatigue in the Intensive Care Unit/Step-down Unit

Lewis, Carmencita Lorenzo, BSN, RN, CCRN; Oster, Cynthia A., PhD, RN, APRN, MBA, ACNS-BC, ANP, FAAN

Dimensions of Critical Care Nursing: May/June 2019 - Volume 38 - Issue 3 - p 160–173
doi: 10.1097/DCC.0000000000000357
Research DIMENSION
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Introduction The research literature is replete with evidence that alarm fatigue is a real phenomenon in the clinical practice environment and can lead to desensitization of the need to respond among nursing staff. A few studies attest to the effectiveness of incorporating parts of the American Association of Critical-Care Nurses recommended nursing practices for alarm management. No studies could be found measuring the effectiveness of the American Association of Critical-Care Nurses recommendations in their entirety or the effectiveness of a nursing-driven, evidence-based, patient-customized monitoring bundle.

Purpose/Research Question The purpose of this study was to describe the effect of implementing CEASE, a nurse-driven, evidence-based, patient-customized monitoring bundle on alarm fatigue. CEASE is an acronym for Communication, Electrodes (daily changes), Appropriateness (evaluation), Setup alarm parameters (patient customization), and Education (ongoing). Research questions: (1) In a 36-bed intensive care unit/step-down unit (ICU/SDU) with continuous hemodynamic and respiratory monitoring, does application of an evidence-based, patient-customized monitoring bundle compared with existing monitoring practice lead to less alarm fatigue as measured by the number of hemodynamic and respiratory monitoring alarms? (2) In a 36-bed ICU/SDU with continuous hemodynamic and respiratory monitoring, does application of an evidence-based, patient-customized monitoring bundle compared with existing monitoring practice lead to less alarm fatigue as measured by duration of alarms? and (3) In a 36-bed ICU/SDU with continuous hemodynamic and respiratory monitoring, does application of an evidence-based, patient-customized monitoring bundle compared with existing monitoring practice lead to less alarm fatigue as measured by nurse perception?

Methods This was an institutional review board approved exploratory, nonrandomized, pretest and posttest, 1-group, quasi-experimental study, without-comparators design describing difference in pretest and posttest measures following CEASE Bundle implementation. The study was conducted over a 6-month period. Convenience sample of 74 registered nurses staffing a 36-bed ICU/SDU using the CEASE Bundle participated. Preimplementation/postimplementation number of alarms and alarm duration time for a 30-day period were downloaded from the monitoring system and compared. Nurses completed an electronic 36-item Clinical Alarms Survey provided by the Healthcare Technology Foundation: 35 before implementation and 18 after implementation. Researchers measured CEASE alarm bundle adherence. χ2 and t-tests determined statistical significance.

Results Total number of monitoring alarms decreased 31% from 52 880 to 36 780 after CEASE Bundle implementation. Low-priority Level 1 alarms duration time significantly decreased 23 seconds (t = 1.994, P = .045). Level 2 duration time did not change. High-priority Level 3 alarms duration time significantly increased to 246 seconds (t = 4.432, P < .0001). CEASE alarm bundle adherence significantly improved to 22.4% (χ2 = 5.068, P = .0244). Nurses perceived a significant decrease in nuisance alarm occurrence (68% to 44%) postimplementation (χ2 = 3.243, P = .0417). No adverse patient events occurred.

Conclusions Decreased total number of monitoring alarms improved nurse perception of alarm fatigue. Continued monitoring of CEASE Bundle adherence by nursing staff is required. Longer high-priority Level 3 alarms duration suggests need for further research.

Carmencita Lorenzo Lewis, BSN, RN, CCRN, is a staff nurse and charge nurse at the intensive care unit/step-down unit, Porter Adventist Hospital in Denver, Colorado. She is currently enrolled in the clinical nurse specialist master's degree program at the University of Colorado, College of Nursing, Aurora, Colorado.

Cynthia A. Oster, PhD, RN, APRN, MBA, ACNS-BC, ANP, FAAN, is nurse scientist for patient safety, Emory Healthcare, and adjunct assistant professor, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia. At the time this study was conducted, she was the nurse scientist and clinical nurse specialist for critical care and cardiovascular services at Porter Adventist Hospital, Denver, Colorado. In 2016, Dr Oster received a 2nd Place American Journal of Nursing Book Award in the Professional Issues Category for the textbook High Reliability Organizations: A Healthcare Handbook for Patient Safety & Quality.

The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

Address correspondence and reprint requests to: Carmencita Lorenzo Lewis, BSN, RN, CCRN, Centura Health–Porter Adventist Hospital, 2525 S Downing St, Denver, CO 80210 (carmencita.lorenzo@gmail.com).

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.dccnjournal.com).

Dr. Cynthia Oster and Carmencita Lorenzo Lewis presented this research at the 2019 Royal College of Surgeons in Ireland (RCSI) 38th Annual International Nursing & Midwifery Research and Education Nursing Conference in Dublin, Ireland, 27-28 February 2019.

In the health care setting, the intention of an alarm is to alert the care provider to the need for an action. A clinical alarm may signify a pump or machine dysfunction or a critical life-threatening event. Although alarms are important in the care of patients, the constant barrage of alarm signals can overwhelm the health care provider and thus threaten patient safety. The number of alarm signals per patient per day can reach several thousand, depending on the unit and hospital. A phenomenon called “alarm fatigue” develops from continued exposure to the drone of beeping environmental noises, with the clinician becoming desensitized and ignoring or mismanaging alarms.1-18 In 2013, The Joint Commission made clinical alarm management a national patient safety goal to help address the alarm fatigue phenomenon. Between January 2009 and June 2012, 98 alarm-related events were reported to The Joint Commission. Of those events, 80 resulted in death, 13 in permanent loss of function, and 5 in unexpected extended stay.11 Alarm mismanagement can threaten patient safety. According to the Emergency Care Research Institute, alarm hazards have made the top 10 health technology hazards for 5 consecutive years.4 It is important to appropriately manage alarms without compromising patient safety. An evidence-based, patient-customized monitoring bundle is necessary to standardize the care of these patients and give direction in the management of their alarms.

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REVIEW OF LITERATURE

The American Association of Critical-Care Nurses (AACN) published an evidence-based practice alert on recommended nursing practices for alarm management.1 Key points of the AACN-recommended practices include establishing an interprofessional team to address alarms, appropriate skin preparation before daily changes of electrocardiogram (ECG) electrodes, as-needed pulse oximetry sensor changes for respiratory monitoring, monitoring only patients with appropriate clinical indications, customizing alarm parameters, and initial and continuing education. Some of these recommendations have been reported to decrease the amount of clinical alarms. Sendelbach and colleagues15 used a quality improvement framework to evaluate some components of the AACN recommendations and reported an 80% to 90% reduction in ECG alarms. Another study in the pediatric population decreased the median number of alarms per patient day from 180 to 40.19 No studies were found measuring the effects of the AACN recommendations in their entirety. No studies were found in a mixed intensive care unit and step-down unit (ICU/SDU) community hospital setting.

Communication is important in alarm management. Communication among colleagues regarding procedures and patient conditions can aid in monitoring surveillance and alarm management. Certain patient care activities and procedures may produce false alarms or expected nonactionable alarms. For example, ambulation, suctioning secretions, or patient repositioning can create false or nonactionable alarms due to artifact and extra movement. Suspending alarms during these procedures and nursing cares can decrease alarms and provide clinical context to alarms.9

Evidence suggests daily ECG electrode changes can decrease the number of alarms by 46%.9 Changing electrodes decreases technical alarms occurring due to incorrect lead placement or lack of lead skin contact. Appropriate skin preparation to the area of lead application improves electrode-to-skin contact to reduce artifact. Clipping excessive hair and washing the electrode skin area with soap and water and then wiping with a washcloth have been recommended to enhance conductivity and ECG detection.20-22 Rubbing a rough washcloth over the lead site during skin preparation removes part of the outer layer of the epidermis; this allows electrical signals to travel with less interruption, thus fewer opportunities for technical alarms to occur.20-22

A misconception of cardiac monitoring is it significantly reduces caregiver liability and saves lives by alerting staff of major cardiac events.6,7 However, one study's results suggest very rare benefit of patient monitoring and found only 3 in 8932 patients having a survivable cardiac event while monitored.23 Best evidence recommends monitoring only those patients with clinical indications for monitoring, which can significantly decrease the number of nonactionable alarms.24-26 Overmonitoring remains a significant issue in hospital settings.24,26,27 Although the American Heart Association Practice Standards for Electrocardiographic Monitoring specifies indications and duration of monitoring, research has shown that monitoring is overused, with as much as 43% of patients unnecessarily monitored.23,26,27 Another study examined 1816 patients in cardiac units and discovered 85% of patients with telemetry monitoring did not meet American Heart Association indications.26 Furthermore, efforts to reduce alarms and the number of patients being monitored have not reported increases in patient morbidity or mortality.18-20,24,27,28 These studies suggest a more discriminatory look at the appropriate need and practices for telemetry monitoring in patients is needed.

According to the literature, customizing alarm parameters for patients can decrease unnecessary alarms.15,18,19,28 In the health care setting, clinical alarms are necessary to safely care for a multitude of patients. In a critical care setting, a caregiver can be subject to 140 to 400 alarms per patient day.12 In 2013, The Joint Commission Sentinel Event Alert estimated between 85% and 99% of alarm signals do not require clinical intervention. These nonactionable alarm conditions are from parameters set too tight and default settings not adjusted for the individual patient.11 Several hospitals have been able to reduce alarm signals that do not require clinical intervention by comparing clinical practices and inventory of alarm signals. These hospitals changed alarm parameters and alarms levels or placed delays on alarm signals. Default alarm parameters were changed to parameters staff would typically intervene, with a 43% to 89% reduction in physiological alarms and no adverse events following alarm default parameter changes.17,18,28 The literature is replete with studies demonstrating standardized monitor default parameters can decrease the number of patient alarms; however, no study was found measuring the effects of nurses customizing alarm parameters based on patient condition.

Alarm fatigue is a consequence of an excessive amount of alarms in the practice environment.2,3,6,9,10,14,29 Alarm awareness and education of the nursing staff are crucial to the resolution or mitigation of alarm fatigue. The perceptions and attitudes of the nursing staff toward alarm occurrences contribute to the complexity of alarm fatigue.5,16,30 Several research studies surveyed nursing staff at different types of facilities, and each study reported a common theme of alarm desensitization due to false and nonactionable alarms.5,7,16,31 After 10 years of surveying workers, the Healthcare Technology Foundation's Clinical Alarms Committee discovered little improvement with alarm perception. In fact, even with increasing alarm improvement initiatives in the past several years, alarm-related adverse events are on the rise.31 The Healthcare Technology Foundation's Clinical Alarms Committee surveyed a variety of health care workers such as nurses, respiratory therapists, clinical engineers, and monitor technicians.29,31 False or nonactionable alarms were a large contributor to alarm fatigue across all 3 surveys.7,29,31

The research literature is filled with evidence supporting alarm fatigue is a real phenomenon in the clinical practice environment leading to desensitized staff ignoring or mismanaging alarms. A few studies attest to the effectiveness of incorporating parts of the AACN-recommended nursing practices for alarm management.15,19 However, no studies could be found measuring the effectiveness of the AACN recommendations in their entirety or the effectiveness of a nursing-driven, evidence-based, patient-customized monitoring bundle. There is opportunity to understand the effect of standardized nursing practices customized to individual patient need on alarm fatigue in the ICU/SDU setting. Therefore, the purpose of this study is to describe the effect of implementing a nurse-driven, evidence-based, patient-customized monitoring bundle on alarm fatigue. The 3 research questions were as follows:

  • In a 36-bed ICU/SDU unit with continuous hemodynamic and respiratory monitoring, does application of an evidence-based, patient-customized monitoring bundle compared with existing monitoring practice lead to less alarm fatigue as measured by the number of hemodynamic and respiratory monitoring alarms?
  • In a 36-bed ICU/SDU with continuous hemodynamic and respiratory monitoring, does application of an evidence-based, patient-customized monitoring bundle compared with existing monitoring practice lead to less alarm fatigue as measured by duration of alarms?
  • In a 36-bed ICU/SDU with continuous hemodynamic and respiratory monitoring, does application of an evidence-based, patient-customized monitoring bundle compared with existing monitoring practice lead to less alarm fatigue as measured by nurse perception?
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METHODS

Design

Following local institutional review board approval, the study was conducted over a 6-month period in 2016 using a nonrandomized, pretest and posttest, 1-group, quasi-experimental without-comparators design. Preintervention data were collected 2 months prior to intervention. Postintervention data were collected 2 months following intervention implementation.

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Setting

The setting is a 36-bed ICU/SDU that provides high-intensity nursing care to a variety of patient populations including, but not limited to, kidney, liver, and pancreas transplants; medical and interventional cardiac; cardiovascular thoracic surgery; radical head and neck surgery; general medical and sepsis; general surgery; and spine surgery. The hospital is a 368-bed, not-for-profit, Magnet-designated acute care facility located in an urban area in the western region of the United States.

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Procedures

The study protocol and timeline are summarized in Table 1. The outcomes collected before and after intervention were number of auditory monitoring alarms, duration of auditory monitoring alarms, nurse perception of alarms, adherence to the intervention bundle, and number of adverse alarm events. Thirty days of alarm data were downloaded from the monitoring system into an Excel (Microsoft, Bellview, Washington) spreadsheet. The number of auditory monitoring alarms was counted. The duration of an alarm was measured in seconds and was the time elapsed between the start and end time. Start time was the time an alarm was initially generated, with end time being time the alarm was recorded as ended on the download from the monitoring system. The ICU/SDU staff nurse perception of alarm fatigue was measured by the Healthcare Technology Foundation Clinical Alarms Survey via email SurveyMonkey technology.29 The survey is divided into 4 main sections. The first section is demographic information. The second section is a number of general statements about clinical alarms and prompts the respondents to rate their level of agreement with the statement using a 5-point Likert-type scale of strongly disagree, disagree, neutral, agree, and strongly agree. The higher the score, the more the respondent agrees with the statement. The third section presents a listing on 9 issues that inhibit effective clinical alarm management and asks the respondent to rank them on a scale of 1 (most important) to 9 (least important). The fourth section provides space for comments. Informed consent was included in the invitation to complete the Clinical Alarms Survey. The number of adverse events related to hemodynamic and respiratory monitoring alarms was monitored for safety purposes.

TABLE 1

TABLE 1

The intervention was the CEASE Bundle, a nurse-driven, evidence-based, patient-customized monitoring bundle (Table 2). CEASE is an innovative acronym based on the 2013 AACN practice alert recommendations for alarm management and is an acronym for Communication, Electrodes, Appropriateness, Setup, and Education.1 The CEASE Bundle incorporates AACN practice alert strategies of proper skin preparation, electrode changes, customization of alarm parameters and levels on ECG and pulse oximetry, ongoing education about alarms, and interprofessional teams into an innovative format. Adherence to the CEASE Bundle was measured using the CEASE Bundle Audit Tool developed by the researchers (Table 3).

TABLE 2

TABLE 2

TABLE 3

TABLE 3

The principal investigators recruited 9 CEASE champions from ICU/SDU clinical expert nurse leaders. Champions were 1 charge nurse, 2 staff nurses, 4 assistant nurse managers, and 2 unit nurse educators. Five worked day shift, 3 worked night shift, and 1 worked day and night shifts. Champions attended a hands-on educational session taught by one of the principal investigators during May 2016. Champion education sessions were guided by the CEASE education/competency packet that included the CEASE Bundle, monitoring system and alarms, monitoring system demo, and reading 1 evidence-based article (see Supplemental Digital Content 1, http://links.lww.com/DCCN/A44). Champions demonstrated competency by successfully completing champion education and the CEASE Champion Competency Checklist (Table 4). Champion competency was validated by one of the principal investigators. The role of champions was to provide encouragement and support and answer questions, as well as educate the staff nurses to ensure competency with the CEASE Bundle.

TABLE 4

TABLE 4

Seventy-four of 83 eligible ICU/SDU registered nurses attended 1 hands-on CEASE champion–led educational session during June 2016. Day- and night-shift clinical nurses were educated by CEASE champions with the same materials used to educate CEASE champions. However, clinical nurses did not complete the monitoring system demo. Clinical nurses demonstrated competency by successfully completing clinical nurse education (see Supplemental Digital Content 1, http://links.lww.com/DCCN/A44) and the CEASE Clinical Nurse Competency Checklist (Table 5). Implementation of the CEASE Bundle occurred on July 1, 2016.

TABLE 5

TABLE 5

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Statistical Analysis

Statistical analysis was performed using SAS version 4.0 (SAS Institute, Cary, North Carolina) software. Frequency distributions and descriptive statistics describe the data. Comparisons before and after intervention were made using χ2 and independent-group Student's t-test, with P < .05 considered statistically significant. A power analysis was not conducted as there was no control group.

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RESULTS

Total number of auditory monitor alarms decreased 30.45% from 52 880 to 36 780 (Table 6). No adverse alarm events occurred during the study period. The monitoring system software grouped auditory alarms into 3 groups: Level 1, low-priority events such as low battery alerts and artifact; Level 2, moderate-priority events such as high/low blood pressure, irregular heartbeat, paired beats and high/low SpO2; and Level 3, high-priority or life-threatening events such as apnea, asystole, ventricular tachycardia or fibrillation, and rapid oxygen desaturation. The number of Level 1 auditory monitor alarms decreased 7.7% from 14 131 to 13 040. The number of Level 2 auditory monitor alarms decreased 39.35% from 31 251 to 18 955. The number of Level 3 auditory monitor alarms decreased 36.18% from 7498 to 4785.

TABLE 6

TABLE 6

Low-priority Level 1 auditory alarm average duration time significantly decreased 23 seconds from 198 seconds preintervention to 175 seconds postintervention (t = 1.994, P = .045). Level 1 alarm sounds decreased 143.3 hours from 777.21 hours preintervention to 633.9 hours postintervention. Level 2 average duration time did not significantly change but increased 3 seconds from 22 to 25 seconds (t = 0.109, P = .9135). Level 2 alarm sounds decreased 59.3 hours from 190.9 hours to 131.6 hours. High-priority Level 3 alarm average duration time significantly increased 246 seconds from 55 to 301 seconds (t = 4.432, P < .0001). Level 3 alarm sounds increased 285.4 hours from 114.5 to 400.1 hours (Tables 7 and 8).

TABLE 7

TABLE 7

TABLE 8

TABLE 8

Adherence to the CEASE Bundle significantly increased from 9% to 22.4% (χ2 = 5.068, P = .0244). Clinical practices of nurses over 281 shifts (134 day shifts, 147 night shifts) preintervention and 272 shifts (145 day shifts, 127 night shifts) postintervention were audited to calculate adherence to the bundle.

Nurses perceived a significant decrease in nuisance alarm occurrence (Table 9). Nurse perception data were analyzed in 2 groups: preintervention and postintervention survey responses. Thirty-five nurses completed the survey preintervention (47.3% response rate), and 18 completed the survey postintervention (24.3% response rate). Preintervention, 68% of responding nurses strongly agreed nuisance alarms occurred frequently compared with 44% postimplementation (χ2 = 3.243, P = .0417). A significant increase in no perception of alarm nuisance change or a neutral survey response (5% to 27%) was reported postintervention (χ2 = 8.922, P < .0028). There was no significant difference in perception of those nurses who agree nuisance alarms occur frequently.

TABLE 9

TABLE 9

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DISCUSSION

Implementation of the CEASE Bundle is a first attempt by one hospital to understand its own situation and develop a systematic, coordinated, evidence-based approach to mitigate alarm fatigue to meet the 2019 National Patient Safety Goal to reduce the harm associated with clinical alarm systems.32 Alarm fatigue is the lack of response due to excessive numbers of alarms resulting in sensory overload and desensitization. A clinical alarm system is intended to alert nursing staff to patient problems, but if alarm systems are not well managed, the system may compromise patient safety.11 Proper management of a clinical alarm system is a multifaceted problem. Individual alarm signals can be difficult to detect because many patient care areas have numerous alarm signals and the resulting noise and displayed information contribute to alarm fatigue, causing staff to miss or ignore alarm signals. Other factors contributing to desensitization include default settings that are not at an actionable level and alarm limits that are too narrow. There is general agreement that alarm fatigue is an important safety issue.

The CEASE Bundle is a standardized approach grounded in the 2013 AACN practice alert recommendations that contributes to mitigating alarm fatigue by safe alarm system management.1 The innovative CEASE Bundle design and subsequent implementation demonstrate the 4 elements of performance to meet the 2019 National Patient Safety Goal to reduce harm associated with clinical alarm systems: leaders establish alarm system safety as a hospital priority, identify the most important alarm signals to manage, establish policies and procedures to manage alarms, and educate staff about the purpose and proper operation of alarm systems.32 The conduct of this study was supported by hospital leaders as alarm system safety is a hospital as well as health system priority. The CEASE Bundle sought to identify the most important alarm signals to manage based on input from the medical staff, whether specific alarm signals contribute to alarm noise and alarm fatigue, potential for patient harm based on internal incident history, and published practices and guidelines. The CEASE Bundle measured the effectiveness of an established policy and procedure for managing alarms that included clinically appropriate settings for alarm signals; when alarm signals can be disabled; when alarm parameters can be changed; who in the organization has the authority to set alarm parameters; who in the organization has the authority to change alarm parameters; who in the organization has the authority to set alarm parameters to “off”; monitoring and responding to alarm signals; and checking individual alarm signals for accurate settings, proper operation, and detectability. Implementation of the CEASE Bundle included educating nursing staff about the purpose and proper operation of alarm systems for which they are responsible.

There was a 30% reduction in the number of alarms with no adverse alarm-related events following the implementation of the CEASE Bundle. The number of Level 1, 2, and 3 alarms all decreased without patient harm. These results suggest the CEASE Bundle is an effective intervention to reduce the number of clinical alarms in an ICU/SDU setting without compromising patient safety. The purpose of an alarm is to enhance patient safety by alerting clinicians to a deterioration in patient condition or to a device or piece of technology not functioning as intended. A perfect alarm system would ideally perform with high sensitivity and specificity.14 A perfect alarm system would never miss a clinically important event (100% sensitivity) or go off when there is no clinically important event (100% specificity). Alarm systems are designed to be highly sensitive often at the expense of alarm specificity. Nurses exposed to an excessive number of alarms experience alarm desensitization or alarm fatigue due to exposure to an overwhelming number of alarms. Studies have shown that alarm fatigue has caused nurses to turn down the volume of audible alarms, adjust alarm settings outside limits that are safe and appropriate for the patient, ignore alarms, or even deactivate alarms.33-36 These actions can result in sentinel events and patient deaths.11 In reality, there is no perfect alarm system with 100% sensitivity and 100% specificity. The goal was to best match the equipment and the clinical environment to alert ICU/SDU nursing staff to a significant change in patient condition.

Nurse perception of alarm fatigue improved following implementation of the CEASE Bundle as nurses perceived a significant decrease in nuisance alarm occurrence. Decreasing the total number of monitoring and improving the adherence to the evidence-based best practice CEASE Bundle probably contributed to decreasing nuisance alarm frequency perception by the nursing staff. The results of this study support previous findings that nuisance alarms occur frequently and disrupt patient care in the absence of a standardized method for alarm management and parameter settings.16,37 Results of this study suggest the evidence-based, patient-customized monitoring CEASE Bundle is a tool nurses can use to mitigate alarm fatigue by better matching the equipment to the patient in the clinical environment to alert ICU/SDU nursing staff to a significant change in patient condition without compromising patient safety.

The literature reports slowness or lack of caregiver response to alarms may be a sequela of excessive alarms or alarm fatigue.38,39 It is plausible that duration time of alarms could be viewed as a proxy for alarm fatigue in the clinical environment. Level 1 average alarm duration significantly decreased postintervention, whereas Level 2 average alarm duration did not significantly change. It is reasonable to assume alarm fatigue probably improved for Level 1 and Level 2 alarms as total duration time for these alarms decreased postintervention. This assumption is further supported by the finding of improved nurse perception of fewer nuisance alarms after implementation of the CEASE Bundle.

Surprisingly, Level 3 alarm duration significantly increased postintervention. Level 3 alarms are high priority and signal life-threatening events such as apnea, asystole, ventricular tachycardia or fibrillation, and rapid oxygen desaturation. Nurses respond to alarms for different reasons, not only the fact that the alarm sounds. Additional strategies nurses use to determine response include the criticality of the patient, signal duration, rarity of the alarming device, and workload.40-42 Evidence suggests nurses adjust the order of their activities in relation to the patient's condition and have a greater tendency to react to alarms of greater duration and considered rare.41-43 The longer duration of Level 3 alarms may be a beacon and reflects a strategy nursing staff use to call for assistance from their peers in order to deliver needed care activities quickly to a critically ill patient. However, there is evidence to suggest as nursing workload or task complexity increases, alarm response and task performance deteriorate.41 Clearly, the significantly longer Level 3 alarm duration postintervention requires further investigation.

The 30% decrease in the total number of alarms suggests a quieter environment more conducive for patient healing and a healthier work environment for nursing staff. It is assumed that fewer number and hours of Level 1 and Level 2 alarms support a quieter ICU/SDU environment. However, the higher number of Level 3 alarm hours stands in contradiction to a quieter ICU/SDU environment. The high number of aggregate hours of noise generated by the alarm system reported in this study is astounding. Alarms generate noise that may present occupational hazards or hinder patient recovery.44 The hospital environment, particularly the ICU/SDU, can be characterized by irregularly occurring noises from sources such as medical devices (alarms), telephones, pagers, conversations, door sounds, and nursing activities. Sound levels in 39 ICUs were reported to be 78 decibels (dB) by Litton and colleagues.45 These sound levels are well above the World Health Organization recommendation that noise levels not exceed 35 dB during daytime hours and 30 dB for nighttime hours. It is likely the noise levels in the study ICU/SDU are similar to those reported in the literature. Such noise hinders patient recovery by increasing cardiovascular stress, lengthening healing times, increasing doses of pain medication, increasing patient readmission rates, and disturbing sleep.45-47 There is increasing evidence of the negative effects of noise on nursing staff. Noise-induced stress has been linked to burnout, diminished well-being, and reduced work performance.48 In addition, staff often attribute feelings of annoyance, irritation, fatigue, and tension headaches to a noisy work environment.49 Other studies suggest environmental noise affects speech intelligibility, leading to misunderstandings that result in medical error.48,50 Additional research is needed to explore strategies to mitigate noise levels in the ICU/SDU work environment in order to improve the health of both patients and nursing staff.

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RECOMMENDATIONS FOR PRACTICE

The most current alarm management recommendation from the critical care nurses' professional association was the 2013 AACN Practice Alert for Alarm Management when the CEASE Bundle was created.1 In 2018, an AACN practice alert was published reflecting the evolution from elementary alarm management to managing alarms in acute care across the life span for electrocardiography and pulse oximetry.51 The CEASE Bundle does include pausing alarms before the nurse performs care activities that create false alarms, daily electrode changes with skin preparation, multidisciplinary examination of appropriate patient monitoring criteria, alarm customization, and ongoing education as recommended in the 2018 AACN Practice Alert. However, the CEASE Bundle does not include the 2018 evidence-based practices of prohibiting the placement of finger clip SpO2 sensors on the ear and the placement of SpO2 sensors on warm extremities. Revision of the CEASE Bundle is in process and includes a plan for nursing staff education. The shared governance unit–based practice council, ICU/SDU email Listserv, and weekly ICU/SDU newsletters are strategies to disseminate the revised CEASE Bundle to nursing staff upon completion of revisions.

Hemodynamic and respiratory monitoring technology is one of the vital components to providing safe patient care in the ICU/SDU. Nursing practice must reflect the knowledge, skills, and attitudes required to effectively utilize technology to balance essential surveillance for change in patient condition with alarm management. The CEASE Bundle is an ongoing strategy in the ICU/SDU that has decreased nonactionable alarms and made the alarms that do sound more meaningful without compromising patient safety. Two safety recommendations from The Joint Commission are to identify the most important alarms to manage and identify alarms that may contribute to unnecessary excessive noise.52 This is accomplished by establishing policies to make alarm settings clinically appropriate, defining when to change or disable alarm parameters, and identifying who can make these changes. An interdisciplinary team authored a policy and procedure including default parameters, customization restrictions, evidence-based indications for monitoring, tactics to minimize alarm fatigue, and process to safely transport monitored patients.7,8,16,19,24,25 Alarm customization includes a balance between activating too many alarms and too few alarms. Alarm customization includes selecting alarm settings based on the needs of the ICU/SDU and the condition of the patient.53 A policy and procedure grounded in best evidence-based practices included in the CEASE Bundle aid ICU/SDU nurses to manage alarms to lessen the alarm fatigue phenomenon. More or inappropriate monitoring causes more alarms to occur.19,23,25,26 Thoughtful application of evidence-based indications for patient monitoring aids in decreasing the overall number of alarms sounding every day in the clinical environment. Nurses in the ICU/SDU participate in daily interdisciplinary team rounds and actively contribute to identifying clinically appropriate monitoring required and customized to patient-specific need.

The ICU/SDU staff continue to mitigate excessive alarms by incorporating the CEASE Bundle into daily practice with emphasis on daily ECG lead changes, pausing or suspending alarms when performing nursing care that could create nonactionable alarms, and understanding how to use the technology in order to troubleshoot nonactionable alarms.1,52 Study results demonstrated a significant increase in CEASE Bundle compliance postintervention to 22% along with a decrease in total number of alarms. Increasing CEASE Bundle adherence should continue to decrease the number of sounding alarms.

At the forefront of alarm management are nurse education and how individual nursing practices can influence alarm fatigue. Current nursing staff knowledge and clinical practices on clinical judgment related to alarms, alarm policy, and procedure and the use of available monitoring equipment have been enhanced through participation in this study. The clinical nurse education/competency packet used in this study has been adapted and is now included in the new graduate nurse on-boarding curriculum. The same curriculum is provided during the on-boarding of experienced nursing staff as well. Emphasizing alarm management upon hire to lessen the occurrence of alarm desensitization and alarm fatigue creates a practice environment culture that values patient safety. A quieter work environment with less noise and fewer alarms improves patient safety, patient satisfaction, and employee satisfaction.12,48,49

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RECOMMENDATIONS FOR FUTURE RESEARCH

A significant increase in Level 3 alarm duration postintervention is an unexpected finding and suggests the need for further research. Gaining insight into why and for what purpose high-priority alarm duration increased when the number of Level 3 alarms decreased is imperative in the ICU/SDU. One hypothesis for this finding is contextual nursing judgment. High-priority alarms indicate a significant change in patient condition, and in this context, nursing judgment mandates treating the patient first and then silencing the alarm sounds. Another hypothesis is that high-priority alarms are not silenced quickly as the sound acts as a beacon or alert to other nurses and care providers in the environment to come immediately to help. It is not known if patient acuity was higher postintervention as acuity data were not collected during this study. Clearly more research is needed to test these and other hypotheses.

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LIMITATIONS OF THE STUDY

This study does have several limitations. There is no control group for comparison, and the design lacked randomization. Lack of a control group and no randomization limit generalizability. In addition, the number of registered nurses who completed the alarm perception survey was less than optimal. The survey response rate of 47.3% before and 24.3% after intervention is below the average response rate of 52.7% reported by Baruch and Holtom.54 Therefore, nonresponse bias, the error resulting from distinct differences between those nurses who responded to the survey versus those nurses who did not, is possible. Another issue was that the monitor system underwent a software upgrade during the study, thereby introducing potential for error in data collection. Lastly, the work environment changed during the study period. Large monitors displaying hemodynamic and respiratory waveforms for groups of patients were installed in the hallways of the ICU/SDU. The increased visibility of these waveforms to nursing staff could have affected the number of alarms. The monitor technician dedicated to watching waveforms for ICU/SDU patients was moved to a centralized monitoring station on another floor of the hospital. Relocation of this individual to a centralized monitoring station expanded their responsibilities beyond the ICU/SDU to include watching waveforms for patients throughout the hospital. This change may have affected not only the number of alarms but also the duration of alarms following the intervention.

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CONCLUSION

The literature is replete with evidence that alarm fatigue is a real phenomenon in the clinical practice environment and can lead to desensitization of need to respond among nursing staff. A few studies attest to the effectiveness of incorporating parts of the AACN recommendations for alarm management into clinical practice. However, no studies could be found measuring the effectiveness of the AACN recommendations or the effectiveness of a nursing-driven, evidence-based, patient-customized monitoring bundle. To our knowledge, this is one of the first studies to evaluate the effectiveness of a nurse-driven, patient-customized monitoring bundle based on all components of the 2013 AACN practice alert recommendations.1 This study expands the body of knowledge aiming to understand the effect of standardized nursing practices customized to individual patient need on alarm fatigue in the ICU/SDU setting.

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Acknowledgments

The authors thank Tiffany Meister, MSN, RN, CCRN and Morgan Nestingen, MSN, RN for their support during the study; and Mary E. Siegrist, PhD for providing statistical analysis.

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References

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Keywords:

Alarm fatigue; Intensive care unit; Nurse-driven monitoring bundle; Nurse perception; Patient-customized monitoring bundle; Patient safety

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