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The proliferation of alarming devices in neonatal intensive care (NICU) has created significant risk of patient harm due to alarm desensitization and missed alarms.
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A large proportion of clinical alarms in NICUs are nonactionable, creating a cry wolf phenomenon that promotes alarm fatigue.
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Safe alarm practices require attention to device functionality, alarm settings, staff operating the devices, patient condition, and environment of care.
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Sound quality improvement methods can significantly reduce
Alarm Safety and Alarm Fatigue
Section snippets
Key points
The alarm safety problem
Medical device alarms present care providers with a dilemma: they contribute crucially to effective patient care; however, they may also cause unintended adverse consequences. Safe and effective use of device alarms requires an understanding of the technology sufficiently clear to balance inherent benefits and risks. For some patients in intensive care settings, the number of alarm signals may reach several hundred per day, creating such a high alarm burden that desensitized staff may miss,
Human Factors and Alarms
Human response to clinical alarms has correlates in other fields, including aviation, nuclear power, and many others. A significant body of human factors research exists related to alarms. Binary alarm systems are automated decision aids that classify current condition into either normal or critical. The positive predictive value (PPV) of an alarm system represents the probability that there is a true critical event in case of an alarm: PPV = true alarms/(true alarms + false alarms).6 When PPV
Key Drivers of Alarm Fatigue
Many factors contribute to clinical alarm burden and alarm fatigue. Quality improvement (QI) efforts to address alarm fatigue may benefit from classification of such factors into a key driver diagram (Fig. 1).
Primary Driver: Devices
There may be situations in which alarming devices are used unnecessarily. A stable term infant treated for hypoglycemia may not require pulse oximetry monitoring. Unnecessary oximetry monitoring in a vigorous infant likely begets motion artifact and false alarms. Similarly, the device may
Total alarm count
When implementing changes to address alarm fatigue, the most commonly used measure is total number of alarms per day. Many devices store a time-stamped alarm history, creating an easily collected source of QI data. Numerous studies and quality reports have used total alarm quantity as their primary outcome.2, 22, 26, 35, 36, 37, 38, 39 One team in a pediatric bone marrow transplant unit implemented a standardized cardiac monitor care process and noted a reduction in median number of alarms per
Monitor
Downloads or recordings directly from the alarming device are efficient ways to obtain alarm data.50 Biomedical or clinical engineering or information technology support may be helpful to optimize device alarm data storage configuration and to understand electronic data export and analysis options.26, 36, 39
Third-Party Systems
Long-term, efficient alarm data collection and analysis may be enhanced through the use of clinical data warehouse or middleware systems. Such third-party systems may be customized to
Summary
Alarm fatigue is a real safety concern in NICUs because the high alarm burden, coupled with a high proportion of nonactionable alarms, leads to a cry wolf phenomenon, causing missed alarms and patient harm. PBPs to address alarm fatigue include policies and staff training that clarify safe alarm practices, use of evidence-based and data-driven alarm settings to standardize response to alarms, and leveraging device alarm features to reduce nuisance and false alarms.
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Disclosure Statement: The authors have no financial conflicts of interest to disclose.