1. Reducing Monitor Alarm Fatigue in the Neonatal Intensive Care Unit
Mary E. Hefferan
Ferris State University

2. Identifying a Need Alarm fatigue
Leads to desensitization, loss of trust, and disruption in patient care
Each monitored bed can produce up to 700 physiologic alarms per day
Up to 80-99% of alarms are not clinically significant and require no clinical intervention
: reported 566 patient deaths
: 98 alarm related sentinel events
(AACN, 2013; Cvach, 2012; Cvach, Biggs, Rothwell, & Charles-Hudson, 2013; Stokowski, 2014)

3. Identifying a Need The Joint Commission (JC)
New National Patient Safety Goal (NPSG) announced:
Phase I: “Establish alarms as an organizational priority” (JC, 2013, p. 1)
Phase II: Focus on policy development and staff education
Emergency Care Research Institute (ECRI)
Alarm hazards listed as #1 in 2015 top 10 Health Technology Hazards
Excessive alarming leads to “cry wolf” environment
logonoid.com
(ECRI, 2007; ECRI, 2014; JC, 2013)

4. Environment Helen Devos Children’s Hospital
Neonatal Intensive Care Unit (NICU)
8 ward style rooms (6-12 patients per room)
New addition: 40 private rooms
Total = 103 available beds
Either open cribs, warmer tables, or isolettes

5. Researching a Solution
American Association of Critical-Care Nurses found proper skin preparation
Enhances skin conductivity
Reduces skin impedance
Proper placement of EKG leads
Reduces can reduce false alarms due to rapid heart rate and arrhythmias
Customization of alarms
Decreased alarms by 43% per bed per day
solutions.3m.com
(AACN, 2013; ECRI, 2007)
preemies.about.com

6. Project Plan Provide staff education Establish protocol
Increase awareness of alarm safety
Encourage discussion of alarm parameters into nurse hand off
Establish protocol
Identifies proper skin preparation and placement for EKG/pulse ox leads to reduce false alarming
yourethecure.org

7. Key Stakeholders Christina Schmoekel MSN, RNC-NIC, CPHIMS
Amy Atwater, RN, BSN
Kari Luymes
Beth Huizinga, CNS
improvecarenow.org

8. QSEN Competencies Safety Teamwork and Collaboration Knowledge Skill
Attitude

9. ANA Scope and Standards of Practice
Standard 1: Assessment
Standard 2: Problem and Issues Identification
Standard 5: Implementation

10. Root Cause Analysis

11. Change and Leadership theory
Kurt Lewin’s Theory of Planned Change
1. Unfreezing
2. Movement/change
3. Refreezing
Transformational Leadership
(Manchester et al., 2014; MindTools, 2014)

12. Outcome Measurement Biomedical Engineering Bedside tally sheet
Collect monitor alarm data
Bedside tally sheet
Alarms that cannot be measured electronically

13. Predicted Results Support the JC’s new NPSG of alarm safety
Increase awareness and discussion of alarm parameters and safety
Reduce non-clinically significant and false alarms by 25% per day
Less alarm fatigue
No significant events missed due to alarm fatigue

14. Goals
Goal 1:
Create an educational program that increases awareness of alarm safety and encourages nurse-hand off discussion of alarm parameters
Goal 2:
Create an EKG/pulse ox skin preparation protocol with supporting education based on evidence based research

15. Timeline
1/2015
Survey nurses regarding factors that contribute alarm fatigue
Gather baseline monitor alarm data
1/2015-3/2015
Create presentations that will be available through Spectrum Health (SHILO)
3/2015-4/2015
Answer questions and receive feed back through weekly or bi-weekly on site visits
4/2015-5/2015
Assess follow up monitor alarm data
Future recommendations

16. References
American Association of Critical-Care Nurses. (2013). Alarm management. Critical Care Nurse, 33(2013), Retrieved from American Association of Critical-Care Nurses. (2013). Strategies for managing alarm fatigue [PowerPoint slides]. Retrieved from fatigue-final.ppt Cvach, M. (2012). Monitor alarm fatigue: An integrative review. Biomedical Instrumentation and Technology,46(4), doi: / 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), doi: /NCQ.0b013e bc Emergency Care Research Institute. (2007). The hazards of alarm overload. Health Devices, Retrieved from Emergency Care Research Institute. (2014). ECRI institute announces top 10 health technology hazards for Retrieved from Hazards-for-2015.aspx Giltinane, L. C. (2013). Leadership styles and theories. Nursing Standard, 27(41), Retrieved from 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), doi: /ajcc The Joint Commission. (2013). The Joint Commission announces 2014 national patient safety goal. Retrieved from 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 promoting evidence based practices of health professionals. Evaluation and Program Planning, 47(2014), Retrieved from Marshall, E.S. (2010). Transformational leadership in nursing: From expert clinician to influential leader. (1st ed.). New York: Springer Publishing Company, LLC Phillips, J., & Barnsteiner, H. J. (2005). Clinical alarms: Improving efficiency and effectiveness. Critical Care Nursing Quarterly, 28(4), Retrieved from QSEN Institute. (2012). Graduate KSAs. Retrieved from Stokowski, A. L. (2014). Time to battle alarm fatigue. Retrieved from