MCCC Alarm Fatigue in Clinical Practice Critical Appraisal of The Literature Paper

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1. Use the Casey, Avalos & Dowling (2018) article attached down below to complete the Critical Appraisal/Quantitative Critique.To complete the critique refers to the quantitative critique directions attached with the list of questions.

PLEASE WRITE THE ANSWERS IN ESSAY FORMAT, USE APA FORMATTING, AND CITE REFERENCES USED. The article needed is attached

GOA elements and questions:

PICOT Question

Overview of the study

1.Why was the study done (purpose)?

2.What was the study design?

3.Was appropriate ethics review reported

General description of the study

1.Research question or hypothesis

2.Sampling

  • What was the sampling technique?
  • What was the sample size?
  • Major variables studied

    1.What were the dependent and independent variables?

    2. Are the measurements of the major variables valid and reliable?

    3. How were the data analyzed? Were the statistics

    appropriate?

    4. Were there any untoward events during the conduct of the study?

    5. How do the results fit with previous research?

    6. What does this mean for clinical practice?

    Conclusion

    Unformatted Attachment Preview

    Intensive & Critical Care Nursing xxx (2018) xxx–xxx Contents lists available at ScienceDirect Intensive & Critical Care Nursing journal homepage: www.elsevier.com/iccn Research article Critical care nurses’ knowledge of alarm fatigue and practices towards alarms: A multicentre study Siobhán Casey a,⇑, Gloria Avalos b, Maura Dowling c a Intensive Care Unit, Galway University Hospital, Galway, Ireland School of Medicine, Medical Informatics and Medical Education, National University of Ireland, Galway, Ireland c School of Nursing and Midwifery, National University of Ireland, Galway, University Road, Galway, Ireland b a r t i c l e i n f o Article history: Accepted 7 May 2018 Available online xxxx Keywords: Alarm fatigue Alarm management Clinical alarms Patient safety a b s t r a c t Objectives: To determine critical care nurses’ knowledge of alarm fatigue and practices toward alarms in critical care settings. Research methodology/design: A cross-sectional survey using an adaptation of The Health Technology Foundation Clinical Alarms Survey. Setting: A sample of critical care nurses (n = 250) from 10 departments across six hospitals in Ireland. Results: A response rate of 66% (n = 166) was achieved. All hospital sites reported patient adverse events related to clinical alarms. The majority of nurses (52%, n = 86) did not know or were unsure, how to prevent alarm fatigue. Most nurses (90%, n = 148) agreed that non-actionable alarms occurred frequently, disrupted patient care (91%, n = 145) and reduced trust in alarms prompting nurses to sometimes disable alarms (81%, n = 132). Nurses claiming to know how to prevent alarm fatigue stated they customised patient alarm parameters frequently (p = 0.037). Frequent false alarms causing reduced attention or response to alarms ranked the number one obstacle to effective alarm management; this was followed by inadequate staff to respond to alarms. Only 31% (n = 50) believed that alarm management policies and procedures were used effectively. Conclusion: Alarm fatigue has the potential for serious consequences for patient safety and answering numerous alarms drains nursing resources. Ó 2018 Elsevier Ltd. All rights reserved. Implications for clinical practice  Non-actionable alarms continue to burden nurses despite customising patient alarm parameters. Research regarding effective alarm reduction strategies must be prioritised  The findings suggest that the majority of nurses are unaware of current evidence-based approaches to attenuate alarm fatigue. Education and training regarding all aspects of alarm management should be ongoing for critical care nurses  Alarm management practices need to be evaluated locally and governed by evidence based policies and procedures to protect patient safety Introduction Medical devices rely on auditory alarms to alert clinicians to deviations from a predetermined normal status in either equipment or patient. This ensures safeguarding against harm (American ⇑ Corresponding author. E-mail addresses: siobhan.casey@outlook.ie (S. Casey), Gloria.avalos@nuigalway. ie (G. Avalos), Maura.dowling@nuigalway.ie (M. Dowling). College of Clinical Engineering Healthcare Technology Foundation [ACCE HTF], 2007). However, healthcare technology advances have resulted in the exponential growth of medical device auditory alarm sounds (Borowski et al., 2011). Nurses have become overwhelmed by the sheer volume of alarms leading to alarm apathy (Sendelbach and Funk, 2013). The number of alarms has exploded to as many as 171 alarms per monitored bed per day (Graham and Cvach, 2010) and the majority are estimated to be false or in-actionable (Siebig et al., 2010). The tech- https://doi.org/10.1016/j.iccn.2018.05.004 0964-3397/Ó 2018 Elsevier Ltd. All rights reserved. Please cite this article in press as: Casey, S., et al. Critical care nurses’ knowledge of alarm fatigue and practices towards alarms: A multicentre study. Intensive & Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.05.004 2 S. Casey et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx nology that has been designed to save lives has therefore been accused of becoming the ‘problem’ (Emergency Care Research Institute (ECRI), 2014a,b). This viewpoint is supported by records associating clinical alarms with patient deaths. For instance, Cvach (2012) reviewed the Manufacturer and User Facility Device Experience (MAUDE) database kept by the Federal Drug Administration (FDA) for four months in 2010 finding 73 deaths related to alarms, of which 33 were attributed to physiological monitors. In addition, a search of the MAUDE database discovered 216 deaths related to physiologic monitor alarms, and while alarms sounded in 73 cases, they were not attended due to being silenced, volumes lowered or other reasons (Keller, 2012). Moreover, it is claimed that the actual death rate related to clinical alarms may be ten times higher than declared (The Association for the Advancement of Medical Instrumentation [AAMI], 2011). It is therefore not surprising that up until 2016 the United States (US) patient safety research organisation (ECRI) has positioned alarm hazards as number one, or two, of the annual ‘Top 10 Health Technology Hazards’ list since it was first devised in 2007. Additionally, alarm management was designated a National Patient Safety Goal in 2014, 2015 and 2016. Researchers have only recently explored the phenomenon of alarm fatigue (Alsaad et al., 2017; Bonafide et al., 2014; Cho et al., 2016; Deb and Claudio, 2015; Funk et al., 2016; Funk et al., 2014; Gazarian et al., 2015; Honan et al., 2015; Joshi et al., 2017; Ruppel et al., 2018; Varpio et al., 2012). Most of this research emanates from North America. This could partly be explained by different nurse-patient ratios and single occupancy rooms employed in the United States (US) compared to elsewhere, rendering the phenomenon more apparent. querying nurses’ familiarity with the term alarm fatigue, whether they knew what caused alarm fatigue, and how to prevent alarm fatigue. An additional question (Q19) gathered information on the extent to which the practice of customising alarms to patients occurs in practice. The HFT survey has previously been used to survey healthcare professionals nationally throughout the US in 2005–2006, 2011, and 2016 (Korniewicz et al., 2008: Funk et al., 2014; Ruppel et al., 2018), and also in several other studies to evaluate nurses’ perception of alarms (Baird, 2015; Cho et al., 2016; Deb and Claudio, 2015; Sowen at al., 2015; Petersen and Costanzo., 2017; Turmell et al., 2017). The adapted instrument was pretested among nine critical care nurses and issues with the layout of the survey’s nine-point scale were highlighted and subsequently re-organised. A reliability analysis of the adapted instrument generated a Cronbach’s Alpha of 0.73. Ethical considerations Ethical approval was granted for sites A and B on December 3rd, 2015, site D on January 11th, site C on January 14th, site F on January 16th and site E on March 11th, 2016. Participant confidentiality and anonymity were maintained throughout the study. Setting This study aimed to determine critical care nurses’ knowledge of alarm fatigue and their attitudes, perceptions, and practices towards clinical alarms. A cross-sectional survey design was used. Nurses working at six hospitals in the West of Ireland were surveyed; All were teaching hospitals with university affiliation (Table 1). Five were Model 3 hospitals, which have intensive care facilities on site and emergency departments open 24/7. Site A had Model 4 status as it was the regional tertiary referral centre. Site A was the only hospital with a post anaesthetic care unit (PACU). Nurses at this hospital rotated between the ICU, PACU and high dependency unit, (HDU), therefore, it was deemed appropriate to include PACU in the study despite the short-term nature of this patient population. The small number of PACU nurses 2.87% (n = 8) was not anticipated to affect the data. Instrument Participant selection The Health Technology Foundation (HFT) 2011 Clinical Alarms Survey (CAS) (Funk et al., 2014) was used. This instrument consists of four main sections. The first section seeks demographic information including type of hospital and critical care department. The second section consists of general statements about clinical alarms and asks respondents to rate their level of agreement with the statements on a five-point Likert scale (Strongly agree to Strongly disagree). The third section presents a list of nine obstacles to effective clinical alarm management and asks respondents to rank them on a scale of one (most important) to nine (least important). The final section is an open question requesting views on what is needed to improve clinical alarm recognition and response. Permission was granted from the Health Technology Foundation (HTF) to use the instrument and to make adaptations as necessary. For instance, question 21 was omitted as it pertained to telemetry which is utilised in only two of the study settings. Questions 23 and 30 on the HFT questionnaire were also omitted as they pertained to alarm communication systems and central monitor watchers which are not utilised throughout the study settings. The time frame for question 20, which queried adverse events related to clinical alarms, was changed from ‘two’ to ‘five’ years to capture whether nurses were knowledgeable about confirmed alarm-related deaths occurring in an intensive care unit (ICU) in Ireland (Geraghty, 2015). Three knowledge questions were added Non-probability consecutive convenience sampling was used. Excluding 12 nurses from the single private hospital in the study, the total population included 266 public sector nurses representing 19% of the total public sector critical care staff across Ireland. Excluding non-clinical nurses reduced the target population to 250. Methodology Research design Data collection The two-page paper instrument was distributed by the first author in person to each site. Data was collected over a onemonth period from mid-February to mid-March 2016. A tray of study questionnaires was positioned beside the sealed survey collection box. Respondents were asked to take a survey and return the completed survey to the collection box. Coloured A3 posters were hung in the staff rooms of each site to advertise the study. A champion was recruited for each site to promote the study. The first author collected the sealed box at the end of the data collection period. Data analysis Collected data were entered INTO IBM SPSS version 22 for descriptive and statistical analysis. Descriptive statistics were Please cite this article in press as: Casey, S., et al. Critical care nurses’ knowledge of alarm fatigue and practices towards alarms: A multicentre study. Intensive & Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.05.004 3 S. Casey et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx Table 1 Description of Study Sites. Site A B C D E F Sample Population N = 250 (%) Response N = 166 (%) Hospital Model Capacity Description 106 (45%) 29 (10%) 34 (11%) 43 (14%) 12 (7%) 26 (13%) 75 (71%) 16 (55%) 19 (56%) 23 (53%) 12 (100%) 21 (81%) Model 4 Model 3 Model 3 Model 3 Model 3 (JCI accredited) Model 3 708 Bed Regional Referral Centre:ICU x11,CTICU up to 5, PACU x 4, HDU x6 26 220 Bed Combined Unit:ICU x 2, HDU x 3,CCU x 3.Telemetry monitoring for 6 hospital beds. 8 332 Bed Combined Unit: ICU/HDU/CCU x 8, variable dependency. 8 326 Bed ICU x 5, HDU, 4 126 Bed Combined Unit:ICU & HDU x 8. Telemetry monitoring for 4x CCU beds on a separate floor and 12 Hospital beds. 8 359 Bed Combined Unit: ICU/HDU/CCU x 5 variable dependency. 5 Critical Care Beds reported as frequency and percentage (%) for categorical data and median and interquartile range (IQR) for skewed data. The level of significance was based on an alpha value of 0.05. The combined number of those who strongly agreed or agreed with the Likert items 1–19 in the instrument were ranked from the highest agreement (1) to the lowest agreement (19). The nonparametric Mann-Whitney U (U) test was applied for skewed continuous data and compared participants’ responses to questions 1– 19 with the three knowledge questions related to alarm fatigue (i.e. are you familiar with the term alarm fatigue, do you know what causes it and how do you prevent it?).” The chi-square test (v2) explored the relationship between the question, ‘do you know how to prevent alarm fatigue?’ and participant demographics and responses to questions 1–22. Site A was characteristically different to the other five sites; hence Site A data were compared to the merged data of the other sites to identify the site’s influence on the overall findings. Findings Sample and response rate A response rate of 66% (n = 166) was achieved across the six hospital sites (Table 1). A high proportion of the respondents were female (89%, n = 146), while 12% (n = 19) were male. The majority were staff nurses, (93%, n = 154), while 7% (n = 11) were clinical nurse managers (CNMs). The majority of respondents (66%, n = 108) were educated to postgraduate (Higher diploma or Diploma) level, and of these, 11% (n = 17) held a master’s degree. Twenty-seven percent (n = 45) of respondents held a degree and 7% (n = 11) held a preregistration certificate in general nursing. Almost two-thirds of the participants (62%, n = 98) had 11 years or more critical care experience. Knowledge of alarm fatigue Most nurses (88%, n = 146) stated they were familiar with the term alarm fatigue. Similarly, 84% (n = 138) stated they knew what caused alarm fatigue. However, when their knowledge level was explored further, 52% (n = 86), did not know, or were uncertain how to prevent alarm fatigue. Among 79 nurses who knew how to prevent alarm fatigue, significantly more were from Site A (58%, n = 46 vs 42%, n = 33), v2 (2) =14.4, p = 0.001. However, despite initiatives to address alarm fatigue at Site A, 39%, (n = 29) of respondents from Site A did not know or were unsure how to prevent alarm fatigue. 9 There was no association between nurses’ knowledge of how to prevent alarm fatigue and years of experience (v2 (1 3 0) = 131.8, p = 0.439), educational level (v2 (8) = 9.156, p = 0.329), overseas experience (v2 (12) = 19.780, p = 0.071), gender (v2 (2) = 0.081, p = 0.960), department (v2 (6) = 8.078, p = 0.232), or job title (v2 (2) = 0.268, p = 0.874). Nurses did not possess greater knowledge of alarm fatigue prevention if they had worked in a Joint (International) Commission Hospital (v2(4) = 4.262, p = 0.372). The Joint Commission (JC) is responsible for accrediting 21,000 healthcare organisations in the US, and The Joint Commission International (JCI) accredits over 100 hospitals worldwide. The JC is one of the organisations at the forefront of efforts to increase awareness of alarm fatigue and has incorporated alarm management into their accreditation standards. Nurses who were familiar with the term alarm fatigue agreed that non-actionable nuisance alarms occurred frequently (Q3), (U = 783, p = 0.005) and that alarms in their area were adequate to alert staff of actual or potential changes in a patient’s condition, (Q8) (U = 727, p = 0.024). Nurses who knew what caused AF agreed that non-actionable/nuisance alarms occurred frequently (Q3) (U = 824, p = 0.019). Nurses familiar with how to prevent AF agreed that alarm management practices within their area incorporated best available evidence to prevent patient adverse events (Q18) (U = 1045, p = 0.038) (Table 2). Alarms Recognition, settings and checks Customising patient alarm parameters at the beginning of a shift and adjusting them throughout the day (Q19) ranked 4th highest agreement level (88%, n = 145) and was significantly related to nurses’ knowledge of preventing alarm fatigue (92%, n = 72 vs. 8% n = 60) v2 (4) = 10.2, p = 0.037. The 2nd lowest level of agreement (30.9%, n = 50) was that properly setting alarm parameters and alerts is overly complex in existing devices (Q6), while difficulty setting alarms properly (Q1 in the 1–9 scale) was ranked 8th as an obstacle to effective alarm management (Table 3). A low percentage of nurses 36% (n = 59) agreed that alarms frequently could not be heard or were missed (Q9). However, 62% (n = 102) felt that environmental background noise had interfered with alarm recognition (Q12), while 50% (n = 82) agreed that, when a number of devices were alarming, there was confusion determining which device was alarming (Q13). There was almost unanimous agreement among the 166 nurses in this study (99%, n = 164) that alarms should indicate alarm priority (Q1) (Table 3). Within the nine-point scale ranking issues inhibiting effective alarm management, difficulty understanding alarm priority (Q4) Please cite this article in press as: Casey, S., et al. Critical care nurses’ knowledge of alarm fatigue and practices towards alarms: A multicentre study. Intensive & Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.05.004 4 S. Casey et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx Table 2 Alarm Fatigue Knowledge vs Perception of Alarms Mean Rank Median IQR (25th-75th) p-value Q3. Non-actionable/nuisance alarms occurfrequently Are you familiar with the term alarm fatigue? Yes (n = 144) No (n = 14) 78 95 1 1 0(1–1) 1(1–2) 0.005* 0(1–1) 1(1–2) 0.024* Q8. The alarms in my area are adequate to alert staff of potential or actual changes in a patient’s condition Are you familiar with the term alarm fatigue? Yes (n = 142) 77 1 No (n = 14) 97 1.5 Q3. Non-actionable/nuisance alarms occur frequently Do you know what causes Alarm Fatigue? Yes (n = 136) 74 1 No (n = 15) 89 1 0 (1–1) 1 (1–2) Q.18. Alarm management practices within my area incorporate best available evidence to prevent patient adverse events Do you know how to prevent alarm fatigue? Yes (n = 77) 52 1 No (n = 35) 65 2 0.019* 1 (1–2) 2 (1–3) 0.038* Table 3 Survey items on adapted HTF questionnaire and respondents’ ranking. Likert Questions (Total % (n) for those who Strongly Agree or Agree with the Statements) Total N = 166 % (n) Rank 1. 2. 3. 4. 5. 99% 88% 90% 91% 81% 1 5 2 3 7 Alarm sounds and/or visual displays should differentiate the priority of alarm. Alarm sounds and/or visual displays should be distinct based on the parameter (e.g. heart rate) or source (device type). Non-actionable/Nuisance alarms occur frequently. Non-actionable/Nuisance alarms disrupt patient care. Non-actionable/Nuisance alarms reduce trust in alarms and cause caregivers to turn alarms off at times other than setup or procedural events. 6. Properly setting alarm parameters and alerts is overly complex in existing devices. 7. Newer monitoring systems (less than three years old) have solved most of the problems we experienced with clinical alarms. 8. The alarms in my area are adequate to alert staff of potential or actual changes in a patient’s condition. 9. There have been frequent incidences where alarms could not be heard or were missed. 10. Clinical staff are sensitive to alarms and respond quickly. 11. The medical devices used in my area all have distinct outputs (i.e. sounds, repetition rates, visual displays, etc.) that allow users to identify the source of the alarm. 12. When a number of devices with alarms are used with a patient, it can be confusing to determine which device is in alarm. 13. Environmental background noise has interfered with alarm recognition. 14. Smart alarms (e.g. where multiple parameters, rate of change of parameters, and signal quality, are automatically assessed in their entirety) would be effective for reducing false alarms. 15. Smart alarms (e.g. where multiple parameters, rate of change of parameters, and signal quality are automatically assessed in their entirety) would be effective to use for improving clinical response to important patient alarms. 16. There is a requirement in my institution to document that the alarms are set and appropriate for each patient. 17. Clinical policies and procedures regarding alarm management are effectively used in my facility. 18. Alarm management practices within my area incorporate best available evidence to prevent patient adverse events. 19. I always customise patient alarm parameters at the beginning of a shift and adjust accordingly throughout the day. 20. Has your hospital experience adverse patient events in the last five years related to clinical alarms? 21. Has your hospital instituted new technological solutions to improve clinical alarm safety? 22. Has your area developed clinical alarm improvement initiatives over the past two years? Education, training and improvement initiatives New technology had been instituted to improve clinical alarm safety in their area according to 47% (n = 76) of respondents (Q21). This was significantly related to nurses’ knowledge of alarm fatigue 30.9% (50) 18% (29) 78% (126) 36% (59) 76% (123) 77% (125) 17 19 8 16 10 9 50% (82) 62% (102) 72% (117) 14 13 11 71% (105) 12 82% (134) 30.8% (50) 48% (77) 89% (145) 6 18 15 4 Yes No Unsure 54% (88) 46.6% (52) 50.3% (81) 21.5% (35) 31.9% (52) 33.5% (54) 24.5% (40) 21.5% (35) 16.1% (26) Ranking statements on issues which inhibit effective management of clinical alarms (Most important = 1 to Least important = 9) Q1 Difficulty in setting alarms properly. Q2 Difficulty in hearing alarms when they occur. Q3 Difficulty in identifying the source of an alarm. Q4 Difficulty in understanding the priority of an alarm. Q5 Frequent false alarms, which lead to reduced attention or response to alarms when they occur. Q6 Inadequate staff to respond to alarms as they occur. Q7 Over reliance on alarms to call attention to patient problems. Q8 Noise competition from non-clinical alarms and pages. Q9 Lack of training on alarm systems. was ranked 4th, while difficulty hearing alarms when they occur (Q2) was ranked 5th and difficulty identifying the source of an alarm (Q3) was ranked 6th. (164) (143) (148) (145) (132) Mean Rank 4.14 3.80 3.81 3.69 2.43 2.66 3.40 4.31 3.86 Rank 8 5 6 4 1 2 3 9 7 prevention (58%, n = 45 vs. 42%, n = 33), v2 (4) = 15.3, p = 0.004. Half of the sample (50%, n = 81) stated that their area had instituted clinical alarm improvement initiatives in the preceding two years (Q22). This was significantly related to nurses’ knowledge of alarm fatigue prevention (61% n = 47 vs. 39% n = 33), v2 (4) = 12.9, p = 0.011. Nurses believed smart alarm technology, which uses multiple parameters in alarm algorithms, would be effective at reducing false alarms (72%, n = 117) (Q14), and would improve clinical response to important alarms (71%, n = 115) (Q15). This was Please cite this article in press as: Casey, S., et al. Critical care nurses’ knowledge of alarm fatigue and practices towards alarms: A multicentre study. Intensive & Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.05.004 S. Casey et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx significantly related to knowledge of alarm fatigue prevention (70%, n = 54 vs. 30%, n = 23), v2 (4) = 10.81 p = 0.029. The item achieving the lowest agreement level (18%, n = 29) ranking 19th, stated that newer monitors had solved most problems experienced with clinical alarms (Q7). This was significantly related to alarm fatigue prevention knowledge (24%, n = 19 vs. 24%, n = 59), v2 (4) = 11.40, p = 0.022. Too many false alarms The second, third, and seventh highest level of agreement in order, was that nuisance alarms are frequent (Q3) (90%, n = 148), disruptive to patient care (Q4) (91%, n = 145), and reduced trust in alarms causing nurses to disable alarms (Q5) (81%, n = 132). The frequency of false alarms causing a subsequent reduced attention and response to alarms was ranked the number one obstacle to effective alarm management (1–9 Scale). Staffing Nurses agreed (76% n = 123) that clinical staff were sensitive to alarms and responded quickly (Q10). However, nurses ranked ‘inadequate staff to respond to alarms as they occur’ in 2nd place (Q6, 1–9 scale) while over-reliance on alarms to alert staff to patient problems was ranked 3rd (Q7, 1–9 scale). Alarm related patient adverse events Just over half of participants (54%, n = 88) had knowledge of adverse patient events related to clinical alarms (Q20). Significantly more nurses from Site A (95%, n = 71) were aware of previous adverse events when compared to other sites (19%, n = 17), v2 (2) = 93, p  0.001. Although not statistically significant, (v2 (2) = 4.559, p = 0.102), among the 71 nurses from Site A who confirmed their hospital had experienced adverse patient events related to clinical alarms, 37% (n = 26) did not know or were unsure how to prevent alarm fatigue. Discussion To our knowledge, only one other European study (Joshi et al., 2017) reports on critical care nurses’ practices toward alarms. The findings of this study suggest that more education on prevention of alarm related adverse events is needed across all hospital sites. International literature suggests that practitioners are often unaware of the intricacies of monitors (ACCE, 2007; Borowski et al., 2011; Harris et al., 2011) and tend to underestimate their knowledge deficits (ACCE, 2007). Even experienced nurses need ongoing education regarding medical devices (AACN, 2013; Cvach et al., 2013). The level of agreement for the Likert scale questions (Table 3) are similar to those reported by ICU nurses isolated from HTF surveys conducted in the US (Korniewicz et al., 2008; Funk et al., 2014), and Cho et al’s (2015) study in South Korea. The vast majority of ICU nurses from these aforementioned studies responded that alarms should indicate alarm priority. Frequent false alarms causing a subsequent reduced attention or response to alarms was ranked number one across all samples. Difficulty understanding the priority of an alarm was ranked in the top four across all studies. Inadequate staff to respond to alarms was ranked number two in our study and number three in the Korean study (Cho et al., 2015) and number six among the HTF ICU nurses (Korniewicz et al., 2008; Funk et al., 2014). This study demonstrates that nurses perceive alarm fatigue from high alarm load, frequent inactionable alarms, alarm flood and poor alarm design which feature commonly in Irish critical 5 care departments. Respondents agreed unanimously that alarm sounds or visual displays should indicate alarm priority. However, alarm alerts which do not match the criticality of the situation are well documented in the literature (Mondor and Finley, 2003; Momtahan et al., 2007; Schmid et al., 2013). Often they are difficult to localise or discriminate their level of urgency or priority (Edworthy and Helier, 2005). Matching alarm priority to the clinical situation is recommended by ECRI (2015). However, alarm alerts which do not match the criticality of the situation continues to be an issue (Edworthy, 2013). Alarm loads from physiological monitors at site A had been reported as 30,000 per week between ICU and HDU (17 beds) (Geraghty, 2015). This equals approximately one alarm every 20 s from the monitor alone which is classified as an alarm flood. Alarm flood is defined by the American National Standards Institute/International Society of Automation ANSI/ISA 18.2 as ‘‘10 or more annunciated alarms in any 10 min period per operator”. Alarm floods are classified as extremely hazardous and undesirable by other high-risk industries. In this study, most nurses felt that non-actionable alarms occurred frequently and that they disrupted patient care. Although it is known that most alarms are non-actionable, Paine et al. (2016) conclude that there appears to be a relationship between alarm exposure and response time that could be caused by alarm fatigue. However, it is not known which interventions are the most effective in reducing the number of unnecessary alarms safely (Paine et al., 2016). This study and others (Cho et al., 2015; Korniewicz et al., 2008; Funk et al., 2014) report that the majority of nurses agreed that alarms are being disabled due to trust erosion in the alarm system. Moreover, this study provides evidence that adverse events related to clinical alarms are occurring, as all sites studied reported patient adverse events related to clinical alarms. However, given that alarm fatigue is a complex, multifactorial problem, examination of associated sentinel events requires a broad outlook defining circumstances that contribute to its development. Limitations The study was confined to the West of Ireland limiting generalisability of findings. Furthermore, site A is distinctly different from the other sites, as it is significantly larger and is the only model 4 hospital in the region. Moreover, the adoption of recommended ECRI alarm management practices within critical care departments is unique to this site. Additionally, two alarm-related deaths had occurred in the department at Site A within the previous five years, hence the heightened awareness of nurses working at this Site likely influenced the results. Also, the first author worked in Centre A, and although attempts were made to prevent introduction bias, this may have influenced the results. The HFT survey assesses nurses’ perceived views of alarm management in their area rather than the actual occurrence of alarm fatigue in clinicians. Moreover, the psychometric properties of the HTF instrument have not been rigorously tested or evaluated, however, Torabizadeh et al. (2016) report good internal homogeneity and retest methods for their new tool which measures alarm fatigue. Conclusion The full extent of alarm fatigue has not been properly considered outside the US. In this study, nurses perceive that the antecedents of alarm fatigue are prevalent in West of Ireland critical care areas. Nurses reported a knowledge deficit regarding alarm fatigue prevention despite reports of adverse patient events from all sites. Please cite this article in press as: Casey, S., et al. Critical care nurses’ knowledge of alarm fatigue and practices towards alarms: A multicentre study. Intensive & Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.05.004 6 S. Casey et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx Alarm fatigue has profound consequences for patient safety with the worst-case scenario resulting in death or serious patient harm. An environment of excessive alarms is conducive to error. Moreover, the burden of responding to numerous non-actionable alarms drains nursing resources. Future research should focus on identifying levels of alarm fatigue among critical care nurses and evaluating education and training approaches to manage alarm fatigue. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflicts of interest The primary author is a practicing staff nurse at one of the study sites included in the research. The authors whose names are listed immediately below certify that they have NO affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patentlicensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript. Author names: Siobhán Casey, Gloria Avalos, Maura Dowling. Acknowledgements Dr. David S Evans – Senior Research Officer, Department of Public Health Merlin Park Hospital Galway (Statistics support). Dr. Kristopher Fennie PhD, Florida International University, Miami Florida, Dr. Marjorie Funk, RN, PhD, Yale University School of Nursing (HTF Clinical Alarms 2011, 2006, Survey Data). Kim HwaSoon PhD, RN, Professor, Department of Nursing, Inha University Incheon, Korea (Data for Ok Min Cho et al., 2016 Clinical Alarms Survey South Korea doi: 10.4258/hir.2016.22.1.46. Dr. R.L. Wears M.D, Ph.D., M.S Professor of Emergency Medicine, University of Florida. Special Interest; Patient Safety (Patient Safety advice). References Alsaad, A.A., Alman, C.R., Thompson, K.M., Park, S.H., Monteau, R.E., Maniaci, M.J., 2017. A multidisciplinary approach to reducing alarm fatigue and cost through appropriate use of cardiac telemetry. Postgrad. Med. J. 93 (1101), 430–435. https://doi.org/10.1136/postgradmedj-2016-134764. 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Electrocardiol. 45 (6), 588–591. Korniewicz, D.M., Clark, T., David, Y., 2008. A national online survey on the effectiveness of clinical alarms. Am. J. Crit. Care 17 (1), 36–41. Mondor, T.A., Finley, G.A., 2003. The perceived urgency of auditory warning alarms used in the hospital operating room is inappropriate. Can. J. Anesthesia 50 (3), 221–228. Momtahan, K., Hétu, R., Tansley, B., 2007. Audibility and identification of auditory alarms in the operating room and intensive care unit. Ergonomics 36 (10), 1159–1176. Paine, C.W., Goel, V.V., Ely, E., Stave, C.D., Stemler, S., Zander, M., Bonafide, C.P., 2016. Systematic review of physiologic monitor alarm characteristics and pragmatic interventions to reduce alarm frequency. J. Hospital Med. 11 (2), 136–144. Petersen, E.M., Costanzo, C.L., 2017. Assessment of clinical alarms influencing nurses’ perceptions of alarm fatigue. Dimensions Crit. Care Nurs. 36 (1), 36–44. Ruppel, H., Funk, M., Clark, J.T., Gieras, I., David, Y., Bauld, T.J., Coss, P., Holland, M.L., 2018. Attitudes and practices related to clinical alarms: a follow-up survey. AJCC Am. J. Crit. Care 27 (2), 114–123. Schmid, F., Goepfert, M.S., Reuter, D.A., 2013. Patient monitoring alarms in the ICU and in the operating room. Crit. Care 17 (2), 216. Sendelbach, S., Funk, M., 2013. Alarm fatigue: a patient safety concern. AACN Adv. Crit. Care 24 (4), 378–386. Siebig, S., Kuhls, S., Imhoff, M., Gather, U., Schölmerich, J., Wrede, C.E., 2010. Intensive care unit alarms-how many do we need? Crit. Care Med. 38 (2), 451– 456. Sowen, A., Tarriela, A.F., Gomez, T.M., Reed, C.C., Rapp, K.M., 2015. Nurses’ perceptions and practices toward clinical alarms in a transplant cardiac intensive care unit: exploring key issues leading to alarm fatigue; JMIR. Hum. Factors 2 (1), e3. Torabizadeh, C., Yousefinya, A., Zand, F., Rakhshan, M., Fararooei, M., 2016. A nurses’ alarm fatigue questionnaire: development and psychometric properties. J. Clin. Monit. Comp. 31 (6), 1305–1312. Turmell, J.W., Coke, L., Catinella, R., Hosford, T., Majeski, A., 2017. Alarm fatigue: use of an evidence-based alarm management strategy. J. Nurs. Care Qual. 32 (1), 47– 54. Varpio, L., Kuziemsky, C., MacDonald, C., King, W.J., 2012. The helpful or hindering effects of in-hospital patient monitor alarms on nurses: a qualitative analysis. Comp. Inform. Nurs. 30 (4), 210–217. Please cite this article in press as: Casey, S., et al. Critical care nurses’ knowledge of alarm fatigue and practices towards alarms: A multicentre study. Intensive & Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.05.004
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    Critical Appraisal of the Literature: Alarm Fatigue in Clinical Practice

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    Critical Appraisal of the Literature: Alarm Fatigue in Clinical Practice
    Alarm fatigue is defined as desensitization to alarms when healthcare providers like
    nurses and clinicians are exposed to numerous warnings resulting in sensory overload. It is a
    developing and growing severe problem worldwide in the healthcare systems, mainly brought by
    the medical field’s advanced technological advancements that have proven to pose a significant
    threat to a patient’s wellbeing (Casey, Avalos & Dowling, 2018). When nurses and clinicians
    become used to many physiological alarms per day, their central nervous system tends to become
    highly unresponsive to those specific alarms because the sensory threshold becomes too high.
    This degree of desensitization makes proper critical warnings be ignored. Therefore, the patient
    in question become negatively affected as they are not managed on time. This has become an
    emerging cause of hospital fatalities in the United States and other countries. Thus, the purpose
    of the study was to find out whether critical care nurses knew about alarm fatigue and the
    practices associated with alarms in critical care settings.
    A study was conducted among nurses in six hospitals in the west of Ireland. It was done
    to assess the critical care nurse’s awareness and knowledge of alarm fatigue. It also aimed to
    determine their practices towards alarm fatigue...


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