8/30/2021

Alarm Fatigue Data

Overview
Betty Miller

Background

Sentinel event reviewed at ED CRC event found alarms to be a contributing factor

Alarm fatigue project proposed to EMERGE committee

• Bedside staff ownership is essential

Literature review and data collection completed, ready for next steps

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Audit Form

Definitions

Tone Type
• High alert = red alarm 
• Warning= yellow or blue alarm

Alarm Type
• Real Alarm = Alarm accurately displays the parameter 
• False Alarm = Nuisance alarm that is not accurately displaying the parameter (i.e. artifact reading as VT) 
• InOp Alarm = Related only to monitor functionality, (i.e. pulse ox off)

Clinically relevant = Alarm is accurately displaying parameter and requires clinical intervention (ie. sepsis pt is 

hypotensive)

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Data Overview:

ED observed for a total of 396 minutes (6.6 hours)

- In one zone at a time

276 total alarms recorded - 41 alarms per hour per zone

Alarm Types

53% of alarms are “in-op” alarms; 19% are false alarms

Of the real alarms, 36% are clinically relevant
ECG, SpO2, & BP account for the highest number of in-op and false alarms

ALARM TYPE CLINICALLY RELEVANT?

28%

36%

InOp Alarm
No (not clinically relevant)
No (false alarm)
53% Yes (clinically relevant)
Yes (real alarm)

64%

19%

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Alarm Type by Parameter

100

90

80

70

60

Yes (real alarm)

50
No (false alarm)
InOp Alarm
40

30

20

10

0
BP ECG EtCO2 HR Other RR SpO2

InOp Reason by Parameter

BP InOp Alarms ECG InOp Alarms SpO2 Inop Alarms

35 35 60

4b - Cannot 1b - REUSABLE
analyze SpO2 not sensing
30 30 QT/ST/ECG 50

25 25
40 1c - SpO2
2c - BP cuff too STICKER not
LARGE sensing
20 20 4d - Cardiac
lead
disconnected 30
2e - BP cuff/cable
15 disconnected 15
1d - Spo2 not on
finger
20
10 10
4e - Patient
movement/artif
act 10 1e - SpO2 on same
5 5
side as BP cuff

0 0 0
InOp Alarm ECG InOp Alarm
BP InOp Alarm SpO2

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Alarm Type by Parameter

160

140 SpO2

120 RR

100 Other

80 HR

60 EtCO2

ECG
40

BP
20

0
InOp Alarm No (false alarm) Yes (real alarm) Yes (real alarm)
N/A No (not clinically relevant) Yes (clinically relevant)

Parameters

NOT CLINICALLY RELEVANT ALARMS

CLINICALLY RELEVANT ALARMS 7b - Parameters
incorrect for 2b -
clinical HYPERtension
condition 3a - Bradycardia
1a - Desat
2a - HYPOtension 14% 6b - LOW
18% ETCO2

6a - HIGH
ETCO2
3a - Bradycardia
7% 3b - Tachycardia
5b -
Apnea/Bradypne
a
5a - Tachypnea
11%

4a - Arrhythmia
14% 5a - Tachypnea
3b - Tachycardia
36%

4a - Arrhythmia

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Staff Response

25% of alarms are repeat alarms

Almost half of alarms were either silenced or ignored

INTERVENTION
REPEAT ALARMS
14%
20%

25%
Fixed

No action (continued to
alarm)
No (new alarm)
Self-resolved
Yes (repeat alarm) 28%
Silenced

75% 38%

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Intervention by Alarm Type

100%

90%

80%

70%

60%

Silenced
50%
Self-resolved
No action (continued to alarm)

40% Fixed

30%

20%

10%

0%
InOp Alarm No (false alarm) Yes (real alarm) Yes (real alarm)
N/A No (not clinically relevant) Yes (clinically relevant)

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Intervention by Parameter

BP ALARM INTERVENTION ECG ALARM INTERVENTION SPO2 ALARM INTERVENTION

Fixed 11%
15%
18% 22% 20%
Fixed Fixed
35% No action
5% (continued to No action (continued No action (continued
alarm) 26% to alarm) to alarm)
Self-resolved Self-resolved
Self-resolved
Silenced 33% Silenced
32%
Silenced
42% 41%

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