Alarm fatigue, the lack of response due to excessive numbers of alarms resulting in desensitization, has emerged as a growing concern for patient safety in healthcare. In April, 2013, The Joint Commission (TJC) received reports of 80 alarm-related patient deaths as released in their Sentinel Event Alert. In July, 2014, TJC released a new National Patient Safety Goal with the aim to reduce harm associated with clinical alarm systems. With this growing problem occurring in the healthcare setting nationwide, the Emergency Department at Homestead Hospital implemented a performance improvement project to helpaddress this issue.
Plan (Includes: Specific goal(s) ; and the who, what, and when of the planning process):
The purpose of this project is to decrease the number of clinically insignificant alarms in the ED by 20%, focusing on the heart rate and oxygen saturation alarms, thereby decreasing alarm fatigue and increasing patient safety. A gap analysis using a nursing survey was performed to check the knowledge and perception of the staff on clinical alarms. The total number of alarms were recorded in a 12 hour period for 7 days, pre-intervention.
Do (What did or will you implement to address the problem? What data did you or will you collect to determine the effectiveness of what you did?):
Educating the staff through in-services focusing on skin prep, customization of alarm parameters, and monitoring patients with clinical indications was used as intervention for this project. The total number of alarms were recorded to see if there is a reduction after the intervention.
Check (Results – data – i.e. graphs, charts, tables):
Pre intervention, 1542 alarms were recorded. Fifty five percent of the alarms were due to Low Heart Rate, 27% on High Heart Rate, 9% on Low Oxygen Saturation and 8% on Desaturation. Post implementation, the number of alarm reduced per category: Low Heart Rate (25%), High Heart Rate (16%), and, Low Oxygen Saturation (54%) . Desaturation increased by 44%.
The total number of alarms decreased by 17% post intervention (1542 to 1291).
Act (Were any policies or procedures changed – or did the project expand – i.e. hospital-wide, system-wide? If there were stumbling blocks to success, what were they? What are your next steps? Were new questions raised or new problems uncovered?):
The plan for sustainability will focus on the compliance on alarm customization. Evidence based studies will be reviewed to improve oxygen saturation monitoring. Inclusion of the EKG alarms will be included in the future performance improvement projects for clinical alarms.
Alarm fatigue is a multifaceted problem with a very high potential of causing patient harm and therefore should be a top priority in hospitals. Although there is a significant amount of work to be completed in the future, the Emergency Department is making strides in the right direction.
12th Annual BHSF Research Conference
Baptist Health South Florida Affiliations:
Nancy Doctura, BSN, RN
Tamra DaCosta, MSN, RN
Doctura, Nancy and DaCosta, Tamra, "Do you Hear What I Hear, A Clinical Alarm Fatigue Project" (2017). All Publications. 2101.
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