Knowledge and Management of Alarm Fatigue on a

Medical Intermediate Care UnitKathleen A. Williams, SN

IntroductionThe purpose of this project is to improve nurses’ knowledge and management of alarm fatigue on the Medical Intermediate Care Unit at Hershey Medical Center.

Methods

• Survey response 30/48 for an overall response rate of 62.5%.• Knowledge deficits identified in the following areas: definition and impact of

alarm fatigue; current alarm monitor policy; practice points for management of alarms.

• Following distribution of flyer and educational intervention, 25/48 signatures were obtained for an educational impact of 52%.

DiscussionThe vast majority of alarms are false (85-99%). Nurses on the MIMCU expressed frustration at how disruptive false alarms are to daily workflow (8.1 out of 10). A count of alarms in a 24-hour period revealed an average of 260 alarms per bed per day with maximum daily alarms per bed as high as 1,000. False alarms lead to the potential of ignoring or missing important alarms. 90% of nurses on the MIMCU have witnessed delays in response to an urgent alarm situation and almost half have witnessed patient harm in the last year as a result of alarm fatigue.

Conclusions and Implications for PracticeInitial and ongoing education is beneficial to increasing nurses’ knowledge of alarm fatigue and methods of alarm management. Translation of knowledge into practice is expected to decrease noncritical alarms to reduce alarm fatigue and improve patient safety.

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• Administer survey via SurveyMonkey to nursing staff.• Identify gaps in knowledge.• Create educational flyer from research of current best evidence.• Distribute flyer and other supportive handouts.• Educate staff at each shift change and other opportunities as they present.• Obtain staff signatures confirming receipt of education and commitment to

expected practice and nursing actions.

Results

Infographic - Physician-Patient Alliance for Health & Safety - http://www.ppahs.org/2013/06/two-resources-on-alarm-safety-from-the-joint-commission-and-the-ecri-institute/