Major Factors in Alarm Fatigue Among Labor Nurses

Major Factors in Alarm Fatigue Among Labor Nurses Major Factors in Alarm Fatigue Among Labor Nurses Appraise two (2) research articles using appraisal worksheets. Do not submit these until you Self-correct the appraisals. Identify scholarly practices for appraisal. All supporting documentation attached. mod2_brantley_education_intervention_alarm_micu_2016_.pdf _mod_2_brantley2_appraisal_worksheet_appendix_e___3__1.docx _qualitative_false_alarms_and_overmonitoring_major_factors_in_alarm_fatigue_among_labor_nurses.pdf _simpson_qualitative_ Major Factors in Alarm Fatigue Among Labor Nurses. AACN Advanced Critical Care Volume 27, Number 3, pp. 283-289 © 2016 AACN Clinical Trial of an Educational Program to Decrease Monitor Alarms in a Medical Intensive Care Unit Arian Brantley, APRN, MS, NP-C, ACCNS-AG Sandra Collins-Brown, Jasmine Kirkland, Meghan Knapp, Jackie Pressley, Melinda Higgins, RN, BSN RN, BSN PhD James P. McMurtry, RN, BSN APRN, MSN, CNS-BC, CCRN RN, BSN ABSTRACT Clinical research to identify effective interventions for decreasing nonactionable alarms has been limited. The objective of this study was to determine if a staff educational program on customizing alarm settings on bedside monitors decreased alarms in a medical intensive care unit (MICU). A preintervention, postintervention, nonequivalent group design was used to evaluate an educational program on alarm management in a convenience sample of MICU nurses. A 15-minute session was provided in a 1-week period. The outcome variable (number of alarms for low oxygen saturation via pulse oximetry [SpO2]) was A larm signal events from medical equipment are an audible signal designed to alert nursing staff to a physiological change in a patient’s condition, a technical problem requiring investigation, and/or a situation requiring intervention. Some alarm signal events also occur when there are no actual clinical problems with the patient but because of artifact or small physiological changes that exceed the upper or lower alarm limits. High frequency of the latter alarms, often called nuisance or nonactionable alarms, can desensitize staff’s reaction to alarms. This situation, called “alarm fatigue,” may cause staff to react more slowly to alarm signal events or ignore them altogether.1-4 determined from monitor log files adjusted by patient census. Data were collected for 15 days before and after the intervention. r2 analysis was used, with P less than .05 considered significant. After 1 week of education, low SpO2 alarms decreased from 502 to 306 alarms per patient monitored per day, a 39% reduction (P < .001). Instructions for nurses in the medical intensive care unit on individualizing alarm settings to patients’ clinical condition decreased common monitor alarms by 39%. Keywords: alarm fatigue, alarm avoidance, nonactionable alarms, nuisance alarms, false alarms Arian Brantley is Staff Nurse, 71 Intensive Care Unit, Emory University Hospital Midtown, Atlanta, Georgia. Sandra Collins-Brown is Staff Nurse, 71 Intensive Care Unit, Emory University Hospital Midtown, Atlanta, Georgia. Jasmine Kirkland is Staff Nurse, 71 Intensive Care Unit, Emory University Hospital Midtown, Atlanta, Georgia. Meghan Knapp is Staff Nurse, 71 Intensive Care Unit, Emory University Hospital Midtown, Atlanta, Georgia. Jackie Pressley is Staff Nurse, 71 Intensive Care Unit, Emory University Hospital Midtown, Atlanta, Georgia. Melinda Higgins is Associate Research Professor, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia. James P. McMurtry is Clinical Nurse Specialist, 71 Intensive Care Unit, Emory University Hospital Midtown, Atlanta, 550 Peachtree St, NE, Atlanta GA 30308 ([email protected] emoryhealthcare.org).NUR4165 West Florida Major Factors in Alarm Fatigue Among Labor Nurses Major Factors in Alarm Fatigue Among Labor Nurses. The authors declare no conflicts of interest. DOI: http://dx.doi.org/10.4037/aacnacc2016110 283 Downloaded from http://acc.aacnjournals.org/ by AACN on September 6, 2016 B R A NT L EY E T A L W W W . A A C N AC C O N L I N E . O RG Alarm fatigue can be a dangerous phenomenon because staff may not intervene quickly enough to alarms that occur when a patient’s condition has changed, jeopardizing patient safety with the potential to result in adverse events and even death.5-13 In addition to staff fatigue from large numbers of bedside alarm signal events, the audible alarm signal events can disturb patients and prevent sleep/rest and patients’ recovery.2,14,15 Lack of sleep/rest during hospitalization is a major dissatisfier for patients.16,17 Background The frequency of monitor alarm signal events is high in critical care units,10,18 with experts estimating that more than 300 physiological monitor alarm signal events occur each day for each patient.18 Although the percentage of those alarm signal events that are nonactionable varies, experts10,18 and clinicians4,11 believe that the frequency of nonactionable alarm signal events is high. In the past decade, clinicians have continued to rate nonactionable alarm signal events as the largest issue related to monitor alarms at their institutions.11 Clinicians believe that a primary underlying cause of nonactionable alarm signal events with physiological monitoring is inappropriately set alarm limits, which leads to the triggering of alarm signal events even when physiological fluctuations are normal and/or small.4 Monitor technology experts concur,8,19-21 but recognize that until technological advancements in monitoring equipment allow the technology to automatically set alarm settings that are customized for each patient, the key to decreasing many nonactionable alarm signal events lies in getting clinicians to individualize or customize monitor alarms for each patient.8 One approach sometimes used by hospitals, including our own facility in 2013, to decrease nonactionable alarm signal events is to change the monitor’s default settings (low and high rates; response priority level) for alarms.22,23 Although this approach decreases the frequency of some alarms, it does not eliminate the underlying problem that for individual patients, the default alarm settings may not be appropriate. National regulatory groups,13,18 professional associations,3,5,19-21 and critical care experts1,11,23-26 have urged clinicians to intervene to decrease nonactionable alarm signal events. Aside from studies to improve the hardware and/or programming of physiological monitors, limited clinical evaluations have been done on other approaches to decrease nonactionable alarm signal events.12,27-30 Prior evaluations were quality improvement or performance improvement projects focused almost exclusively on electrocardiographic (ECG) monitor alarms, all of which evaluated a “bundle” of different interventions to decrease nonactionable ECG alarm signal events. Those approaches included improving the quality of the ECG signal (skin preparations before electrode placement; frequent ECG electrode changes), elimination of duplicative ECG alarms, changes in default alarm settings in the computer software, and staff education on customizing ECG alarm signal event limits to each patient’s clinical condition. Although all of the projects found substantial decreases in ECG alarm signal events following implementation of practice changes, the impact of each individual intervention of the bundle is not known. Only one of the quality improvement projects included non-ECG physiological monitor alarm signal events (low Spo2; high and low respiratory rates).NUR4165 West Florida Major Factors in Alarm Fatigue Among Labor Nurses ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS Major Factors in Alarm Fatigue Among Labor Nurses. 28 To date, no research has been published on interventions designed to increase clinicians’ use of customization for high and low alarm signal events for physiological monitor parameters as an attempt to decrease nonactionable alarm signal events. Review of alarm history data in our medical intensive care unit (MICU) in late 2012 indicated that more than 1500 alarm signal events per patient per day were occurring, with approximately 70% of those alarm signals coming from non-ECG physiological parameters. The vast majority of those nonECG alarm signal events were from low saturated oxygen level shown by pulse oximetry (Spo2). The hospital’s default setting for low Spo2 alarm signal events was 90%, based on an assumption of a relatively normal respiratory function for adult patients in the hospital’s ICUs. Many of the MICU patients had moderate to severe respiratory insufficiency, so their Spo2 levels were often at or below the default settings. Similar to prior surveys of nursing practice,3,11 anecdotal observation in our MICU indicated that nursing staff did not routinely customize their alarm signal event limits to each patient’s clinical condition. We believed that this lack of customization of alarm settings was contributing to the high number of Spo2 alarm signal events. 284 Downloaded from http://acc.aacnjournals.org/ by AACN on September 6, 2016 VO L U M E 2 7 • N U M B E R 3 • J U LY- S E P T E M B E R 2 016 The purpose of this study was to determine if a brief educational program for nurses on alarm management for non-ECG physiological parameters could decrease the number of low Spo2 alarm signal events per patient per day. Methods Study approval was obtained from the institution’s investigational review board before data collection. Data collection was completed during a 5-week period. Study Design A pretest, posttest, nonequivalent group design was used to evaluate the effect of a staff educational program on alarm management. The dependent variable for the study was the number of low Spo2 alarm signal events per patient per day during a 15-day period. Study Setting The study was conducted in a 20-bed MICU, with a total of 54 registered nurses employed in 0.2 to 1.0 full-time-equivalent (FTE) positions. Monitoring capabilities at each bedside included a range of physiological parameters, with all patients monitored for ECG rhythm, blood pressure, respiratory rate, and Spo2 (Solar 8000M/I V5, GE Healthcare). Oxygen saturation monitoring was done with a finger probe (Oxysensor MAXN, Covidien) connected to an Spo2 module using Nellcor pulse oximetry technology (OxiMax Technology, GE Healthcare) within the bedside monitoring system. Each monitor physiological parameter was programmed with default values for alarm settings common to all monitored beds in the ICUs and intermediate care units for the facility. The default values were based on the monitor manufacturer’s suggestions and consensus opinion of expert nursing and medical clinicians in the ICUs and intermediate care units. Bedside alarm settings could be customized by bedside clinicians on the basis of individual patient care situations. When alarm settings were exceeded, audible alarms occurred at the bedside and at the unit’s central monitoring station. Sample Selection Participants in this study were registered nurses working as bedside clinicians on the MICU. Inclusion criteria included being a permanent employee on the study unit, at a ICU ALARMS minimum of 0.2 FTE each week, and completion of new-employee unit orientation. A minimum sample size of 21 staff members (40% of MICU staff) was required for this study to ensure that an adequate number of staff participated in the alarm management education.NUR4165 West Florida Major Factors in Alarm Fatigue Among Labor Nurses Major Factors in Alarm Fatigue Among Labor Nurses. Study Intervention The educational program on alarm management was a 15-minute session designed to review the rationale for minimizing alarms and provide strategies for reducing nonactionable alarms by customizing the low and high alarm settings for the non-ECG parameters to each patient’s current condition and/or situation (Table 1). Content of the educational class was developed by the study investigators and was based on the monitor manufacturer’s educational materials and expert advice on minimizing nonactionable alarms.12,22,24,26 Classes were taught by 1 of 5 study investigators, all of whom were registered nurses experienced with the MICU patients and monitoring equipment. Investigators were trained to provide the educational intervention following a standard curriculum and use of pocket-card guides for customizing alarm parameters. During a 1-week period, educational sessions were provided at the beginning or end of the nurses’ patient care shifts in a unit room used for staff education and meetings. Although a number of non-ECG physiological parameters were discussed, the major focus was on low Spo2 because it represented the highest number of alarm event signals in previous quality data monitoring. Examples of patients with normal and abnormal Spo2 values were provided, with suggestions for appropriate alarm signal event limits. Appropriate alarm signal event limits were determined a priori and were based on manufacturers’ suggested parameters in educational materials and review by expert clinicians familiar with the MICU patient population. Because the vast majority of the MICU patients had usual Spo2 values on the steep portion of the oxygen saturation curve, the lower alarm signal event limit recommendation was conservatively set (1% below the lowest value in the previous 2-hour period). Participants were provided with a pocket card summarizing key information for setting alarm limits individualized to each patient. Pocket cards were also attached to all bedside monitors for easy reference when caring for patients. The educational program was provided for 1 week. 285 Downloaded from http://acc.aacnjournals.org/ by AACN on September 6, 2016 B R A NT L EY E T A L W W W . A A C N AC C O N L I N E . O RG Table 1: Content Outline for a Staff Educational Intervention on Oxygen Saturation and Respiratory Alarm Management 1. Rationale for keeping nonactionable alarm signal events (eg, nuisance alarms) at a minimum A. Staff alarm fatigue B. Noise disruptions affect patients’ rest/sleep and satisfaction 2. Management of alarms with high rates of occurrence on the unit A. Parameter alarms with highest occurrence are either from low oxygen saturation shown by pulse oximetry (SpO2) or high respiratory rate (> 50% of alarms), causing more than 300 000 alarms on the unit in a 1-month period. Many are nonactionable alarms. B. Nursing strategies to decrease nonactionable alarm signal events: (1) During assessment of patient at the beginning of the shift, and periodically during the shift, set realistic high and low alarm levels for SpO2 and high respiration parameters on the bedside monitor: (a) SpO2 low alarms—Set the patient’s SpO2 to 1 percentage point below the lowest value for the past 2-hour trend (excluding isolated spikes). (b) Respiration high alarms—Set the patient’s high respiration rate alarm to 10 breaths per minute above the highest value for the past 2-hour trend. (2) Check the skin adherence and placement of electrocardiography chest electrodes on admission and every 24 hours. Respirations are detected by measuring thoracic impedance in lead con?gurations I, II, and RL-LL. The monitor “learns” the patient’s respiration patterns according to these con?gurations for 8 breaths. Changing the leads automatically starts the relearning process, or relearning can be selected from the monitor menu. Periodically, the relearning process is necessary if the patient’s breathing pattern has changed and the monitor is no longer calculating the respiratory rate. NUR4165 West Florida Major Factors in Alarm Fatigue Among Labor Nurses Major Factors in Alarm Fatigue Among Labor Nurses. The lead con?gurations are as follows: (a) Lead I for upper chest breathers (b) Lead II for abdominal breathers (c) RL-LL lead for abnormal breathers (3) Check SpO2 ?nger probe adherence each shift and replace as necessary 3. Question and answer period 4. Provide each participant with a pocket card summarizing key information for setting individualized patient’s alarm limits and lead locations for optimal respiratory monitoring. Participants should also be told that cards will be attached to all bedside monitors for easy reference when caring for patients. Outcome Variable For the purposes of this study, the low Spo2 alarm signal event was selected for outcome monitoring because it had the highest rate of occurrence on the study unit and accounted for more than 50% of all non-ECG dysrhythmia alarm events. The number of low Spo2 alarm signal events was obtained through review of existing bedside monitor computer alarm history for each monitored patient on the unit with a software program developed by the monitor manufacturer (Alarm Reporting Tool, GE Healthcare).31 Alarm data were extracted from existing computer log files, which occurred whenever an audible monitor alarm signal event occurred. The number of alarm signal events was adjusted by the number of patients being monitored during the study period each day and was reported as low Spo2 alarm signal events per patient per day. Alarm data were collected for 15 days immediately before and 15 days after implementation of the study educational intervention. Data Analysis Data were summarized by using descriptive statistics. r2 analysis was used to compare preintervention and postintervention frequency of low Spo2 alarms per day and the number of patients monitored during each study period. The level of significance was set at P less than .05. Results A total of 22 nurses completed the 15-minute educational intervention during a 1-week period. All but 2 nurses were female, with a mean age of 37.9 (SD, 14.8) years (age data available for only 17 nurses). Years of experience in nursing and in critical care nursing varied, with the majority of nurses having 5 or more years of experience in nursing and critical care nursing (Table 2). 286 Downloaded from http://acc.aacnjournals.org/ by AACN on September 6, 2016 VO L U M E 2 7 • N U M B E R 3 • J U LY- S E P T E M B E R 2 016 ICU ALARMS Table 2: Experience of 22 Nurse Participants Characteristic No. of nurses Nursing experience, y <1 1-5 > 5 to 10 > 10 to 20 > 20 1 10 2 4 5 Progressive and critical care experience, y <1 1-3 > 3 to 5 >5 3 7 1 11 Before the intervention, low Spo2 alarms made up 50% of all alarms; after the intervention, they made up 44% of all alarms. The total number of low Spo2 alarm signal events during the 15-day baseline period was 128 186 or 503 alarm signal events per patient per day for 17 patients. Following the educational intervention, the total number of low Spo2 alarm signal events during the 15-day postintervention period was 78 267 or 307 alarm signal events per patient per day for 17 patients. The 39% reduction in Spo2 alarms after the educational intervention was statistically significant (P < .001). Discussion This study was the first study in which an intervention to decrease non-ECG physiological alarm signal events in critically ill patients was analyzed. After the 40% of MICU staff received a brief educational intervention on alarm management, the highest number of non-ECG monitor alarms (low Spo2) decreased 39%. The 15-minute alarm management education provided at change of shift emphasized the importance of avoiding nonactionable alarm signal events by customizing alarms limits to be appropriate for each patient’s current physiological situation rather than accepting the monitor’s default values. Prior published reports of approaches to alarm management were descriptive designs or quality or performance improvement projects.12,27-30 Practice changes that were implemented focused almost exclusively on ECG alarms, and each included multiple interventions to decrease nonactionable alarm signal events, making it difficult to understand the contribution of individual strategies to the overall outcomes. For example, strategies used by Graham and Cvach28 included computer software adjustments to default alarm settings for selective ECG and physiological parameters, elimination of duplicate alarm signal events, and staff education about the importance of setting patient-specific alarm limits as a way to decrease nonactionable alarm signal events. Although this bundle of strategies resulted in a 43% decrease in total alarms during the 1-year period of the quality improvement project, it is not known which interventions were most important and/or if other changes on the unit during the long study period could account for the decrease in the number of alarms. Our results show that a single, brief educational intervention focused on customizing alarm limits to each patient’s condition can significantly reduce the number of non-ECG physiological alarm signal events. Limitations This study evaluated only a single, brief educational intervention for MICU nursing staff focused on non-ECG alarm setti …NUR4165 West Florida Major Factors in Alarm Fatigue Among Labor Nurses Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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