title: Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational study of consecutive intensive care unit patients.
abstract: OBJECTIVE
  Physiologic monitors are plagued with alarms that create a cacophony of sounds and visual alerts causing "alarm fatigue" which creates an unsafe patient environment because a life-threatening event may be missed in this milieu of sensory overload. Using a state-of-the-art technology acquisition infrastructure, all monitor data including 7 ECG leads, all pressure, SpO(2), and respiration waveforms as well as user settings and alarms were stored on 461 adults treated in intensive care units. Using a well-defined alarm annotation protocol, nurse scientists with 95% inter-rater reliability annotated 12,671 arrhythmia alarms.
  
  
  RESULTS
  A total of 2,558,760 unique alarms occurred in the 31-day study period: arrhythmia, 1,154,201; parameter, 612,927; technical, 791,632. There were 381,560 audible alarms for an audible alarm burden of 187/bed/day. 88.8% of the 12,671 annotated arrhythmia alarms were false positives. Conditions causing excessive alarms included inappropriate alarm settings, persistent atrial fibrillation, and non-actionable events such as PVC's and brief spikes in ST segments. Low amplitude QRS complexes in some, but not all available ECG leads caused undercounting and false arrhythmia alarms. Wide QRS complexes due to bundle branch block or ventricular pacemaker rhythm caused false alarms. 93% of the 168 true ventricular tachycardia alarms were not sustained long enough to warrant treatment.
  
  
  CONCLUSIONS
  The excessive number of physiologic monitor alarms is a complex interplay of inappropriate user settings, patient conditions, and algorithm deficiencies. Device solutions should focus on use of all available ECG leads to identify non-artifact leads and leads with adequate QRS amplitude. Devices should provide prompts to aide in more appropriate tailoring of alarm settings to individual patients. Atrial fibrillation alarms should be limited to new onset and termination of the arrhythmia and delays for ST-segment and other parameter alarms should be configurable. Because computer devices are more reliable than humans, an opportunity exists to improve physiologic monitoring and reduce alarm fatigue.
authors.affiliation: Department of Physiological Nursing, University of California San Francisco, San Francisco, California, United States of America.
authors.forename: Barbara J
authors.initials: BJ
authors.lastname: Drew
authors.affiliation: Department of Physiological Nursing, University of California San Francisco, San Francisco, California, United States of America.
authors.forename: Patricia
authors.initials: P
authors.lastname: Harris
authors.affiliation: School of Nursing, University of North Carolina, Chapel Hill, North Carolina, United States of America.
authors.forename: Jessica K
authors.initials: JK
authors.lastname: Zègre-Hemsey
authors.affiliation: Department of Nursing, University of California San Francisco Medical Center, San Francisco, California, United States of America.
authors.forename: Tina
authors.initials: T
authors.lastname: Mammone
authors.affiliation: Department of Physiological Nursing, University of California San Francisco, San Francisco, California, United States of America.
authors.forename: Daniel
authors.initials: D
authors.lastname: Schindler
authors.affiliation: Department of Physiological Nursing, University of California San Francisco, San Francisco, California, United States of America.
authors.forename: Rebeca
authors.initials: R
authors.lastname: Salas-Boni
authors.affiliation: Department of Physiological Nursing, University of California San Francisco, San Francisco, California, United States of America.
authors.forename: Yong
authors.initials: Y
authors.lastname: Bai
authors.affiliation: Department of Physiological Nursing, University of California San Francisco, San Francisco, California, United States of America.
authors.forename: Adelita
authors.initials: A
authors.lastname: Tinoco
authors.affiliation: Department of Physiological Nursing, University of California San Francisco, San Francisco, California, United States of America.
authors.forename: Quan
authors.initials: Q
authors.lastname: Ding
authors.affiliation: Department of Physiological Nursing, University of California San Francisco, San Francisco, California, United States of America.
authors.forename: Xiao
authors.initials: X
authors.lastname: Hu
mesh_terms: D000328:Adult; D000368:Aged; D001145:Arrhythmias, Cardiac / Q000175:diagnosis*; D001281:Atrial Fibrillation / Q000175:diagnosis*; D056902:Clinical Alarms / Q000706:statistics & numerical data*; D016638:Critical Illness; D003951:Diagnostic Errors / Q000706:statistics & numerical data*; D004562:Electrocardiography / Q000295:instrumentation; D004868:Equipment Failure / Q000706:statistics & numerical data*; D005189:False Positive Reactions; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000295:instrumentation