<p><strong>BACKGROUND: </strong>Electrocardiographic telemetry monitors are ubiquitous in hospitals. Dedicated monitor watchers, either on the unit or in a centralized location, are often responsible for observing telemetry monitors and responding to their alarms. The impact of use of monitor watchers is not known.</p>

<p><strong>OBJECTIVES: </strong>To evaluate the association of monitor-watcher use with (1) nurses' knowledge of electrocardiographic (ECG) monitoring and (2) accuracy of arrhythmia detection.</p>

<p><strong>METHODS: </strong>Baseline data from 37 non-intensive care unit cardiac patient care areas in 17 hospitals in the Practical Use of the Latest Standards for Electrocardiography trial were analyzed. Nurses' knowledge (n = 1136 nurses) was measured using a validated, 20-item online test. Accuracy of arrhythmia detection (n = 1189 patients) was assessed for 5 consecutive days by comparing arrhythmias stored in the monitor with nurses' documentation. Multiple regression was used to evaluate the association of use of monitor watchers with scores on the ECG-monitoring knowledge test. The association of monitor-watcher use with accuracy of arrhythmia detection was examined by χ2 analysis.</p>

<p><strong>RESULTS: </strong>Of the 37 units, 13 (35%) had monitor watchers. Use of monitor watchers was not independently associated with ECG-monitoring knowledge (P = .08). The presence of monitor watchers also was not significantly associated with the accuracy of arrhythmia detection (P = .94).</p>

<p><strong>CONCLUSION: </strong>Although the use of monitor watchers was not associated with diminished nurses' knowledge of ECG monitoring, it also was not associated with more accurate arrhythmia detection. If implementing a monitor-watcher program, critical safety points, such as ensuring closed-loop communication, must be considered.</p>

<p><strong>BACKGROUND: </strong>Alarm fatigue threatens patient safety by delaying or reducing clinician response to alarms, which can lead to missed critical events. Interventions to reduce alarms without jeopardizing patient safety target either inaccurate or clinically irrelevant alarms, so assessment of alarm accuracy and clinical relevance may enhance the rigor of alarm intervention studies done in clinical units.</p>

<p><strong>OBJECTIVES: </strong>To (1) examine approaches used to measure accuracy and/or clinical relevance of physiological monitor alarms in intensive care units and (2) compare the proportions of inaccurate and clinically irrelevant alarms.</p>

<p><strong>METHODS: </strong>An integrative review was used to systematically search the literature and synthesize resulting articles.</p>

<p><strong>RESULTS: </strong>Twelve studies explicitly measuring alarm accuracy and/or clinical relevance on a clinical unit were identified. In the most rigorous studies, alarms were annotated retrospectively by obtaining alarm data and parameter waveforms rather than being annotated in real time. More than half of arrhythmia alarms in recent studies were inaccurate. However, contextual data were needed to determine alarms' clinical relevance. Proportions of clinically irrelevant alarms were high, but definitions of clinically irrelevant alarms often included inaccurate alarms.</p>

<p><strong>CONCLUSIONS: </strong>Future studies testing interventions on clinical units should include alarm accuracy and/or clinical relevance as outcome measures. Arrhythmia alarm accuracy should improve with advances in technology. Clinical interventions should focus on reducing clinically irrelevant alarms, with careful consideration of how clinical relevance is defined and measured.</p>

<p><strong>BACKGROUND: </strong>Alarm fatigue is a widely acknowledged patient safety concern in hospitals. In 2013, The Joint Commission issued a National Patient Safety Goal on Alarm Management, making addressing alarm management a priority. To capture changes in attitudes and practices related to alarms, the Healthcare Technology Foundation conducted and reported findings from national online surveys in 2006 and 2011 and completed a third survey in 2016.</p>

<p><strong>OBJECTIVES: </strong>The goal of the 2016 survey was to identify how hospital practices and clinicians' perceptions of alarms have changed since 2006.</p>

<p><strong>METHODS: </strong>The online survey was distributed via national health care organizations during a 2-month period. Results of the 2016 survey (N = 1241) were compared with results of the 2006 and 2011 surveys by using χ and Kruskal-Wallis analyses.</p>

<p><strong>RESULTS: </strong>Responses were significantly different for almost all items across the 3 surveys. Respondents in 2016 were more likely to agree that nuisance alarms occur frequently and disrupt patient care and were less likely to agree that clinical staff responds quickly to alarms. Compared with respondents in 2011, those in 2016 were almost twice as likely to report that their hospitals had experienced adverse events related to alarms in the past 2 years. However, in 2016 a much higher proportion of respondents indicated that their hospitals had implemented alarm improvement initiatives.</p>

<p><strong>CONCLUSIONS: </strong>Although survey findings show disappointing trends in the past 10 years, including worsening perceptions of nuisance alarms and more alarm-related adverse events, the increase in alarm improvement initiatives is encouraging.</p>

<p>Nurses are the end-users of most technology in intensive care units, and the ways in which they interact with technology affect quality of care and patient safety. Nurses' interactions include the processes of ensuring proper input of data into the technology as well as extracting and interpreting the output (clinical data, technical data, alarms). Current challenges in nurse-technology interactions for physiologic monitoring include issues regarding alarm management, workflow interruptions, and monitor surveillance. Patient safety concepts, like high reliability organizations and human factors, can advance efforts to enhance nurse-technology interactions.</p>

<p><strong>BACKGROUND: </strong>Clinicians in intensive care units experience alarm fatigue related to frequent false and non-actionable alarms produced by physiologic monitors. To reduce non-actionable alarms, alarm settings may need to be customized for individual patients; however, nurses may not customize alarms because of competing demands and alarm fatigue.</p>

<p><strong>OBJECTIVE: </strong>To examine the effectiveness and acceptance of physiologic monitor software to support customization of alarms.</p>

<p><strong>METHODS: </strong>This pre/post intervention study was conducted in a 56-bed medical intensive care unit. IntelliVue® Alarm Advisor customization support software for alarm limit violations was installed on all monitors and education on its use provided. For 2 months before and after implementation of the software, data were collected on patient characteristics from the electronic health record, alarm counts and duration from the monitoring system, and nurses' experience of alarms from a survey.</p>

<p><strong>RESULTS: </strong>Medium-priority heart rate, respiratory rate, and arterial pressure alarms were significantly reduced after software implementation (9.3%, 11.8%, and 15.9% reduction respectively; p&lt;0.001 for all). The duration of these alarms was also significantly shorter (7.8%, 13.3%, and 9.3% reduction respectively; p&lt;0.05 for all). The number and duration of SpO2 alarms did not decrease (p&gt;0.05 for both). Patients post-intervention had worse Glasgow Coma Scale scores (p = 0.014), but otherwise were comparable to those pre-intervention. Nurses reported less time spent on non-actionable alarms post-intervention than pre-intervention (p = 0.026). Also lower post-intervention were the proportions of nurses who reported that alarms disturbed their workflow (p = 0.027) and who encountered a situation where an important alarm was ignored (p = 0.043). The majority (&gt;50%) agreed that the software supported setting appropriate alarm limits and was easy to use.</p>

<p><strong>CONCLUSION: </strong>Alarm customization software was associated with a reduction in alarms. Use of software to support nurses' recognition of trends in patients' alarms and facilitate changes to alarm settings may add value to alarm reduction initiatives.</p>

<p><strong>AIM AND OBJECTIVE: </strong>The purpose of this study was to explore clinical reasoning about alarm customization among nurses in intensive care units.</p>

<p><strong>BACKGROUND: </strong>Critical care nurses are responsible for detecting and rapidly acting upon changes in patients' clinical condition. Nurses use medical devices including bedside physiologic monitors to assist them in their practice. Customizing alarm settings on these devices can help nurses better monitor their patients and reduce the number of clinically irrelevant alarms. As a result, customization may also help address the problem of alarm fatigue. However, little is known about nurses' clinical reasoning with respect to customizing physiologic monitor alarm settings.</p>

<p><strong>DESIGN: </strong>This article is an in-depth report of the qualitative arm of a mixed methods study conducted using an interpretive descriptive methodological approach.</p>

<p><strong>METHODS: </strong>Twenty-seven nurses were purposively sampled from three intensive care units in an academic medical center. Semi-structured interviews were conducted by telephone and were analyzed using thematic analysis. Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guidelines were used.</p>

<p><strong>RESULTS: </strong>Four themes were identified from the interview data: unit alarm culture and context, nurse attributes, motivation to customize, and customization "know-how." A conceptual model demonstrating the relationship of these themes was developed to portray the factors that affect nurses' customization of alarms.</p>

<p><strong>CONCLUSIONS: </strong>In addition to drawing on clinical data, nurses customized physiologic monitor alarms based on their level of clinical expertise and comfort. Nurses were influenced by the alarm culture on their clinical unit and colleagues' and patients' responses to alarms, as well as their own technical understanding of the physiologic monitors.</p>

<p><strong>RELEVANCE TO CLINICAL PRACTICE: </strong>The results of this study can be used to design strategies to support the application of clinical reasoning to alarm management, which may contribute to more appropriate alarm customization practices and improvements in safety. This article is protected by copyright. All rights reserved.</p>

<p><strong>BACKGROUND: </strong>Customizing monitor alarm settings to individual patients can reduce alarm fatigue in intensive care units (ICUs), but has not been widely studied.</p>

<p><strong>OBJECTIVES: </strong>To understand ICU nurses' approaches to customization of electrocardiographic (ECG) monitor alarms.</p>

<p><strong>METHODS: </strong>A convergent mixed methods study was conducted in 3 ICUs in 1 hospital. Data on the type and frequency of ECG alarm customization were collected from patient monitors (n=298). Nurses' customization clinical reasoning was explored through semi-structured interviews (n=27).</p>

<p><strong>RESULTS: </strong>Of the 298 patients, 58.7% had ≥1 alarm(s) customized. Heart rate limits, irregular heart rate, and atrial fibrillation were the most commonly customized alarms. Interviews revealed that customization practices varied widely and were influenced by factors including clinical expertise, lack of customization education, and negative experiences.</p>

<p><strong>CONCLUSION: </strong>Alarm customization is nuanced and requires adequate support to develop safe and effective practices. The challenges identified can inform development of strategies to improve alarm customization.</p>