JMIR Publications

ABSTRACT

Background:

Alarm fatigue is the presence of, ‘frequent false alarms, leading to reduced response to alarms.’ Critical care areas provide ample opportunities for IV medication error with the frequent administration of high-alert, critical short half-life infusions that require rigorous maintenance for continuity of delivery. Most serious medication errors in critical-care occur during the execution of treatment, with performance level failures outweighing rule-based or knowledge-based mistakes. Appropriate and timely response to IV pump alarms is crucial to infusion continuity, and the difficulty for clinicians of filtering critical short half-life infusion (CSHLI) alarms from non-urgent alarms is a key challenge for risk-management.

Objective:

The objectives of the study were to establish baseline data for the types and frequency of alarms that critical care clinicians are exposed to from a variety of infusion devices: both large volume pumps and syringe drivers, to identify the volume of these alarms that specifically relate to CSHLIs, and to evaluate user response times to alarms from infusion devices delivering CSHLIs.

Methods:

The anonymized event logs of 1,183 infusion pumps used in critical-care environments and in general care areas within the European region over a period of 6,482 days were mined via Microsoft SQL Server Management Studio v17.9.1 for a range of alarm states. The study then focused on a selection of infusion alarms from devices delivering CSHLIs that would warrant rapid attention from clinicians in order to avoid potentially harmful prolonged infusion interruption. A third stage of alarm analysis was the interrogation of individual pump’s event logs to allow for an assessment of ‘first time’ reaction time to infusion-interruption states and alarms for the selected critical short half-life infusions via Date/Time Stamps where: Reaction Time [in secs] = [Time [hh:mm:ss] Issue Resolved and Pump Restarted] – [Time [hh:mm:ss] Pump Stopped and Alarm Triggered]

Results:

Initial analysis showed a mean average of 4.5 Alarms per Infusion in the general critical-care pump population as opposed to a Whole Hospital rate of 1.39. In the Pediatric Intensive Care Unit (PICU) group the Alarms per Infusion value was significantly above the mean average for all critical-care with 8.61 alarms per infusion. The ratio of Downstream Occlusion:Infusion Starts in the general critical-care pump population was 1.38 whilst in the Neonatal Intensive Care Unit (NICU) group it was 2.06. The study indicates how it is both possible to identify problematic areas of the hospital for potential alarm fatigue but also that particular issues of infusion and infusion line management can also be ascertained. Infusion-interruption of CSHLIs was found to be a significant problem in all areas of the general critical care pump population with End of Infusion and End of Syringe events being noted as well as a significant number of downstream [vein/access] occlusion events. Whilst the mean and median response times to CSHLI interruption were generally within the half-lives of the selected medications there was a high prevalence of outliers in terms of reaction times for all the critical short half-life infusions studied with some response times being longer than 6 and 13 minutes, or 5 to 6 times greater than the accepted plasma half-life of the concerned medication.

Conclusions:

The study gives a strong indication of what might be expected in critical care environments in terms of the volume of general infusion alarms, for the frequency of alarms and infusion interruptions for CSHLIs, and for clinician reaction times to CSHLI interruption events. It is posited that these values and the ability to easily assess ‘pre and post change’ through application of the proposed protocols is of value for the creation of benchmarks for pump alarm management and clinician reaction times, and for the construction of studies on the impact of ‘alarm fatigue’, and for the evaluation of protocols, infusion monitoring strategies, and infusion pump based medication safety software aimed at reducing alarm fatigue and ensuring the maintenance of CSHLIs. Given the frequency of infusion alarms seen in this study, the risk of alarm fatigue due to the ‘white noise’ of pump alarms present in critical care, and to which clinicians are constantly exposed, is very high. The doubling of the frequency of alarms in PICUs seen in this study as compared to those in general ICUs also warrants further investigation. Furthermore the added difficulties of maintaining critical short half-life infusions and other infusions in neonates are made clear by the NICU ratio of Downstream Occlusion:Infusion Starts which is almost fifty percent greater than that of the general critical-care pump population. Given that total non-infusion time of an infusion equals Time To Alarm + Reaction Time, sensitive and accurate infusion pump occlusion alarms and the ability to view alarms in dispersed locations, and to filter critical from non-critical alarms might be expected to reduce the Infusion Recovery Time (Time To Alarm + Reaction Time + Resolution) to clinically acceptable values for both general infusions and for CSHLIs. Whilst there are multiple variables in any study of alarm fatigue and infusion continuity the ability to quantitatively track the volume of alarms and CSHLI infusion alarm reaction times through easily applied SQL queries contributes to a greater understanding of the issues of alarm fatigue in ICU, can be applied to clinical audit, and can allow for targeted training to reduce nuisance alarms, and to aid in planning for improvement in the key area of maintenance of steady state plasma levels of CSHLIs. One clear conclusion must be that the Medication Administration ‘Rights’ should be extended to include ‘Right Maintenance’ and ensured delivery-continuity of CSHLIs.* SQL query code is presented in the paper which can be used by other users to interrogate the event logs of the particular pump types studied here via Microsoft SQL Server Management Studio v17.9.1. Comparison of the data and results of the current paper with the data from an NICU where central infusion monitoring was introduced and environmental changes were made indicates that the problems of alarm fatigue and critical short half-life vasoactive infusion interruption can be mitigated to as much as a 56.25% reduction in measured infusion alarms and a 31% reduction in reaction time to infusion alarms for CSHLIs.