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Clinical alarms: friend or foe to the laboring couple.

Holistic care during the labor process is an expectation for many couples. This care delivery model incorporates the mind, body and spirit in order to promote health and healing (Brenner, 2013). This type of approach integrates the total human being with traditional healthcare models to enhance patient healing, self-care, responsibility, and reflection into the patient's experience. Utilizing the holistic approach, labor and delivery clinicians strive to promote a tranquil environment free of unnecessary distractions for reflection, concentration, and a positive birth experience.

The delivery of a child is often a happy and stressful time. Both parents are anxious and anticipating a positive birth experience. The health of the mother and baby is top priority. Clinicians strive to use critical thinking, skill, and judgment to provide a safe delivery. During this process, maternal and fetal monitoring equipment is used to provide clinical updates of mother and baby. These updates often result in a tone or alarm that occurs at the bedside. The sounding of these alarms varies by patient condition and individual alarm settings. This variability can lead to frequent alarm sounds throughout the labor experience. These alarms can be a source of confusion or concern for both parents and family awaiting arrival of a new infant and lead to questioning whether or not alarms are overused. Jo and Paul (2012) reported 83% of alarms were false. This increased stimulation and in-room noise can be a source of anxiety for parents and potentially decrease their overall satisfaction, minimizing holistic care efforts.

The use of clinical alarms in high risk areas such as labor and delivery is mandated by regulatory agencies (Jo & Paul, 2012). These alarms are used to alert care providers of changes in patient condition and potentially life threatening issues. Each alarm must be analyzed by the nurse to determine its significance. Significant alarms often require action by the nurse. This action could include the adjusting of an alarm parameter, addition or adjustment of a medication, or securing a patient device. Nuisance alarms are deemed clinically insignificant by the nurse (Jo & Paul, 2012). While these alarms require no action, alarm tones are the same as other alarms and cause increased stimulation, anxiety, and excess noise for the laboring family.

Alarm volume is also a regulatory concern. While alarm volume is an irritant for the laboring mother, inadequate alarm volume is a noted contributing factor in many failure to rescue events including death (Keller, Diefes, Graham, Meyers, & Pelczarski, 2011). Current regulatory standards insist that alarm volume be audible in room and within the perimeter of adjacent rooms (Shah, 2011). This audibility strengthens the likelihood of clinician response and intervention. While many laboring parents understand the necessity of these alarms, the in-room volume can be perceived as disruptive and can produce increased anxiety regarding the birth process and health of mother and baby.

False or nuisance alarms are the most significant sources of alarms in the clinical environment (Harris, Manavizadeh, McPherson, & Smith, 2011). These alarms are irritants but also can threaten a patient's safety. While some nuisance alarms are inevitable, clinicians are more likely to ignore alarms when there is a high rate of these alarms. As a result, alarm related deaths are increasing (Jo & Paul, 2012; Keller et al., 2011). The Emergency Care Research Institute rated alarm hazards as number one on its annual list of priorities because of an increased number of adverse events (Keller et al., 2011). To date, the Joint Commission also urges leaders to re-evaluate alarm management strategies in order to strengthen alarm protocols, decrease nuisance alarms, and ultimately prevent harm (Freeman, 2010a). These strategies will also increase patient experience and potentially enhance the tranquility of the holistic environment.

Nurses also experience increased anxiety and stress related to alarms. This condition, coined alarm fatigue, occurs when clinicians are exposed to excessive noise or disruption (Phillips & Barnsteiner, 2005). This excessive stimulation leads to alarm desensitization and the potential for an adverse event. In a large progressive care unit, Talley et al. (2011) reported 942 alarms per day occurred constituting a different alarm sounding every 90 seconds. While the number of alarms differs by specialty, this volume of ringing alarms causes chaos in any environment.

Patients and family members also experience uncertainty regarding excess stimulation during the birth process. While the majority of the literature focuses on clinicians, the risk of irritation, overstimulation, and fatigue with laboring patients and family members because of alarms is also a noteworthy concern. This increase in noise and activity leads to uncertainty regarding mother and baby well-being, questions the competency of labor and delivery staff, decreases patient satisfaction, and likely diminishes holistic care efforts during this time.

Clinical Application

The use of clinical alarms must be purposeful and consistent with good nursing practice in order to prevent harm and create minimal interruptions for patients. An alarm management program is the best approach used to decrease irritation and fatigue related to clinical alarms (Shah, 2011). This program can be implemented in any clinical area performing patient monitoring. Goals of the alarm management program include developing unit specific alarm standards, increasing awareness and knowledge of clinical alarms and potential dangers, and ultimately reducing nuisance alarms. These goals will decrease environmental noise, promote a more tranquil holistic environment, and decrease stress and anxiety for patients and clinicians.

Alarm Standards

Alarm standards provide expectations of practice for clinicians. Standards are evidence-based and customized to a particular unit or clinical monitoring area. A unit based multidisciplinary team approach should be used when reviewing and establishing alarm standards. Members of this team should include all groups of clinicians that interact with patient monitoring equipment. First, current alarm data should be reviewed to ensure alarms are clinically relevant and appropriate to the labor and delivery area (Bell, 2010). These data can be retrieved by the facility biomedical engineering department. It is helpful to obtain at least 24 hours of historical alarm data in order to obtain a clear understanding of alarm ranges and occurrences. Frequency of alarms should be reviewed and adjusted according to required nursing action and severity of alarm (Graham & Cvach, 2010). All alarm ranges should be evaluated for significance and relevance. Alarms that require no nursing action should be set for notification only and not with an audible alarm. Finally, unit based alarm standards should be evaluated by hospital staff on a quarterly basis to make sure they are clinically relevant with the current population (Shah, 2011). If alarms are not relevant, but simply a nuisance, they may be removed. Conversely, if the alarms are relevant and are necessary for patient safety, clinicians should act upon them as directed by hospital policy and customize if needed according to patient situation.

Staff and Patient Education

Ongoing staff education regarding alarm management is necessary to provide clinicians with knowledge and skills to decrease nuisance alarms providing a safer, less stressful environment for the laboring family (Graham & Cvach, 2010). Alarm management training should be provided upon initial employment and annually (Korniewicz, Clark, & David, 2008). This training should include current unit protocols, any alarm standardization efforts, methods to decrease nuisance alarms and any bedside monitoring equipment updates. In addition, alarm drills should be randomly scheduled to observe alarm volume and clinician response after an alarm is triggered (Graham & Cvach, 2010).

Patient education regarding alarms should also be considered (Graham & Cvach, 2010). Alarm management awareness should be incorporated into any pre-delivery education and reiterated again during the hospital admission process. Areas of emphasis for the laboring couple include awareness and purpose of patient monitoring during the birth process; expectations regarding alarm volume and in-room sounds; and length of time patient monitoring will ensue. Awareness of alarm necessity, sound, and time frame will set expectations with the laboring couple, ultimately providing decreased anxiety and a more positive birth experience.

Reduction of Nuisance Alarms

Nuisance alarms can result in desensitization. Increased numbers of these alarms can lead to delayed action by the nurse the next time the monitor alarm triggers. Nuisance alarms are also irritants for the laboring family. Reduction in these alarms decreases patient anxiety and excess in-room noise and ultimately provides a safer, more holistic environment for the birth of a child. Strategies to reduce nuisance alarms are often set into motion at the bedside (Yoder & Phillips, 2010). These strategies include the following: (1) Never silence alarms without first checking on the patient, and always perform alarm customization when appropriate while silencing an alarm; (2) Analyze alarm parameters to determine if they are set to levels accurate for the patient; (3) Discharge each patient from bedside monitors upon discharge from the room, unit, or facility; (4) Customize alarms according to patient condition (Yoder & Phillips, 2010), and perform these changes when assuming care of patients, after shift changes, and after patients are transferred; and (5) Listen for sounding alarms on the unit, and take action accordingly (Freeman, 2010b). Take steps to silence alarms and educate patients regarding alarms, their clinical significance, and strategies undertaken to avoid excess alarms (Weil, 2009).

Advice for Educators

Although clinical alarms are necessary, the mishandling of alarms can increase anxiety and ultimately put patients at risk. Nurse educators should be participating in unit based alarm initiatives and be passionate about reducing excess noise decreasing anxiety for the laboring couple. Educators should also assist nurse leaders in screening and introducing new equipment after thorough consideration of application and alarm duplication. Also, educators must ensure that each staff member understands the purpose and significance of clinical alarms. In conjunction with nurse leaders, educators must complete purposeful rounding to assist staff in identifying and standardizing alarm parameters for individual patients. This will provide an immediate feedback and one-on-one staff education and insight into the realm of clinical Clinical Alarms: Friend or Foe to the Laboring Couple alarms. Finally, educators should ensure that patients and families are well informed regarding clinical alarm purpose and sounds in order to promote a safer, positive clinical experience for everyone in the laboring family.

References

Bell, L. (2010). Monitor alarm fatigue. American Journal of Critical Care, 19(1), 38. doi:10.4037/ajcc2010641

Brenner, H. (2013). The center for holistic birth: An organized step back in time when birthing worked. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing, 42(Si), S24-S25. doi:10.iiii/1552-6909.12082

Freeman, G. (2010a). Clinical alert fatigue threatens patient safety. Healthcare Risk Management, 32(9), 101-103.

Freeman, G. (2010b). Take these steps to reduce alert fatigue. Healthcare Risk Management, 32(9), 103.

Graham, K. C., & Cvach, M. (2010). Monitor alarm fatigue: Standardizing use of physiological monitors and decreasing nuisance alarms. American Journal of Critical Care, 19(1), 28-35. doi: 10.4037/ajcc2010651

Harris, R. M., Manavizadeh, J., McPherson, D. J., & Smith, L. (2011). Do you hear bells? The increasing problem of alarm fatigue. Pennsylvania Nurse, 66(1), 10-13.

Jo, M. S., & Paul, R. B. (2012). Managing alarm fatigue in cardiac care. Progress in Pediatric Cardiology, 33, 85-90. doi: 10.1016/j.ppedcard.2011.12.014

Keller, J. P., Diefes, R., Graham, K., Meyers, M., & Pelczarski, K. (2011). Why clinical alarms are a "top ten" hazard: How you can help reduce the risk. Biomedical Instrumentation & Technology, 45, 17-23. doi: 10.2345/08998205-45.s1.17

Korniewicz, D. M., Clark, T., & David, Y. (2008). A national online survey on the effectiveness of clinical alarms. American Journal of Critical Care, 17(1), 36-41.

Shah, R. (2011). On alert! Maximizing performance of hospital clinical alarms. Health Facilities Management, 24(11), 23-27.

Talley, L. B., Hooper, J., Jacobs, B., Guzzetta, C., McCarter, R., Sill, A., & Wilson, S. L. (2011). Cardiopulmonary monitors and clinically significant events in critically ill children. Biomedical Instrumentation &Technology, 45, 38-45. doi: 10.2345/0899-8205-45.s1.38

Weil, K. M. (2009). Alarming monitor problems. Nursing, 39(9), 58. doi:10.1097/01.NURSE.0000360252.10823.b8

Yoder, V. J., & Phillips, A. (20m). Patient safety focus. Alarm management: Clinical perspective. Biomedical Instrumentation & Technology, 44(2), 152-153.

by Richard C Meeks, DNP RN COI

Dr. Meeks is an Assistant Professor of Nursing at Middle Tennessee State University teaching in the graduate and undergraduate programs. His research interests include clinical alarms, childhood obesity, health disparities, and other issues within aggregate populations.
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Author:Meeks, Richard C.
Publication:International Journal of Childbirth Education
Article Type:Report
Date:Oct 1, 2014
Words:2023
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