Clinical Alarms in intensive care: implications of alarm fatigue for the safety of patients

OBJECTIVES: to identify the number of electro-medical pieces of equipment in a coronary care unit, characterize their types, and analyze implications for the safety of patients from the perspective of alarm fatigue. METHOD: this quantitative, observational, descriptive, non-participatory study was conducted in a coronary care unit of a cardiology hospital with 170 beds. RESULTS: a total of 426 alarms were recorded in 40 hours of observation: 227 were triggered by multi-parametric monitors and 199 were triggered by other equipment (infusion pumps, dialysis pumps, mechanical ventilators, and intra-aortic balloons); that is an average of 10.6 alarms per hour. CONCLUSION: the results reinforce the importance of properly configuring physiological variables, the volume and parameters of alarms of multi-parametric monitors within the routine of intensive care units. The alarms of equipment intended to protect patients have increased noise within the unit, the level of distraction and interruptions in the workflow, leading to a false sense of security.


Introduction
Are alarms really a good fit for intensive care?
Even though it seems paradoxical, this question has gained meaning due to the results of studies, especially international studies, which have recently indicated that the presence of a high number of alarms pose a potential risk to the integrity and safety of patients in intensive care units. This is not only due to organic disorders caused by high levels of noise but also because it leads professionals to become desensitized, decreasing alertness and  (1) .

Deactivation of alarms, not programing or not
properly configuring alarms in accordance with a patient's clinical condition and also setting them at a low volume are objects of research (2) . Professionals describe alarms as being "noisy, blatant, a nuisance" requiring the need to interrupt the care being provided to patients in order to attend to alarms (3) .
There is a high incidence of false alarms in intensive therapy units due to monitoring systems characterized by high sensitivity and low specificity. There is an excessive number of such alarms with low clinical relevance (1) .
A lack of standardization of alarm sounds, as to what an appropriate urgent alarm is, and inadequate visual and audio elements in a monitor's alarms, all have been objects of investigation in the nursing field (4) .
In regard to the equipment, researchers note that the complex programing, configuration and operation of alarm systems pose difficulties for staff (4) . Failures in equipment that leads to adverse events in intensive care units are described in the literature as important factors impacting the safety of patients (5) .
In terms of human resources, studies show that professionals lack training on how to handle equipment correctly, that there is a deficit of human resources in units, a lack of adherence on the part of the staff in programming and configuring alarms and a lack of confidence in the urgency of alarms (4) .
Also, the physical disposition of units, which is inadequate to attend properly to alarms, a lack of maintenance of equipment and the involvement of the health staff and clinical engineering, have been investigated (4) . There were, between March and June 2010, more than 73 deaths related to alarms, 33 of which were multiparametric monitors (6) .
The Emergency Care Research Institute (ECRI), an organization specializing in patient safety and the use of electro-medical equipment, listed the 10 dangers of technology in the health field and alarms was in the number one danger in 2012 and 2013 due to the high number of adverse events among inpatients of hospitals in the USA, including death, cardiorespiratory arrest, and cardiac arrhythmias (7) . Based on data involving adverse events caused by alarms, the Joint Commission proposed that, for 2014, the management of clinical alarms should be pursued in order to improve the safety of these systems (8) . It is worth noting that discussions of this subject in Brazil are still incipient and mainly developed by the research group to which the authors of this study belong.
Considering the importance of this topic, we verified the need to gain results able to ground strategies to improve the monitoring systems used in the follow-up of critical patients under intensive care and to minimize alarm fatigue, so that monitoring is more objective and safe.
The study's objectives included: to identify the number of alarms from electro-medical equipment in a coronary care unit; to characterize the types of alarms; and to analyze implications for the safety of patients from the perspective of alarm fatigue.

Method
This quantitative observational study was conducted in a coronary care unit (CCU) of a public university cardiology hospital with 170 beds, located in a city in the Southern region of Brazil.
We observed the production of data in five beds if these are not attended to, there will be 20 alarms in the second hour.      Table 3.

Discussion
It is worth noting that a single nurse is not able to meet all requests, demands or system calls (9) .
The importance of monitoring critical cardiac patients in order to rapidly visualize clinical changes, identify arrhythmias, bundle branch block, ischemia, and critical heart rates, titration of medications, and control of mechanical ventilator support is unquestionable. arrhythmia, in addition to filters (6) .
The adoption of these principles are recommendations provided by studies and research institutes because they decrease the occurrence of false alarms due to interference; false alarms contribute to desensitization, lack of confidence, and lack of response on the part of the staff, that is, they decrease alarm fatigue (3,7) .
Cacophony in the unit, a myriad of alarms from medical devices, creates an environment that poses a significant risk to patient safety. With the accumulation of alarms, it is difficult to identify the origin of a particular alarm, considering the limitations in the ability of human beings to discriminate different categories of sounds in the same environment (10) .
Alarms can go on unendingly and important alarms may be overlooked and intercurrences go unnoticed.
Additionally, noise negatively affects the health staff, possibly leading to stress, burnout, conflict, and among patients, noise may cause insomnia, increase duration of hospitalization, and the use of analgesic and anxiolytics (6) .
Heeding and resolving the causes of alarms both demand time from the staff, interrupt their tasks and cause distractions that may lead to errors due to a lack of concentration and/or lapses in attention (11) . Note that programing, configuring and adjusting alarms is important to meeting the needs of patients. Proper programming ensures that alarms will be valid and warn of truly critical situations, so that the staff can rely on them and decrease unnecessary interruptions and distractions (12) .
Alarm overload and "Alarm fatigue" are conditions that may lead to incidents. The staff may deactivate variables that need to be monitored, lower the volume, disable alarms or inadvertently adjust their parameters beyond the limits appropriate for the patients' needs in an attempt to decrease the number of alarms. Such changes may impede the staff from realizing that patients have clinical conditions requiring attention (7) .
In regard to volume, the staff should analyze whether the alarms are sufficiently audible in the units, and when programing them, the staff should take into account environmental noise, the number of professionals in the unit, patients, and the unit's physical disposition, in order to adapt the alarms to the needs of each unit (6) . Adverse events caused by low-volume alarms have been reported (2) .
This study's results show that the alarms of monitors under observation were set at a low volume  were also observed.
Alarm fatigue is a challenge because it involves human factors, as well as factors concerning equipment, alarm devices, the internal system of units, and workflow components (15) . Its worst consequence is a clinical situation in which there is the real need for immediate care but intervention does not occur because no one pays attention to the alarm, possibly leading patients to experience an adverse event (16)

Conclusion
There is a pressing need to implement safer It is disturbing that the alarms of equipment intended to protect patients may, in fact, lead to increased noise within the unit and consequently lead to alarm fatigue, distraction and interruption of the workflow and then to a false sense of security.
Through appropriate monitoring, the staff will know the real need to attend to alarms, will trust in the clinical relevance and urgency of these devices, reducing trivialization and over-familiarization with noise.
Additionally, patients hospitalized in intensive care units will benefit from measures intended to reduce noise coming from alarms. Therefore, alarms are good for intensive care provided they are properly programed, configured, adjusted, heeded and valued by the staff.