Nurses’ response to frequency and types of electrocardiography alarms in a non-critical care setting: A descriptive study

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Abstract

Background

An important role of the registered nurse is to identify patient deterioration by monitoring the patient condition and vital signs. Increasingly, this is supplemented with continuous electrocardiographic (ECG) monitoring. Continuous monitoring is inefficient in identifying deterioration because of the high number of false and nuisance alarms. Lack of strong evidence or formal guidelines for the care of patients receiving ECG monitoring has led clinicians to rely too heavily on this technology without consideration of its limitations. The nursing workload associated with alarm management remains unexamined.

Objective

To describe nurses’ routine practices related to continuous ECG monitoring, frequency and types of alarms, their associated nursing interventions, and the impact on the patient's plan of care.

Methods

Design. Prospective, descriptive, observational study. Setting and participants. Between January 2011 and March 2011 we observed nine Registered Nurses providing care for patients receiving continuous ECG monitoring in non-critical care areas. The PI and two research assistants observed each nurse for two 3-h observation periods and recorded data on a researcher designed observation tool. At the end of each observation period, the observers printed the alarm events as recorded by the central monitoring computer.

Results

Nurses responded to 46.8% of all alarms. During the observation period, there were no dysrhythmia adverse events. One patient had a change in condition requiring transfer to a higher level of care. A range of nursing interventions occurred in response to alarms.

Conclusion

Nurses routine practices related to monitoring continue to reveal gaps in practice related to alarm management. Observations of practice also revealed the difficulties and complexities of managing alarm systems and the range of nursing interventions associated with managing alarms.

Introduction

One of registered nurses’ fundamental roles is to identify signs and symptoms of deterioration in their patients’ condition and act to interrupt continued deterioration. Early recognition of deterioration can logically be assumed to prevent adverse events such as delay in diagnosis and treatment (Considine and Botti, 2004, Taenzer et al., 2011). Many hospitalized patients exhibit signs of clinical deterioration, such as changes in vital signs, prior to experiencing critical events (Gazarian et al., 2010). Increasingly monitoring of vital signs, especially heart rate and rhythm, is accomplished through various continuous monitoring devices, creating a convergence of technology and clinical processes that has profoundly changed clinical practice. Once considered primarily for critical care areas, many forms of sophisticated monitoring are now available on medical surgical units. This proliferation in technology into non-critical care areas redistributes workflow and tasks. However, overall it increases the physical and cognitive demands for nurses as they integrate technology into their work (Militello, 1998).

The importance of detecting early signs of patient deterioration cannot be understated. However, it is also apparent that continuous electrocardiographic (ECG) monitor alarms are inefficient at alerting clinicians of patient deterioration. Continuous ECG monitoring produces many more false and nuisance alarms than notifications of true clinical events. This results in alarm fatigue and system work-arounds. Applying continuous ECG monitoring to detect deterioration produces a situation that may in fact subvert the nurses’ ability to provide proper clinical surveillance of patients’ conditions (Larson and Brady, 2008). It is important to understand the impact of monitor alarms on nurses’ work in order to inform the appropriate use of continuous ECG monitoring in clinical practice. The purpose of this report is to describe aspects of the nurses’ work on medical surgical units (non-critical care areas) associated with continuous ECG monitoring and their associated alarms.

Section snippets

Deterioration of hospitalized patients

There is a significant body of research demonstrating that many hospitalized patients exhibit signs of clinical deterioration, such as changes in vital signs, prior to experiencing a cardio-pulmonary arrest (CPA) or transfer to an intensive care unit (Buist et al., 2004, DeVita et al., 2010, Goldhill et al., 1999). Other signs of clinical deterioration supported by the research include changes in level of consciousness (LOC) or mental status, and changes in oxygenation status (Gazarian et al.,

Indication for continuous electrocardiographic (ECG) monitoring

Despite the limitations of ECG monitoring to detect patient deterioration, it is the most prevalent method of monitoring patients in hospitals today. It is common practice for patients to have continuous ECG monitoring applied without consideration of clinical indications (Funk et al., 2010). There is evidence that continuous ECG monitoring is of use in specific patient populations, such as those with acute coronary syndrome (ACS), and that sophisticated monitoring parameters such as ST segment

Monitor alarms

Attendant to the prevalence of continuous ECG monitoring are their associated alarms. Several issues have been documented related to clinical alarms. Alarm systems are highly sensitive yet lack specificity (Chambrin et al., 1999), resulting in rates of false alarms as high as 99.4% (Atzema et al., 2006, Chambrin et al., 1999). The proliferation of monitoring equipment and frequency of alarms creates risks for the development of staff desensitization to the alarms or worse, work-a-rounds such as

Design

The data reported are part of a prospective, descriptive project designed to elicit information on how nurses identify and respond to monitor alarms. The intent of this article is to report on the observational data of registered nurses in a milieu of monitor alarms. Specifically, this researcher addressed nurses’ routine practices related to ECG monitoring, the frequency and types of ECG monitoring alarms the nurses encountered in clinical practice, the level of intervention chosen by nurses

Routine nursing practice related to monitor alarms.

The usual nurse to patient ratio was 1:3 (range 2–3) with anywhere from none to three of those patients on ECG monitoring. There are no designated monitor watchers or pagers to alert nurses of an alarm. There is a central monitor station that displays each patient's rate and rhythm in two leads. Each unit has additional monitor displays placed throughout the unit. Nurses are able to adjust the set up and alarm settings at the central monitor station. The study units were using telemetry

Discussion

Key findings from the observation of nine nurses caring for 37 patients receiving continuous ECG monitoring for a total of 54 h are as follows.

Nurses routine practices related to ECG monitoring continue to reveal gaps in practice related to alarm management. Checking alarm parameters and volumes at the beginning of a shift ensures that all alarms are on and audible. Skipping this procedure at the beginning of a shift leaves a nurse vulnerable to missing an important alarm; yet the RNs in 7 out

Limitations

The findings from this study represent a description of practice in one institution among nine participants. This small sample size and use of only one site limit the generalizability of the findings. The mean age of the sample (29.75 years) was younger than the mean age of the nurses at the study institution (45.36) which may further limit generalizability. In addition, because many alarms sounded simultaneously or overlapped, observer's records of alarms were imprecise as compared to the

Implications and recommendations

The findings from this study represent a snapshot of the practice related to alarm management in a large academic medical center. Despite the large number of alarms that nurses did not to respond to, this study demonstrates the range of nursing work associated with responding to alarms. Responding to alarms included patient assessment, consultation and collaboration activities, in addition to managing the equipment. Nursing activities often overlapped and one nursing activity might not have

Conclusions

Much has been written about the need to improve vital sign monitoring among hospitalized patients and identify patients at risk of deterioration (DeVita et al., 2010). Clinicians and researchers recognize that changes in heart rate or rhythm are often not the first or only signs of deterioration (Gazarian et al., 2010, Taenzer et al., 2011). Despite these clinical observations, continuous ECG monitoring is the most prevalent type of monitoring in hospitals today and is used in situations for

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