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Running head: ALARM FATIGUE 1
Reducing Monitor Alarm Fatigue in the Neonatal Intensive Care Unit
Mary Hefferan
Ferris State University
ALARM FATIGUE 2
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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References
American Association of Critical-Care Nurses. (2013). Alarm management. Critical Care Nurse,
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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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
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Emergency Care Research Institute. (2007). The hazards of alarm overload. Health Devices, 73-
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Giltinane, L. C. (2013). Leadership styles and theories. Nursing Standard, 27(41), 35-39.
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Graham C. K., & Cvach, M. (2010). Monitor alarm fatigue: Standardizing use of physiological
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The Joint Commission. (2013). The Joint Commission announces 2014 national patient safety
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Manchester, J., Gray-Miceli, L. D., Metcalf, A. J., Paolini, A. C., Napier, H. A., Coogle, L. C., &
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Marshall, E.S. (2010). Transformational leadership in nursing: From expert clinician to
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