CSI Summary
Available only to registered AACN.org users.
Project Topic
Jessica Sommer, BSN, RN
Heather Williamson, ADN, RN
Jessi Wood, ADN, RN
Alarm Fatigue
Hospital UnitsSouth 3 Adult Critical Care Unit (CCU)
CSI Participants
Patrick Murphy, BSN, RNJessica Sommer, BSN, RN
Heather Williamson, ADN, RN
Jessi Wood, ADN, RN
Project Goals/Objectives
- To decrease the number of yellow and red alarms from our monitoring system in a 24-hour period
- To improve compliance and satisfaction with alarm reduction measures
Project Outcomes
- Decreased the average number of yellow and red monitor alarms in a 24-hour period 20%
- Decreased alarms per patient per day 23%
- Reduced staff alarm fatigue as evidenced by our post-survey results
Project Overview
Between April and September 2019, our critical care unit averaged 1,273 alarms per day from the cardiac monitoring system alone. Excessive clinical alarms can cause desensitization and delayed response. In extreme cases, alarms are turned off, which may result in patient harm due to missed true emergencies.
Baseline data was collected daily for four months from our unit’s monitoring system. A pre-survey was administered to RNs to analyze the current practice of alarm tailoring and the severity of alarm fatigue. The survey demonstrated a knowledge deficit, a high level of alarm fatigue and a concerning lack of urgency in response to critical cardiac alarms.
Our team developed additional education, and distributed handouts to increase staff engagement and project visibility. We recruited well-respected nurses with a known history of diligent alarm-tailoring to serve as alarm champions based on a known history of diligent alarm tailoring to assist with education. An initial large group education was provided and the information was reiterated through one-on-one training as needed. Data was collected and analyzed over a 26-week period and posted in the break room weekly to keep staff informed of the project’s success.
After six months, the average monitor alarms on the unit in a 24-hour period decreased 20%. Both staff and patients commented on how peaceful and quiet the unit had become. We hope to train some of our best alarm champions to become super-users for our monitor system and continue training current and new staff on alarm-tailoring guidelines. Our goal is to eventually create a hospital-wide policy that addresses alarm tailoring and alarm fatigue prevention strategies on all applicable units.
Permission to Reuse Materials
The materials associated with this AACN Clinical Scene Investigator (CSI) Academy project are the property of the participating hospital noted above, not AACN. Requests to use content contained in the CSI team’s summary, presentation or toolkit should be directed to the hospital. We suggest reaching out to the hospital’s Communications, Marketing or Nursing Education department for assistance.
Disclaimer
The AACN CSI Academy program supports change projects based on quality improvement methods. Although CSI teams seek to ensure linkage between their project and clinical/fiscal outcomes, data cannot be solely attributed to the project and are estimations of impact.