Table of Content
Proposal Approval Form
Title Page (Appendix A)
A. Name of Project
B. Student's Name
D. List of Committee Members and Residency Mentors
Body of Document
A. Statement of problem, background, significance
B. Needs Assessment
C. Overview of Project Purpose and Objectives
D. Theoretical Framework
E. Review of Literature
F. Synthesis of Evidence and Levels of Evidence Cited
I. Table or Description of Cited Evidence by Level
I. Description of Setting and Target Population
II. Project Activities
IV. Project Timetable
V. Resources Needed
VI. Evaluation Plan
3. statistical analysis
A. Statement Problem
A nurse working in the intensive care unit received report on a post-operative patient. The patient had routine surgery, but was unable to be extubated secondary to extended periods of apnea. The surgeon and the anesthesiologist felt it was in the best interest of the patient to keep her intubated overnight. The nurse received the patient and places the routine physiological monitoring technology. Pulse oximetry, ECG (electrocardiogram), blood pressure, SCD (sequential compression device), mechanical ventilator, capnography, BIS monitor, and intravenous pumps are all placed. Throughout the shift there had been numerous false alarms from this and the other patients on the unit. The nurse became weary of the alarms and proceeded to adjusts or mutes several of the alarms. Unfortunately because the alarms are muted; she missed some crucial alarms. The monitor began to alarm asystole. The nurse hastily rushed to fix the problem, however the patient was in cardiac arrest. Code blue was called and it took a full 30 minutes before the pulse returns. Review of the monitoring systems showed the patient became apneic multiple times before he became hypoxic with a pulse oximetry of 68. Systematic review of the event concluded the incident and reportable sentinel event was resulted from alarm fatigue.
Alarm Fatigue is an emerging problem leading to serious patient safety issues that has shown to impact patient mortality. Japsen & Sendelbach, (2013), stated Alarm fatigue arises when clinicians become desensitized to the multitude of alarms going off around them. Sensory overload results in clinicians either adjusting or muting the alarms needed to notify them of imminent patient danger (p. 83). Many health care professionals are affected by this phenomenon. It is therefore pertinent to find a resolution to this problem. There is lack of distinction between a genuine alarm and a false alarm. This makes it difficult for the clinician to differentiate between a false alarm and a true emergency. Japsen & Sendelbach, (2013), discussed how difficult it is for human beings to differentiate among more than six different alarm sounds (p. 83). According Japsen & Sendelbach, (2013), 'the average number of alarms in an ICU has increased from six in 1983 to more than 40 different alarms in 2011' (Japsen & Sendelbach, 2013 p. 83). The Joint Commission TJC (2013) , 'confirms The number of alarm signals per patient per day can reach several hundred depending on the unit within the hospital, translating to thousands of alarm signals on every unit and tens of thousands of alarm signals throughout the hospital every day' (The Joint Commissions, 2013, p. 1 ).
The focus of this capstone project will be to develop a plan that would help uncover the cause of alarm fatigue. I will accomplish this with strategies to decrease the number of alarms experienced on a daily basis. This goal will be achieved through examination and application of current evidence base research. By instituting interventional policy based on education to change the current culture surrounding alarm fatigue. It is my hope to achieve a reduction in the amount of false alarms experienced daily in the selected unit. The outcome or success of the project will be measured can be measured by the drop in the number of said false alarms.
The following individuals have been selected as committee members to aid me in gaining IRB approval for my intended project proposal. This committee consists of:
' Helen Miley DNP, ACNP-BC, GNP-BC, APN; Rutgers University faculty
' Marybeth Duffy, DNP, FNP-BC, ACNP-BC; Rutgers University faculty
' Dorothy Meehan MSN, CCRN, RN; Critical Educator
Dr. Miley will serve as the chairperson of my committee.
Alarm fatigue is a growing phenomenon that has gained increased attention not only by the media but various governmental agencies. Kowalczyk, (2011) of the Boston Globe attributed Alarm fatigue to the death of a 60 year old male (Boston globe.com). Kowalczyk, (2011) reported alarms signaling the man's respiratory and cardiac decline went undetected for an extended period of time. As a result of this event the patient subsequently died. The reason for the death was attributed to the alarm response time (Boston globe.com). The Joint Commission (TJC), (2013), 'Sentinel Alert Issue 50' also addressed the issue of alarm fatigue. The report stressed approximately '85-99% of alarm signals are false and do not require immediate attention' (the Joint Commission, 2013, P1). Furthermore TJC 'stated 98 alarm associated incident was reported between 2009 and 2012', (The Joint Commission, 2013, P1). 'And of the 98 reported events, 80 ended in death,' (The Joint Commission, 2013, P1).
Alarm fatigue has been a concern of the Emergency Care Research Institute (ERCI) since 2007. The Emergency Care Research Institute (ERCI) has made Alarm hazards a priority on its 'top 10 technological hazards for 2014' (p 23). Placing emphasis on the significance of alarm fatigue and its effects on patient safety, TJC have mandated health care facilities across the country; to create policy to combat this growing problem by 2015. The Joint Commission (TJC), (2013), 'Sentinel Event Alert Issue 50,' included 'recommendations for potential strategies for improvement,' (The Joint Commission, 2013, P2). The American Association of Critical-Care Nurses (AACN), (2013), has also risen to the occasion and created an action pack to combat the issue. The action pack created by the AACN addresses the core concept for which to achieve the greatest safety efficacy. Throughout this project the action pack from the AACN will be utilized.
B. Needs Assessment:
While discussing this project with my contact at my respective facility; they assured me there is a great need for this project. They are interested in implementing quality improvement efforts around alarm fatigue. A needs assessment is scheduled for April 16, at which time a formal needs assessment and gap analysis will be completed. Both the needs assessment and gap analysis utilize will be from the AACN action pack.
C. Overview of Project Purpose and Objective
Decreasing the number of false alarm and changing the culture surrounding alarm fatigue remains the primary focus of this project. The primary intervention for this project is quality improvement through of education and training. By educating on the alarm system, adjusting the thresholds and sensitivity of the alarm systems, individualizing parameter settings, along with stringent physiological application and monitoring the goals set forth can be attained. The simplest alarm could lead to a potential catastrophic event. Therefore by decreasing the number of false alarming; it is my expectations not only to bring about awareness of this menacing problem but to produce substantial change in the alarm rate in the critical care unit in my perspective facility. The overall objective of this project will be to create a safer patient care environment by decreasing the number of false alarms in the critical care setting.
D. Theoretical Framework
My intent is to utilize the RE-AIM frame work for this project to create a culture of change in the critical care area of any given organization, by translating current research on alarm fatigue into best practice. Dudley-Brown and White (2012) affirm the 'RE-AIM model/framework was originally used to convey research and later organize reviews of the health promotion and disease management literature,' (Dudley-Brown and White, 2012, p. 42). Dudley-Brown and White (2012), the RE-AIM framework encourages behavioral changes, and operates as a connection to integrate evidence-based research into practice (p. 42). As discussed by Dudley-Brown & White (2012), numerous publications have applied the RE-AIM framework for the successful incorporation of research into practice (p 42). One such article 'Using the RE-AIM framework to translate a research-based falls prevention intervention into a community-based program: lessons learned,' by Shubert, Altpeter, & Busby-Whitehead, (2011). The authors used a controlled research intervention targeting older adults at risk for falling in a community setting to reduce the risk and rates of falls (p. 509). In utilizing the RE-AIM framework they successfully concluded 'the product was a highly appealing program to their target audience, resulted in improved outcomes and was successfully adopted and maintained by the community partner' (Shubert, Altpeter, & Busby-Whitehead, 2011, p.509). Another project making use of the RE-AIM framework was 'Applying the RE-AIM framework to the Alberta's Caring for Diabetes Project: a protocol for a comprehensive evaluation of primary care quality improvement interventions,' conducted by Wozniak, Lisa; Rees, Sandra; Soprovich, Allison; Al Sayah, Fatima; Johnson, Steven T.; Majumdar, Sumit R.; Johnson, Jeffrey A., (2012). As stated by (Wozniak, et al., 2012), 'two quality-improvement interventions were implemented, based on previously proven effective models of care and are directed at improving the physical and mental health of patients with type-2 diabetes' (Wozniak, et al., 2012, p1). Their goal was to 'adapt and apply the RE-AIM framework, using a mixed-method approach, to understand the impact of the interventions to inform policy and clinical decision-making' (Wozniak, et al., 2012, p1). They presented 'proposed measures, data sources and data management and analysis strategies used to evaluate the interventions by RE-AIM dimension,' (Wozniak, et al., 2012, p1). The authors determined the RE-AIM model provides a 'framework to elicit contextual information to better interpret the effectiveness of interventions' (Wozniak, et al., 2012, p 2). When employing the RE-AIM framework it is my intent to yield similar or better outcome as the aforementioned projects.
Dudley-Brown and White (2012) proposed there are five components of the RE-AIM Model which aims at the successful acclimation of evidence-based research into the clinical setting. RE-AIM is an abbreviation for 'Reach, Effectiveness, Adoption, Implementation and Maintenance,' (Dudley-Brown and White, 2012, p. 42).
' Reach: Would the target population (clinicians in the ICU) to participate?
' Effectiveness: What will be the outcome, compliance and conformity with the policy?
' Adoption: Will the clinicians adopt the policy and continue to use it on a long term basis?
' Implementation: What adjustments will be needed to accomplish this project in order to meet then need of the clinician while keeping to the fundamentals of the policy?
' Maintenance: How will the project be maintained over time?
Dudley-Brown & White, (2012)
When utilizing the RE-Aim Model/framework it is my goal to use the recommendations of the American Association of Critical-Care Nurses (AACN) to develop and implement policy to meet the mandates set forth by The Joint Commission. I anticipate reaching my target audience (critical care clinicians) through first assessing the structure and readiness of the unit to the impending change. In other words will I have staff by in? Comprehensive assessment of not only the individual (critical care clinicians) but the institution (Hospital or Medical Center) is warranted for the success of a policy and action plan. The effectiveness of the education and policy change will be determined by the outcome. It will be measured progressively with the enhancement of the intervention set forth in the policy by the effect on patient safety and mortality. Adoption is and will be assessed in the clinical setting. The participation of the clinicians will be significant in determining whether the pilot policy can be adopted by other units within the organization. The intervention portion will be comprised of a multidisciplinary approach.
Implementation will consist of biomedical services, environmental services, administration, nursing and education. Initially there has to be assessment as per the magnitude of the problem. In the implementation phase there needs to be education of the staff members on the use and technology of the monitoring systems. Systems adjustments will also needed in the implementation phase in order to make these changes successful. Lastly maintenance, of the policy applies to both individual and institution. This can be accomplished with the institution adoption of and continuous change to the pilot policy. Continuous change will be essential to meet the continual evolution of technology for physiological monitoring. The RE-AIM framework offers a solid foundation on which to cultivate the necessary behavioral change required to elicit best practice and insure patient safety while decreasing mortality. Incorporating recommendations from TJC, AACN, and ECRI institute will allow me; the opportunity to create policy, and incorporate an appropriate action plan to promote the changes needed to combat alarm fatigue through the translation of research into the clinical setting.
E. Review of literature
A literature review of alarm fatigue was conducted for the purpose of completing this capstone project. Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medical Literature Analysis and Retrieval System Online (Medline), and Google databases were searched using the keywords alarm fatigue/alarm management/alarm safety/alarm technology/ sentinel event and alarm and patient safety for the terms 2007 through 2014. 2007 was the start date chosen in order get the most relevant and recent data/research available. Alarm Fatigue is a term which has been used to recognize the inattention of hospital staff to the overabundance of sounding alarms faced on a day to day basis. Many governing agencies and researchers have addressed the subject of alarm fatigue over the years. TJC 'Sentinel Event Alert issue 50,' (2013), used suggestion from the ECRI to issue its own recommendations for change (p. 2). The ECRI (2014) has for a number of years ranked alarm hazards as a priority on their annual list of technological hazards (p 23). Top agencies such as TJC, ECRI, and the AACN have been trying to bring about awareness while trying to reduce the morbidity and mortality associated with alarm fatigue. The problem is so vast and wide that The Joint Commission, (2013) indicated in their 'Sentinel Event Alert issue 50,' the prospect of alarm fatigue becoming a national patient safety goal (p. 2). This no doubt solidifies the severity of the problem.
Throughout the literature there is a need for more ways to combat alarm fatigue. As discussed by Sendelbach & Marjorie, (2013) while there is enough existing information to validate alarm fatigue, greater attention is warranted to aid institutions in their endeavors to decrease /eradicate false alarms (p.382). A common theme among the examined literature called for individualize patient monitoring parameters. The literature pinpoints physiological and technological errors contributing to the overabundance of daily erroneous alarms. The consensus is clear throughout the examine literature; Sendelbach & Marjorie, (2013) points out the alarms that were once considered a life saving measure has now partly due to false alarming become quite the opposite; alarms has now become a patient safety concern (p. 385).
F. Synthesis of Evidence and Levels of Evidence Cited
There have been several quality improvement measures as a result of the heightened awareness of alarm fatigue. Once such improvement measure by Harris, Manavizadeh, McPherson, & Smith, (2011); achieved a reduction in crucial alarm through assessment of alarm boundaries and clarifying correct setting based on biological influences (p. 11). Harris et al, (2011) this was accomplished with the help of biomed to regulating monitoring the alarms systems and development of organizational wide criteria of alarm control is warranted (p.11). Harris et al, (2011) this quality improvement managed to see a 30% reduction in their sounding alarms (p. 12). Another improvement measure by Cvach; M., Maria; Currie, Andrew; Sapirstein, Adam; Doyle, Peter A.; Pronovost, Peter; (2013) achieved even more success with a 43% reduction in their sounding alarms in their progressive care unit (p. 9). There were also literature reviews addressing the phenomena. (Cvach M. , 2012), called for standardization, and future research on the subject in order to fully combat the problem (p.273). Reporting by agencies such as TJC and AACN not only call for improvement in alarm management but they issued developmental proposal for improvements of alarm related safety issues.
i. Table or Description of Cited Evidence by Level
Alarm Fatigue: Evidence Table
Author Year Level of Research or
Non-Research Evidence Type of Study Sample Composition & Size Results/Recommendation Limitations Comments Oxford Ranking
Creighton-Graham Kelly& Cvach, Maria
2010 Quality Improvement measure Literature Review N-30 nurses on a 15 bed unit A reduction in crucial alarm
Assessment of alarm boundaries and clarifying correct setting based on biological influences,
Biomed to regulate and calibrate the monitoring systems.
Organizational wide criteria of alarm control is warranted Use of the same tool for pre and post test
Small sample size External validity threat due to small sample size
Instrumentation tool may not adequately represent or record the change in the variables at the correct time 5
The Joint commission
2013 Reporting '98 alarm related event of which 80 resulted in death' Development of recommendations for improvement of alarm related safety issues No incentive for compliance with recommendations More urgency is needed for combating the problems related and contributing to alarm fatigue. 5
Cvach, Maria 2012 Integrative Review Literature Review '72 Articles were reviewed and included' Promoting advancement in technology; with the utilization of smart alarms
Homogeny of alarm sounds is necessary
A need for multidisciplinary team approach to alarm management is required.
Standardization of alarm policy to include, alarm response time, and alarm parameters to the individual patient setting
Ongoing education and annual competency for staff.
Information Disproportion; the need for research studies are necessary There are no existing studies on monitor settings or the numerous types of alarm and the effect they have on patients.
Expansion in the area of alarm fatigue and the extent of its effect on nurses is warranted. 1
Manavizadeh, McPherson, & Smith, 2011 Quality Improvem-ent Measure Literature Review Leigh Valley Health Network; Muhlenbe-rg Campus a community hospital setting '30% improvement in alarm Management in the ICU'
'12% improvement in the progressive care unit'
'Reassessment and observing the nurse's use of the alarm led to better outcomes and understanding in the handling of the alarms' Generalization- difficulty extending program to a larger scale facility with double the staff and monitoring system Continuous training and yearly competencies are necessary to incorporate alarm fatigue and alarm management while heightening awareness to incorporate this new experience into routine nursing practice. 4
Cvach, et al., 2013 Quality Improvem-ent
initiative Johns Hopkins Progressive Care Unit '43% reduction in critical alarms'
The authors recognizes a methodical method to pinpoint
and tackle concerns in conjunction with alarm fatigue and management Effect of selection
What will be the effect or how will the results differ from shift to shift Alarm fatigue is a growing problem therefore continuing research is need to combat the problem in its totality 5
i. Description of setting and target population
' 14 bedded ICU at the Bayonne Medical Center
' Target population: ICU Attending, ICU nurses and nursing assistants
ii. Project activities
' Complete readiness assessment
' Complete gap analysis
' Construct an interdisciplinary team
' Meeting with Biomedical and IT department to collect data
' Run data analysis using Statistical Package for the Social Sciences (SPSS) on pre, intermediate and post alarming data
' Identify goal and outcome suitable for the department
' Implementation phase
' Observe progress and make necessary change to ensure project success
' create department specific policy
American Association of critical care Nurses (AACN), 2013
' RE-Aim Framework
iv. Time Table
April 16, 2014 Initial meeting: all assessment tools to be completed
Presenting at BMC grand rounds
June 2014 meet with BMC Biomed and
IT department to gather data
September 2014- December 2014 Implementation, observation, and performance improvement
January 2015 ' May 2015 evaluation, analysis of collected data
v. Resources need
' Microsoft PowerPoint
' Monitoring system,
' Clippers (remover hair form chest)
vi. Evaluation Plan
' Compliance audits
' Quality indicators
' Staff satisfaction
' Patient outcome
' Staff satisfaction
' Analysis of collected data
3. Statistical analysis
' Compiling and running data with SPSS.
American Association of Critical Care Nurses (AACN). (2013). Alarm Management Performance Improvement Plan . Retrieved from AACN.ORG: http://www.aacn.org/wd/practice/docs/actionpak/sample-performance-improvement-plan-alarm-safety-final.pdf
American Association of Critical Care Nurses (AACN). (2013). Unit Gap Analysis: Strategies for Managing Alarm Fatigue . Retrieved from AACN.ORG: http://www.aacn.org/dm/practice/actionpakdetail.aspx?itemid=28337&learn=true&menu=practice
American Association of Critical Care Nurses (AACN). (2013). AACN Road Map for Implementing Change: Alarm Fatigue . Retrieved from .aacn.org: http://www.aacn.org/dm/practice/actionpakdetail.aspx?itemid=28337&learn=true&menu=practice
American Association of Critical Care Nurses (AACN). (2013). Change Readiness Assessment. Retrieved from AACN.ORG: http://www.aacn.org/dm/practice/actionpakdetail.aspx?itemid=28337&learn=true&menu=practice
Creighton-Graham, K., & Cvach, M. (2010, Janruary). Monitor Alarm Fatigue: Use of Physiological Monitors and Decreasing Nusiance Alarms. Retrieved Janruary 28, 2014, from American Journal of Critical Care: www.ajcconline.org
Cvach, M. (2012, July/August ). Monitor Alarm Fatigue An Integrative Review. Retrieved from Association for the Advancement of Medical Instrumentation : http://www.aami.org/publications/BIT/2012/JA_alarm_fatigue.pdf
Cvach, M., M., Currie, A., Sapirstein, A., Doyle, P. A., & Pronovost, P. (2013). Managing clinical alarms:Using data to drive change. Safety Solutions, 8-12.
Emergency Care Research Institute (ECRI), E. C. (2014, January). Top 10 Health Technology Hazards Report for 2014. Retrieved from ECRI Institute the Discipline of Science The integrity of Independence: http://www.ecri.org/Press/Pages/2014_Top_Ten_Hazards.aspx
Evans, M., Shumate, P., & lovelace, S. (2011, April ). Improving Alarm Responsiveness: How do we Prevent Alarm Fatigue. Retrieved from EbscoHost : http://eds.a.ebscohost.com.proxy.libraries.rutgers.edu/ehost/search/advanced?sid=fe039085-03a7-4b3f-a582-2985ca4fbbf7%40sessionmgr4001&vid=1&hid=4211
Funk, M., & Sendelbach, S. (2013). Alarm Fatigue:A Patient Safety Concern. American Association of Critical-Care Nurses, 378-386.
Harris, R. M., Manavizadeh, J., McPherson, D. J., & Smith, L. (2011). Do You Hear Bells? The Increasing Problem of Alarm Fatigue. Pennsylvania Nurse , 10-13.
Japsen, S., & Sendelbach, S. (2013). Alarm Management . American Associaation of Critical Care Nurses.
Keller, J. P. (2013, May 1). ECRI Institute Prespective onClinical Alarm Safety; Joint Commission Webnar . Retrieved from jointcommission.org: http://www.jointcommission.org/assets/1/6/ECRI_Institute_Perspectives__Alarm_Safety.pdf
Kowalczyk, L. (2011, September 21). 'Alarm fatigue' a factor in 2d death. Retrieved from The Boston Globe : http://www.boston.com/lifestyle/health/articles/2011/09/21/umass_hospital_has_second_death_involving_alarm_fatigue/
Sendelbach, S., & Marjorie, F. (2013). Alarm Fatigue:A Patient Safety Concern. American Association of Critical Care Nurses , 378-386.
Shubert, T., A. M., & Busby-Whitehead, J. (2011). Using the RE-AIM framework to translate a research-based falls prevention intervention into a community-based program: lessons learned. Journal of Safety Research, 509-516.
Stokowski, L. A. (2014, February 20). Time to Battle Alarm Fatigue. Retrieved from MerdScape.com: http://www.medscape.com/viewarticle/820738
The joint Commission (TJC). (2013, April 8). Sentinel Event Alert Issue 50: Medical device alarm safety in hospitals. Retrieved from The Joint Commission: http://www.jointcommission.org/sea_issue_50/
Wozniak, L., Rees, S., Soprovich, A., Al Sayah, F., Johnson, S. T., Majumdar, S. R., & Johnson, J. A. (2012). Applying the RE-AIM framework to the Alberta's Caring for Diabetes Project: a protocol for a comprehensive evaluation of primary care quality improvement interventions. Retrieved from BMJ.com: http://bmjopen.bmj.com/content/2/5/e002099.full.pdf+html
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