Beep, Beep, Repeat: The Trouble With Intravenous Pump Alarms

Intravenous Smart Pump Alarms: What Nurses Need to Know

Beep ... beep ... repeat ... the sounds of incessant beeping can be heard in the minds of all nurses who have practiced at the bedside. The pervasiveness of alarms in the critical care environment has been well documented. Technologies that may contribute to the cacophony of noises in the hospital environment include our constantly ringing phones, blipping cardiac monitors, honking ventilators, humming continuous renal replacement machines and whirring suction equipment. In this blog, I will focus on intravenous smart pump (IVSP) alarms, why they occur, and what nurses can do to decrease them.

Why Are Alarms Necessary?

Nearly every medical device in the hospital environment is equipped with an alarm, but are they all necessary? IVSP alarms must meet designated decibel levels to alert clinicians to check on a patient's condition. The International Electrotechnical Commission, which sets standards for medical devices, outlines the use and configuration of these alarms to ensure patient safety.

The Problem With Alarms

Alarm fatigue: When everything sounds important, nothing is important.

Alarm fatigue continues to plague clinicians, patients and families, especially in multipatient critical care environments with numerous technologies that have various beeps, boops and squawks. As the primary user of IVSPs, nurses are responsible for managing alarms. These ever-present sounds create an environment that causes nurses to become overwhelmed and desensitized to them, leading to delayed responses or missed alarms. Alarm fatigue may increase the risk of compassion fatigue and burnout. An IVSP data analysis found that addressing IVSP alarms cost a total of 10-13 hours of nursing time a day across four hospitals.

Patient experience

Patients also experience dissatisfaction from alarms in the hospital environment, because they spend 24 hours a day with the same alarms. Alarms may disrupt a patient's sleep, leading to the risk of anxiety and delirium. Interestingly, the World Health Organization (WHO) has defined safe ambient hospital noise levels at less than 35 decibels, but the average sound in an intensive care unit exceeds 45 decibels 50% of the time. Alarmingly (pun intended), it has been documented that IVSP high-alert alarms ring out at 70 decibels.

IVSP Alarms

Nurses don't have to just "deal with it." Addressing alarms is important to improve patient safety and experience, improve nurses' workflow efficiency, and allow more time for meaningful patient care. Many of these alarm mitigation strategies were synthesized and adapted from the Association for the Advancement of Medical Instrumentation's (AAMI's) "Quick Guide: Managing Smart Pump Alarms." Following are actions nurses can take to minimize alarms in their care areas.

Occlusion Alarms - Downstream and Upstream

• Why it happens: Occlusion alarms occur when there is sufficient resistance detected in the fluid pathway to surpass the preset occlusion threshold. A common misunderstanding is that the IVSP can detect infiltration or extravasation; occlusions do not detect these clinical situations. Upstream occlusions occur when resistance is detected above the pump (pump to fluid bag), whereas downstream occlusions occur when resistance is detected below the pump (from pump to patient). This table describes factors that may cause both types of occlusion alarms.

Common Causes of Downstream Occlusion

• Roller clamp, side clamp, manifold or stopcock not opened
• IV tubing kinked
• IV filter clogged
• Rapid IV push delivery below the pump
• Increased pressure in vascular access device (e.g., clot, kink)

Common Causes of Upstream Occlusion

• Roller clamp or side clamp not opened
• IV tubing kinked
• Venting cap not opened for rigid containers
• Air vent gets wet from priming
• Inadequate air in fluid container to allow for fluid displacement
• What you can do: Nurses need to be aware of a number of practice changes or techniques to decrease occlusion alarms. The following table outlines strategies to reduce occlusions.

Downstream Occlusion Prevention

Upstream Occlusion Prevention

• Ensure fluid pathway is unclamped and unkinked
• Many IV tubing administration sets are on the market; work with pharmacy to assess if sets exist that may better suit your patient care needs (e.g., fewer clamps, shorter tubing)
• Ensure fluid is dripping in drip chamber before leaving patient’s bedside; if there’s a high risk of occlusion, revisit often

• Attempt to gain vascular access in non-flexion areas
• Change filters per protocol
• Pause infusion before rapid IV push delivery below the pump
• Practice pulsatile flushing technique to ensure proper clearance of blood and medications

• Keep air vent closed when spiking container to decrease risk of wetting vent filter
• Spike rigid containers (e.g., glass) with air vent closed, but open vent cap during infusion
• Do not “burp” or remove excess air from fluid containers
• Keep air vent filter dry

Air-in-Line (AIL) Alarms

• Why it happens: IVSPs are programmed to alarm when they detect a single air bubble exceeding the organization’s designated threshold. AIL alarms will also activate when the IVSP’s detection logic identifies a total accumulation of air bubbles over a specified infused fluid volume. AIL alarms may occur due to various preventable and nonpreventable factors:
  • Rapid priming, which may introduce air into the fluid, and failure to pause the pump during container changes
  • Inadequate priming of the drip chamber (less than half full)
  • Outgassing of air from cold infusions as they warm to room temperature
  • Viscous and/or large molecule solutions that outgas and trap air in solution
  • Improper loading of IV tubing into the device (e.g., tubing not seated in the air sensor correctly)
  • Debris compromising the air detection system
  • Sensitive air detection parameters
• What you can do: Implement certain interventions to reduce AIL alarms; however, some factors, such as the medication’s chemical composition, are not modifiable. To help prevent AIL alarms:
  • Prime the IVtubing slowly, ensuring the drip chamber is at least half full; some experts recommend priming the fluid upward by holding the tubing in a loop so the fluid “climbs” up the tubing as it primes.
  • Allow cold fluids to reach room temperature before priming, if possible.
  • Consider attaching an antisiphon valve at the end of the IV tubing to increase resistance and drive air back into the solution.
  • Do not “burp” the semirigid fluid bags; it would create negative pressure in the bag, forcing air down the tubing as the drip chamber depletes.
  • Pause infusions when changing the fluid containers.
  • Query your biomedical engineering team if the air bubble alarm threshold can be adjusted.

End of Infusion, Near End of Infusion and Keep Vein Open Alarms

• Why it happens: End of infusion (EOI), near end of infusion (NEOI) and keep vein open (KVO) alarms activate when an infusion is nearing or has reached completion. Typically, these alerts occur when the programmed volume to be infused (VTBI) has infused or the fluid container is empty. They can also occur when the secondary callback alarm is enabled to notify the clinician when the infusion is complete. These alarms serve as expected signals to inform clinicians that the medication or fluid therapy is complete. However, nurses are rarely at the bedside when these alarms occur.
• What you can do: The frequency of EOI, NEOI and KVO alarms may be artificially increased due to the common nursing practice of underprogramming the VTBI to allow time to request the next medication bag. While this practice may seem harmless, it can obscure the underlying reasons it is needed. To reduce these alarms, consider the following:
  • Determine whether bag overfill is accounted for on the medication label; if not, escalate concerns to organizational leaders and highlight the benefits of accurate labeling.
  • Adjust the VTBI to account for loading and bolus doses.
  • Explore phone or computer alerts for volume depletion, as pump alarms sound at the bedside rather than notifying clinicians directly.
  • Estimate the infusion completion time to anticipate when a new fluid or medication bag is needed.
  • During fluid shortages, consider piggybacking available infusion bags onto a primary infusion to extend uninterrupted infusion time.

Battery Alarms

• Why it happens: Alarms that occur from battery depletion or malfunction are frustrating, but typically easy to troubleshoot. Possible battery-related alarms include the following:
  • Power supply or connections are not fully engaged or have been disconnected (e.g., especially after patient is transferred)
  • Fast infusion rates increase battery depletion
  • Battery is at the end of its life cycle or is defective
• What you can do: Coordinating practices across different disciplines or departments can be challenging. Provide feedback on issues related to unplugged IVSPs, and report concerns to your supervisor to help communicate these challenges across teams.
  • Work with accountability partners to ensure IVSPs are plugged in and charging.
  • Include equipment status reviews during environmental or room checks (e.g., similar to how you ensure the call light is within reach).
  • Ensure the power status or battery light is on before you leave the room.
  • Send malfunctioning pumps to biomedical engineering with a clear description of the device’s problem.

Conclusion

IVSP alarms play an important role in patient safety, but their frequency may contribute to alarm fatigue, increased nurse workload and patient dissatisfaction. By understanding the root causes of occlusion, AIL, EOI and battery alarms, nurses can take proactive steps to minimize unnecessary disruptions. Small changes in practice, such as optimizing priming techniques, adjusting VTBI settings, and improving communication across departments, can significantly reduce the burden of alarms. Addressing these challenges not only enhances workflow efficiency but also improves patient care and the overall hospital environment.

What you can do:

• Implement Best Practices – Apply the recommended strategies to reduce IVSP alarms and improve nursing workflow.
• Advocate for Quality Improvement – Collaborate with leadership, pharmacy and biomedical engineering teams to address alarm-related challenges and explore solutions.
• Prioritize Patient Experience – Recognize the impact of alarms on patient well-being and work toward creating a quieter, safer hospital environment.

What are your clinical pearls to reduce IVSP alarms?

Acknowledgements

This blog is part of a series sharing some of the practical knowledge we have gained working with critical care nurses at the front lines of care. I acknowledge the collaboration and support from my advisors and fellow IVSP researchers Jeannine Blake, PhD, RN, Karen Giuliano, PhD, RN, MBA, FAAN, and the Elaine Marieb Center for Nursing and Engineering Innovation.