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Patient Safety Issues ©2020 American Association of Critical-Care Nurses doi:https://doi.org/10.4037/ajcc2020120 Background Nurses in intensive care units are exposed to hundreds of alarms during a shift, and research shows that most alarms are not clinically relevant. Alarm fatigue can occur when a nurse becomes desensitized to alarms. Alarm fatigue can jeopardize patient safety, and adverse alarm events can lead to patients dying. Objective To evaluate how a process intervention affects the number of alarms during an 8-hour shift in an inten- sive care unit. Methods A total of 62 patients from an intensive care unit were included in the study; 32 of these patients received the intervention, which included washing the patient’s chest with soap and water and applying new electrocar- diography electrodes at the start of a shift. The number of alarms, clinical diagnoses, and demographic variables were collected for each patient. A Poisson regression model was used to evaluate the impact of the interven- tion on the overall number of clinical alarms during the shift, with no adjustments to the alarm settings or other interventions. Results After relevant covariates are controlled for, the results suggest that patients in the intervention group presented significantly fewer alarms than did patients in the control group. Conclusions Managing clinical alarms is a main issue in terms of both patient safety and staff workload manage- ment. The results of this study demonstrate that a rela- tively simple process-oriented strategy can decrease the number of alarms. (American Journal of Critical Care. 2020;29:390-395) SKIN PREPARATION AND ELECTRODE REPLACEMENT TO REDUCE ALARM FATIGUE IN A COMMUNITY HOSPITAL INTENSIVE CARE UNIT By Debbie Leigher, BSN, RN, CNML, Paula Kemppainen, BSN, RN, and David M. Neyens, PhD, MPH This article is followed by an AJCC Patient Care Page on page 396. 390 AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2020, Volume 29, No. 5 www.ajcconline.org www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2020, Volume 29, No. 5 391 Alarm events can lead to potential harm for patients. W ithin intensive care units (ICUs), most equipment has safety alarms embed- ded that alert staff of changes in various patient parameters and situations.1 This technology can increase the already large number of alarms—sometimes hundreds—nurses encounter during shifts1,2; many of those alarms are not clinically relevant.3 Frequent auditory alarms can result in unintended con- sequences that have implications for patient safety (eg, patient injuries, fatalities) and quality of care.4 Managing these clinical alarms has been identified as a “top 10” safety concern.5 Although all alarms must be acknowledged or dismissed, clinically relevant alarms require nursing intervention, whereas false alarms do not. Various factors can create false or nonactionable alarms: the patient’s motion, incorrect alarm parameter settings, the patient’s condition, care being provided to the patient (eg, bathing or turning), improper skin prepa- ration or electrocardiography (ECG) electrode place- ment, or faulty connections of leads or electrodes. Here we use the term false alarms to describe both false alarms and nonactionable alarms. In its 2013 Sentinel Alert, the Joint Commission reported that between January 2009 and June 2012, alarm-related events led to the death of 80 patients and to a permanent loss of function in 13 patients.6 Because of the critical importance of patient safety and the rising number of alarm-related events, the Joint Commission issued a national patient safety goal related to alarm management, mandating that hospitals make establishing an alarm safety system a hospital priority and identify the most important alarms to manage.6 In addition, the Joint Commis- sion required accredited hospitals to implement policies and procedures to manage alarms and appropriately educate staff.7 When clinical alarms are more likely to be false than clinically relevant, a work culture can emerge wherein nurses may delay responding to alarms, especially when the setting has a large patient census or a high patient to nurse ratio, and thus may miss critical alarms.8-10 The ever-increasing number of alarms can lead to a phenomenon known as alarm fatigue.7,11 Alarm fatigue can occur when a nurse is exposed to frequent alarms and becomes desensitized to them.8 Alarm fatigue has been described as the most common factor contributing to alarm-related events,3,7,12,13 and it is well known that alarm fatigue can jeopar- dize patient safety and that adverse alarm-related events can lead to patient fatalities3,7,12 and staff workload management issues.13 A recent study showed that alarm management and nuisance alarms remain problems.14 Much of the previous research on alarm fatigue has examined the issue from the perspective of technology and alarm parameters.8,15,16 A technology- only intervention will not, however, completely alleviate alarm fatigue because factors related to organizational best practices and nursing best prac- tices influence alarm management and subsequent alarm fatigue. The litera- ture focuses on special- ized ICUs and ICUs in large academic hospi- tals,2,3,7,15,17 but the patient population in a community hospital’s ICU is typically more diverse than that in specialty ICUs at larger facilities. Com- mon diagnoses and conditions among patients in a community ICU—like the one included in this study—include congestive heart failure, pneumonia, gastrointestinal bleeding, sepsis, cardiac arrhythmia, alcohol withdrawal, suicide attempt, postoperative complications, diabetic ketoacidosis, and chronic obstructive pulmonary disease. This diversity makes managing alarm fatigue through technology-centric strategies (eg, by adjusting alarm parameters) a chal- lenge for nurses.8,16,18,19 Therefore, alternative strate- gies are needed to reduce the number of false alarms and to address and reduce the effects of alarm fatigue and increase patient safety. One possible way to reduce the number of false alarms is to improve skin preparation before placing ECG electrodes. Cvach et al20 reported that daily electrode changes reduced by 46% the number of alarms per bed day in 2 acute care units. Hermens et al21 recommended changes in sensor placement procedures in an effort to reduce the number of false About the Authors Debbie Leigher is a nurse manager and Paula Kemppainen is an assistant nurse manager, Greer Memorial Hospital, Prisma Health System, Greer, South Carolina. David M. Neyens is an associate professor, Department of Indus- trial Engineering, Clemson University, Clemson, South Carolina. Corresponding author: David M. Neyens, PhD, MPH, Depart- ment of Industrial Engineering, Clemson University,100 Freeman Hall, Clemson, SC 29634 (email: dneyens@ clemson.edu). 392 AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2020, Volume 29, No. 5 www.ajcconline.org Red and yellow alarms were counted for an 8-hour shift in an intensive care unit at a community hospital. alarms related to surface electromyography, and they proposed that preparing patients’ skin could improve electrode–skin contact, thereby resulting in fewer non- relevant alarms. In addition, an American Association of Critical-Care Nurses Practice Alert outlined 7 nurs- ing actions related to false alarms that may reduce the number of such alarms22: properly preparing the skin for ECG electrodes, changing ECG electrodes daily, customizing alarm parameters and levels on ECG mon- itors, customizing delay and threshold settings for oxygen saturation via pulse oximetry, providing initial and ongoing nursing education about devices with alarms, establishing interprofessional teams to address issues related to alarms (eg, developing policies and procedures), and monitoring only those patients who present clinical indications for monitoring.1,22 Several of these clinical decision–related or technology-mediated interven- tions can affect the number of alarms that occur in an ICU, and they are well documented in the literature.5,8,15,16,18 We must, however, further evalu- ate how preparing the skin for ECG electrodes and changing the electrodes affect the number of alarms while accounting for spe- cific patient types and characteristics. Therefore, the objective of this study was to evaluate how a process intervention of preparing the skin (ie, washing a patient’s chest with soap and water) and changing electrodes at the start of each shift affected the number of alarms throughout an 8-hour day shift in an ICU. Methods Study Design This study included 2 groups. For patients in the intervention group, a nurse prepared their skin for electrode placement (by washing the patient’s chest with soap and water) and changed the elec- trodes daily (before 8:00 AM). The same clinical staff member prepared the skin and changed electrodes throughout the entire study. We collected data only on weekdays to ensure that the intervention was consistent and done by the same provider. Patients in the control group received standard care that included changing electrodes only as needed, per standard hospital procedure. We used 3M Red Dot monitoring electrodes with foam tape and sticky gel and Philips IntelliVue MP70 Patient Monitors for all patients. Throughout the study, we did not modify or adjust any parameters (eg, alarm thresholds) for the equipment and monitors for any patient. Study Setting and Sample This study was conducted after we obtained approval through the Prisma Health institutional review board (no. Pro00049513). The study took place in the ICU at a community hospital. The ICU is not specialized and is similar to a medical-surgical ICU in that the patient population varies daily and can include patients with diagnoses of cardiac, respi- ratory, or gastrointestinal diseases, sepsis, alcohol withdrawal, postsurgical complications, suicide attempt, and others. Data Collection The study included 100 patients, with 50 patients in each group. Each patient was included in the study for a single 8-hour shift, and no individual patient was included in both groups. If a patient experienced no alarms during the 8-hour period, they were excluded from the analysis. After exclu- sions, the study included 62 patients. We counted alarms hourly during the 8-hour period to calculate the total number of alarms during the work shift. Several demographics were collected for each patient: age, primary and secondary diagnoses, body mass index, activity level