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. 2023 Apr 26;10(8):5531–5540. doi: 10.1002/nop2.1792

Intensive care unit nurses' perceptions and practices regarding clinical alarms: A descriptive study

Lei Wang 1, Wei He 2, Yulu Chen 3, Qiuping Wu 4, Xin Du 5, Qin Li 6, Caiping Song 7,✉
PMCID: PMC10333838  PMID: 37101342

Abstract

Aim

To describe the frequencies of physiologic monitor clinical alarms and to investigate nurses' perceptions and practices regarding clinical alarms in ICUs.

Design

A descriptive study.

Methods

A 24‐h continuous nonparticipant observation study was conducted in ICU. Observers observed and recorded the occurrence time, detail information when electrocardiogram monitor alarms triggered. And a cross‐sectional study was conducted among ICU nurses by convenience sampling, using the general information questionnaire and the Chinese version of clinical alarms survey questionnaire for medical devices. Data analysis was performed using SPSS 23.

Results

A total of 13,829 physiologic monitor clinical alarms were recorded in 14‐day observation and 1191 ICU nurses responded to the survey. Most nurses agreed or strongly agreed the sensitivity to alarms and responded quickly (81.28%), smart alarm systems (74.56%), alarm notification systems (72.04%) and set up alarm administrators (59.45%) were useful to improve alarm management, while frequent nuisance alarms disrupted patients care (62.47%) and reduced nurses' trust in alarms (49.03%), environmental noise interfered with nurses' recognition of the alarms (49.12%) and not everyone received education of alarm systems (64.65%).

Conclusions

Physiological monitor alarms occur frequently in ICU, and it is necessary to formulate or further optimize alarm management measures. It is recommended to use smart medical devices and alarm notification systems, formulate and implement standardized alarm management policies and norms, and strengthen alarm management education and training, so as to improve the nursing quality and patient safety.

Patient or Public Contribution

The patients in the observation study included all patients admitted to the ICU during the observation period. The nurses in the survey study were conveniently selected through an online survey.

Keywords: alarm management, clinical alarm, intensive care unit, nurse, patient safety, physiological monitor

1. INTRODUCTION

The intensive care unit (ICU) is a place for centralized monitoring and intensive treatment of critically ill patients. Ventilators, physiological monitors and infusion pumps are commonly used as medical devices to guide medical staff in making clinical decisions and providing safe treatment and nursing for patients. With the rapid development of critical care medicine, medical devices with alarm functions have increased nearly fourfold during the past 30 years, from approximately 10 to almost 40 in the ICU (Hayhurst, 2020), and medical device clinical alarms occur frequently. Clinical alarms are the warning signal issued when the patient's condition is or may be deteriorating, and the staff needs to be notified to deal with it (Sendelbach & Funk, 2013). Drew et al. (2014) collected approximately 2.55 million physiological monitor alarms from 5 adult ICUs in 31 days using automatic storage devices. An earlier study reported that the number of alarms equated to 942 alarms per day or 1 critical alarm every 92 s in the ICU (Graham & Cvach, 2010).

Frequent clinical alarms can make the ICU environment noisy and even lead to noise pollution. The World Health Organization (WHO) recommends that the noise level of hospital wards should not exceed 35 dB during the day and 30 dB at night (Berglund et al., 2000). Dutch researchers found that the 24‐h average noise level in the ICU was 55.4 ± 5.7 dB (Vreman et al., 2020), and Chinese scholars have found that 24‐h noise levels in the ICU remain between 56.5 and 70.1 dB (Hu et al., 2016), which seriously exceed the recommended levels. The staff (57%), equipment alarms (30%) and equipment operations (13%) were the main sources of ICU noise (Park et al., 2014). Medical equipment alarms are one of the main sources of noise in hospitals; a large number of the loud sounds come from bedside alarm equipment, and bedside physiological monitors make the largest contribution (Darbyshire et al., 2019).

Physiological monitors can simultaneously monitor changes in vital signs such as a patient's pulse, respiration, blood pressure and oxygen saturation and can generate a large number of clinical alarms due to their high sensitivity and low specificity (Cvach et al., 2015). Korean researchers conducted an on‐site observation of 48 ICU nurses for 1 h and collected a total of 2184 alarms, of which the physiological monitor alarms accounted for 81.9% (Cho et al., 2016). Colombian researchers observed 120 h in the ICU and recorded a total of 5147 alarms, of which the physiological monitor alarms accounted for 52.8% that 37.3% were blood pressure, 33.4% oximetry and 29.3% heart rate (Andrade‐Méndez et al., 2020). Japanese researchers conducted a prospective and observational study and collected 11,591 physiological clinical alarms from 18 ICU patients, among which the most often were the direct measurement of arterial pressure (33.5%), oxygen saturation (24.2%), and electrocardiogram (22.9%) (Inokuchi et al., 2013). However, there are few studies on the occurrence of ICU medical equipment alarms in China. Due to the differences in cultural background, medical level, and medical staff structure in different countries especially in developing countries, it is necessary to conduct empirical studies in Chinese ICUs to fully understand the conditions.

In ICUs, nurses are the direct caregivers and must respond to clinical alarms. When ICU nurses are exposed to a working environment with frequent alarms for a long time, it not only interferes with nursing work but also creates pressure, produces negative emotions such as tension and anxiety and leads to alarm fatigue (Lewandowska et al., 2020). Alarm fatigue, a desensitization caused by excessive alarms, causes nurses to turn off or mute alarms and slowing their response times because a large number of nonactionable alarms causes nurses to lose trust in the alarms (Turmel et al., 2017). The results of a survey by Korean researchers showed that ICU nurses' alarm fatigue was at an upper middle level (Cho et al., 2016). A Turkish study pointed out that ICU medical equipment alarms have increased significantly and ICU nurses' alarm fatigue has also increased significantly during COVID‐19 (Akturan et al., 2022). Alarm fatigue has been regarded as a serious problem threatening patient safety in the digital age of medical technology; thus, it is imperative to establish a safe alarm management system, improve ICU nurses' awareness and ability to manage alarms, reduce ICU nurse alarm fatigue, and improve patient safety (Winters et al., 2021).

When ICU nurses lack the ability to manage the alarms and respond to them appropriately, it may lead to improper alarm setting or responses, and then they may omit, ignore or miss alarm signals, which could affect patient safety and even lead to patient death and other adverse events (The Joint Commission, 2013). It is imperative to establish a safe alarm management system, improve ICU nurses' awareness and ability of alarm management to improve patients' safety. The United States (US) Healthcare Technology Foundation (HTF) launched the national quality improvement programme to reduce the harm of clinical alarms in 2004 (Korniewicz et al., 2008), and completed three surveys in 2005–2006 (Korniewicz et al., 2008), 2011 (Funk et al., 2014) and 2016 (Ruppel, Funk, et al., 2018). However, the development of relevant assessment tools to understand the current status of alarm management in ICU and the ability of ICU nurses' alarm management in China is limited and lacks pertinence.

In 2003, the US listed improving the overall effectiveness of clinical alarms as one of the national patient safety goals, and related studies began to be widely discussed (Korniewicz et al., 2008). However, the discussion of clinical alarms started late in China, and medical device safety and alarm management were listed as one of the patient safety goals in 2019 (Chinese Hospital Association, 2019). Given the potential harm that a large number of clinical alarms signal and the differences in cultural backgrounds and medical standards between developed and developing countries, more localized studies are needed. Therefore, the purpose of this research was to conduct an observation study to understand the frequencies of clinical alarms in ICU physiological monitors in China and use a revised questionnaire of the HTF 2016 Clinical Alarms Survey to investigate the ICU nurses' perceptions and practices of clinical alarms to improve the safety management of alarms and further improve the quality of nursing and patient safety.

2. METHODS

2.1. Objectives

To describe the frequencies of physiologic monitor clinical alarms and to investigate nurses' perceptions and practices regarding clinical alarms in intensive care units.

2.2. Design

An observational study and a cross‐sectional study.

2.3. Setting

The 14‐day observational study was conducted in the Department of Critical Care Medicine ICU of a university hospital in Chongqing from China between 8:00 on January 25, 2021 and 8:00 on February 8, 2021 (according to the rich ICU work experiences of the head nurse and the director of the observation institute, a 14‐day observation study was planned after consultation with them). The department included 15 beds and 33 nurses. Each bed was equipped with a physiological monitor from the same manufacturer. There were six nurse workstations, and one central system monitoring area where patients' conditions could be observed clearly and the alarm information could be monitored, with no designated individual to manage the alarms. Beds No. 1 to 13 were separated by curtains, and Beds No. 14 and 15 were standard single rooms. Patients who received treatment had physiological monitoring for vital signs.

Then, a cross‐sectional study was conducted among ICU nurses by convenience sampling in Chongqing from September 7 to 17, 2021. Participants were Registered Nurses on duty in the ICU. Practice nurses, nurses coming to study and receive standard training, off‐duty nurses, nurses on leave and nurses on sick leave were excluded.

2.4. Ethics statement

This study was approved by the ethics committees of the researcher's hospital (Decision Date: 19/01/2021). All members were informed that participation was voluntary and that the results would be kept confidential and reported anonymously. This study was following the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) checklists.

2.5. Data collection procedures

2.5.1. Set up for the research team

The research team consisted of 12 members, including 1 nursing doctoral supervisor who was responsible for developing the project and controlling the quality; 2 nursing specialists who were responsible for implementing the project and supervising the process; and 4 graduate nursing students and 5 nursing undergraduate students who were responsible for data collection and collation. All members had ICU work or rotation experiences and were not involved in clinical work for this study.

2.5.2. Physiologic monitor alarm data collection

Nine participants (4 graduate nursing students and 5 undergraduate nursing students) observed patients during three time periods (08:00 ~ 16:00, 16:00 ~ 24:00, 00:00 ~ 08:00); each period had at least two observers. The first observer of each day filled in the first part of the record forms, and if there was a new patient that day, the observer of each shift would supplement the first part by himself. During the observation periods, the observers did not participate in the nursing work at all. When the alarm was triggered, through auditory and visual signals, observers observed and recorded the alarm information. At the end of each day, the data were reviewed by 2 nursing specialists for the first time. At the end of the study, 2 nursing graduate students used Excel software to sort, input and classify the data for the first time, and 2 nursing experts checked the data for the second time.

2.5.3. Cross‐sectional survey data collection

General information questionnaire

The general information questionnaire designed by the research team included questions about sex, age, education, marital status, work years, job title, work position and night shift.

Chinese version of the clinical alarm survey questionnaire for medical devices

In 2004, the HTF developed the clinical alarm survey questionnaire, and then completed the first large‐scale survey to identify issues related to clinical alarms in 2005–2006 (Korniewicz et al., 2008). The clinical alarm survey questionnaire was revised in 2011 (Funk et al., 2014) and 2016 (Ruppel, Funk, et al., 2018), and the second and third surveys were completed to explore whether and how clinical alarm perceptions and practices had changed over time. The HTF survey has been used in several other studies (Casey et al., 2018; Cho et al., 2016; Jeong & Kim, 2022; Mirhafez et al., 2019; Petersen & Costanzo, 2017; Sowan et al., 2015).

The 2016 Clinical Alarms Survey was revised by the US. HTF in 2016 (Ruppel, Funk, et al., 2018). In February 2021, permission was granted from the HTF to use the 2016 Clinical Alarms Survey and translated and adapted into Chinese. Some language expressions in the original were revised. For instance, the original “on my floor/area”, “your hospital/institution/unit”, and “my facility” were translated into “your ward”, “the staff” was translated into “the nurse”, “monitor watchers” was translated into “a special person (alarm administrator)”, and “The Joint Commission's National Patient Safety Goal on Alarm Management that became effective in 2014 has reduced adverse patient events” was translated into “Since the Chinese Hospital Association implemented the alarm management projects in the 2019 Patient Safety Goals, the incidence of alarm‐related adverse events has decreased in your hospital”.

The Chinese version of the clinical alarm survey questionnaire for medical devices was validated through translation, reverse translation, expert consultation, and pre‐survey. A total of 31 items of the questionnaire, which consisted of 7 groups of alarm‐related information about Nuisance Alarms, Experience with Alarm Systems, Alarm Notifications, Smart Alarms, Institutional Requirements, Clinical Alarms Management Improvements and Alarm‐related Adverse Events. Among them, 16 items were provided with five options of strongly disagree, disagree, unsure, agree and strongly agree, which were used to investigate nurses' perceptions of clinical alarms. The Cronbach's α coefficient in this study was 0.77, indicating that the questionnaire items had a good correlation. Eight items were provided with three options of no, yes and not sure, which were used to investigate nurses' practices of clinical alarms. Seven items were open questions, which were views on 7 groups of questions. The item‐level content validity index (I‐CVI) of the questionnaire ranged from 0.86 to 1.00, and the scale‐level content validity index (S‐CVI) was 0.98. In the survey of HTF, the evaluation of the survey results was analysed according to the proportion of the number of people selected for each item. Therefore, only 24 closed items were evaluated, and 7 open items were not summarized in this study.

Data collection

In this study, an anonymous online survey was adopted to relieve the psychological pressure on respondents and facilitate the collection of objective and true information. The first page of the questionnaire states the purpose, voluntary nature and confidentiality of the study. The respondents provided informed consent, completed the questionnaire and submitted it immediately after completion. A total of 1269 questionnaires were collected, of which 1191 were valid, with an effective recovery of 93.85%.

2.6. Data analysis

Collected data were entered into IBM SPSS version 23 for descriptive and statistical analysis. The quantitative data that conformed to a normal distribution are represented as the mean (M) and standard deviation (SD). The counting data were represented by frequency and percentage (%).

3. RESULTS

3.1. General information on patients and the frequencies of ICU physiologic monitor alarms

A total of 14 days of continuous nonparticipation observation was conducted, and there were no alarm‐related patient adverse events. During this period, a total of 32 patients were admitted, including 20 males and 12 females; the ages were 20–88, six were under 50, three were 50–59, four were 60–69, nine were 70–79, and 10 were 80 and older. Of these patients, 12 were discharged, 9 were transferred to the general ward, 10 stayed in the ICU and 1 died.

During the 14‐day observation period, 13,829 physiological monitor alarms were recorded, including 13,642 physiological alarms (98.65%) and 187 technical alarms (1.35%). Out of 13,642 physiological alarms, signals were recorded for noninvasive blood pressure (NIBP) 1431 (10.49%), heart rate (HR) 1791 (13.13%), electrocardiograph (ECG) 2366 (17.34%), respiration rate (RR) 2474 (18.14%), invasive blood pressure (IBP) 2683 (19.67%) and oxygen saturation SpO2 2897 (21.24%). The details are shown in Table 1.

TABLE 1.

The frequency of physiological monitor alarms (n = 13,829).

Types Frequency (%)
Physiological alarm
SpO2 2897 (21.24)
IBP 2683 (19.67)
RR 2474 (18.14)
ECG 2366 (17.34)
HR 1791 (13.13)
NIBP 1431 (10.49)
Technical alarm 187 (1.35)
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3.2. General information on ICU nurses

A total of 1191 ICU nurses completed the online survey. The details of the ICU nurses' demographic and professional characteristics are shown in Table 2.

TABLE 2.

The general information of ICU nurses (n = 1191).

Characteristics No. (%)
Sex
Female 100 (8.40)
Male 1091 (91.60)
Age (year)
≤25 265 (22.25)
26 ~ 29 396 (33.25)
30 ~ 35 378 (31.74)
36 ~ 39 85 (7.14)
≥40 67 (5.63)
Education
Junior College 328 (27.54)
Undergraduate 857 (71.96)
Postgraduate 6 (0.50)
Marital status
Married 715 (60.03)
Unmarried 452 (37.95)
Others 24 (2.02)
Work years
≤3 311 (26.11)
4 ~ 6 276 (23.17)
7 ~ 9 240 (20.15)
≥10 364 (30.56)
Job title
Nurse 259 (21.75)
Senior nurse 650 (54.58)
Supervisor nurse 247 (20.74)
Associate chief superintendent nurse or above 35 (2.94)
Work position
Assistant nurse 28 (2.35)
Primary nurse 935 (78.51)
/Responsibility Group leader 171 (14.36)
Head nurse 57 (4.79)
Night shift
No 292 (24.52)
Yes 899 (75.48)
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3.3. ICU nurses' perceptions and practices regarding clinical alarms

In this study, ICU nurses agreed and strongly agreed that nuisance alarms occur frequently (41.23%, n = 491), disturbed the nurses' care of patients (62.47%, n = 744) and reduced the nurse's trust in the alarms and causing them to turn off the alarm instead of setting it as required (49.03%, n = 584). The majority of ICU nurses agreed and strongly agreed that they were sensitive to alarms and responded quickly (81.28%, n = 968); however, some nurses still thought that environmental noise (49.12%, n = 585), a complex alarm setting (39.29%, n = 468) and patients using multiple medical equipment at the same time (37.53%, n = 447) would affect the effective recognition and response to alarms, and often alarms were not heard and missed (24.94%, n = 297).

The results showed that the ICU nurses in this study agreed and strongly agreed that the alarm system used by the department was sufficient to alert nurses to detect potential or actual changes in patients' conditions (71.45%, n = 851), and the use of an alarm notification system (72.04%, n = 858), the setting of special personnel to manage the alarm (59.45%, n = 708) and newly acquired medical equipment (51.22%, n = 610) could help improve alarm management by nurses. Moreover, intelligent devices could reduce the occurrence of false alarms (67.76%, n = 807) and improve the response of nurses to important alarms (74.56%, n = 888); and the effective implementation of alarm management policies and regulations (59.61%, n = 710) could help reduce the occurrence of alarm‐related adverse events (52.39%, n = 624). The details are shown in Table 3.

TABLE 3.

ICU nurses' perceptions and practices regarding clinical alarms (n = 1191).

Items No. (%)
1. Nuisance alarms occur frequently 491 (41.23) a
2. Nuisance alarms disturb the nurses' care of patients 744 (62.47) a
3. Nuisance alarms reduce the nurses' trust in the alarms, causing them to turn off the alarms instead of setting them as required 584 (49.03) a
4. For the existing equipment, the reasonable setting of alarm parameters and alarms is too complex 468 (39.29) a
5. New equipment (such as those purchased within the last 3 years) has solved most of the problems encountered in clinical alarms 610 (51.22) a
6. The alarm system used in the ward is sufficient to alert the nurses to potential or actual changes in the patients' conditions 851 (71.45) a
7. It often happens that the alarms cannot be heard and are missed. 297 (24.94) a
8. The nurses are sensitive to alarms and respond quickly 968 (81.28) a
9. It is difficult to identify which one is in alarm when several pieces of equipment are used to monitor a patient 447 (37.53) a
10. Environmental noise interferes with nurses' recognition of the alarms 585 (49.12) a
11. Does your ward use alarm notification systems, such as pagers, cell phones or other wireless device to communicate alarm conditions? 634 (53.23) b
12. Alarm notification systems are useful for improving the management and response of nurses to alarms 858 (72.04) a
13. Does your ward set up a special person (alarm administrator) in the central viewing area to manage the alarms and to observe, record or communicate the alarm messages to clinical nurses in time? 387 (32.49) b
14. It is meaningful to set up a special person (alarm administrator) to manage the alarms 708 (59.45) a
15. Does your ward use smart alarm systems (such as multiparameter monitoring, parameter changes and parameter signals that can be automatically evaluated)? 574 (48.19) b
16. The use of smart alarm systems can effectively reduce the false alarms 807 (67.76) a
17. The use of smart alarm systems can effectively improve nurses' response to important patient alarms 888 (74.56) a
18. Have you received education on the purpose and proper operation of alarm systems of equipment? 770 (64.65) b
19. Does your ward require to document the appropriate setting of alarm parameters for each patient in the nursing record sheets? 531 (44.58) b
20. Clinical policies and procedures regarding alarm management have been implemented effectively in your ward 710 (59.61) a
21. Has your hospital developed clinical alarms management improvement projects over the past 2 years (e.g., policies and procedures, education, special projects, new technology)? 555 (46.60) b
22. Has your ward developed new technological solutions to improve the security of clinical alarm management? 606 (50.88) b
23. Have any alarm‐related patient adverse events happened at your ward in the past 2 years? 290 (24.35) b
24. Since the Chinese Hospital Association implemented the alarm management projects in the 2019 Patient Safety Goals, the incidence of alarm‐related adverse events has decreased in your hospital 624 (52.39) a
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a

Frequencies and percentages people who agree and strongly agree with the items.

b

Frequencies and percentages who choose yes for the items.

4. DISCUSSION

4.1. ICU physiologic monitor alarms occur frequently, and it is important to understand the perceptions and practices of ICU nurses regarding clinical alarms

This study conducted a 24‐h continuous nonparticipant observation of 32 patients in the ICU for 14 days, 13,829 physiological monitor alarms were recorded, an average of about 988 alarms per day, and no alarm‐related adverse events occurred, which is similar to Graham and Cvach's (2010) study. These researchers collected a total of 16,953 physiological monitor alarms in an ICU over 18 days, an average of approximately 942 alarms per day. Due to the frequent occurrence of physiological monitor alarms in Chinese hospital ICUs, it is necessary to optimize alarm management measures to reduce the occurrence of alarms. As a medical place for intensive treatment and monitoring of critically ill patients, physiological monitoring alarms inevitably occur in the ICU. Therefore, the core lies in alarm management (Cvach, 2012), that is, how to set and handle alarms to improve the accuracy and response rate of alarms to improve alarm management and patient safety (Winters et al., 2018). Therefore, we selected the HTF 2016 clinical alarm survey questionnaire, translated the questionnaire into Chinese and revised it briefly after authorized use. The Chinese version of the clinical alarm survey questionnaire for medical devices have a total 31 items and mainly investigated nurses' perceptions and practice of clinical alarms, which consisted of 7 groups of questions about Nuisance Alarms, Experience with Alarm Systems, Alarm Notifications, Smart Alarms, Institutional Requirements, Clinical Alarms Management Improvements and Alarm‐related Adverse Events. We surveyed 1191 ICU nurses to understand the perceptions and practices of ICU nurses regarding medical equipment alarms to further improve patient safety.

4.2. Reducing the occurrence of nuisance alarms and the level of ICU nurses' alarm fatigue

In recent years, the number of medical devices with alarm functions has increased gradually, and clinical alarms have increased sharply. The large number of nuisance alarms were the key factors causing alarm fatigue, environmental noise pollution and alarm information overload (Koomen et al., 2021). Alarm fatigue can be understood as the emotional stress of nurses exposed to too many alarms, such as irritability, fatigue, anxiety and stress. Cho et al. (2016) reported that 63.8% of medical equipment alarms in the ICU were nuisance alarms, and the level of ICU nurses' alarm fatigue was above the medium level. A high level of alarm fatigue will directly affect the attention and positive response of ICU nurses to alarms and threaten the safety of patients. Approximately half of the ICU nurses in this study believed that nuisance alarms occurred frequently (41.23%), disturbed the care of patients (62.47%), and reduced nurses' trust in alarms, leading nurses to turn off of the alarms rather than setting them properly as required (49.03%), which was significantly lower than the findings of American scholars Sowan et al. (2015) (95%, 98%, 98%) and Casey et al. (2018) (90%, 91%, 81%). This may be due to the large variation in the sample sizes of survey studies, and differences in cultural backgrounds and medical resources between developed and developing countries. It is recommended that managers choose equipment that can limit the generation of nuisance alarms. Education and training should be actively carried out to make nurses understand the purpose, method and safety of alarm settings to reduce nuisance alarm caused by unreasonable alarm settings and reduce the level of ICU nurses' alarm fatigue.

4.3. Improve the ICU nurses' ability to use the alarm systems and response rate to alarms

In this study, 71.45% of ICU nurses believed that the alarm system used was sufficient to alert nurses to detect potential or actual changes in patients' condition, that the new equipment could solve most of the problems related to clinical alarm (51.22%), and that nurses were sensitive to alarms and responded quickly (81.28%). This was similar to the results of Casey et al. (2018) and Mirhafez et al. (2019). However, Bridi et al. (2014) found that ICU nurses' median reaction time in responding to alarms was approximately 4 min 54 s ~ 4 min 55 s, and the reaction time was longer than 10 min in more than 60% of the alarms. Andrade‐Méndez et al. (2020) also found that ICU nurses' response times were within 1 min for 37% of the alarms, while 42.5% had no response. It can be seen that although most ICU nurses believe that they are sensitive to clinical alarms and respond quickly, this is different from the actual situation. Schondelmeyer et al. (2018) reported that only 7% of alarms required clinical interventions.

In this study, ICU nurses believed that environmental noise would interfere with their effective recognition of alarms (49.12%), the reasonable setting of alarm parameters and alarms was too complex (39.29%), and it might be difficult to identify the specific alarm sounded by which device when patients used multiple medical devices at the same time (37.53%). The alarm was often missed because the alarm sound was not heard (24.94%), which was similar to the report by Ruppel's study (Ruppel, Funk, et al., 2018). It is recommended that managers develop alarm management systems, alarm response processes or disposal specifications and implement safer alarm management. Second, modern intelligent medical equipment can be used to reduce the occurrence of nuisance alarms and improve the accuracy of alarms so that nurses can pay timely attention to urgent alarms and provide timely medical care.

4.4. Establish an alarm notification system to improve the management and response of ICU nurses to alarms

Clinical alarms are “life‐saving signals” when patients' conditions change, and it is very important to communicate these signals to ICU staff for timely treatment. When the equipment is not working properly, it can lead to changes in patients' conditions not being recognized, or the alarm signal is recognized but not transmitted to the ICU nurse, or the signal is transmitted to the ICU nurse but not dealt with. In this study, 72.04% of ICU nurses believed that alarm notification systems are useful, but 53.23% of ICU nurses used them. A total of 59.45% of ICU nurses thought it was very meaningful to set up a special person to manage alarms, while only 32.49% of ICU nurses' wards did so. In view of the importance of setting up the alarm notification system, it is suggested that managers should set up alarm administrators in a timely manner to manage the alarm or improve the alarm notification system according to the actual work situation of the department to improve patient safety. Therefore, it is important to establish an alarm notification system, and it is suggested that managers set up alarm administrators or improve the alarm notification system in a timely manner according to the actual work situation of the department.

4.5. Strengthen the intelligence of medical equipment and improve clinical alarm management effectively

At present, smart medical service not only provides intelligent, personalized and convenient medical services to the public but also provides promising solutions to medical problems and improves the level of medical technology and service quality. Studies have shown that a wearable metacognitive attention aid enables nurses to quickly triage unfiltered alarms, respond to patients' important problems and deliver health care (McFarlane et al., 2018). Physiologic monitor alarm customization software could help ICU nurses personalize alarm parameters and reduce the number and duration of alarms (Ruppel, De Vaux, et al., 2018). However, smart medical services also indicate complex systemic problems, such as network information security and the disclosure of patients' personal information, and it will take some time for popularization in developing countries. In this study, most ICU nurses believed that smart alarm systems can effectively reduce false alarms (67.76%) and improve nurses' response to important patient alarms, but 48.19% of ICU nurses' wards use a system. The use of smart medical devices also suggests the progress and innovation of clinical operations, which needs further exploration by managers or clinical staff.

4.6. Implement alarm management education and training to improve the alarm management ability of ICU nurses

Education interventions based in clinical practice settings have proven to be effective in improving the alarm management ability of ICU nurses (Yue et al., 2017). Cameron and Little (2018) developed a standardized alarm management education programme based on evidence‐based guidelines and hospital management policies, and the cognitive and behavioural ability of nurses on alarms was significantly improved after educating and training for 2 months. Bi et al. (2020) implemented 12 weeks of alarm management training based on the theory of planned behaviour for ICU nurses, which significantly reduced the number of alarms and the level of nurses' alarm fatigue. In this study, 64.65% of ICU nurses received education on the purpose and proper operation of alarm systems. However, Funk et al. (2014) reported that the lack of education and training on alarm systems was still one of the obstacles for ICU nurses attempting to effectively manage alarms. With the rapid development and updating of medical equipment and instruments, managers should constantly improve the training mechanism, strengthen the training and assessment of nurses on alarm systems, and further improve the alarm management ability of ICU nurses.

4.7. Establishing alarm management improvement programmes to improve alarm safety management

In this study, 46.60% of ICU nurses' hospitals developed clinical alarm management improvement projects over the past 2 years, and 50.88% sought new technological solutions to improve the security of clinical alarm management. Studies have pointed out that the personalized setting of alarm parameters (Poole & Shah, 2018) and daily electrode change (Cvach et al., 2013) can reduce the number of alarms, reduce the degree of alarm fatigue and improve patient safety (Sendelbach & Funk, 2013; Walsh‐Irwin & Jurgens, 2015). The default alarm parameter is the physiological baseline value of the indicator threshold. How to guide ICU nurses correctly to set personalized alarm parameters is very important. However, the clinical situation of each patient is different, so the personalized setting of alarm parameters will bring security risks to patients. At the same time, although daily change of electrodes can significantly reduce the number of alarms, it also increases the risk of skin injury and financial burden for patients. The reasonable establishment of alarm management improvement plans still need to be explored, and it is suggested that managers should base their efforts on China's national conditions and patient safety goals to improve the alarm management ability of ICU nurses and patient safety.

4.8. Effectively implement the alarm management programmes to reduce the occurrence of alarm‐related patient adverse events

In 2019, China's Patient Safety Goals pointed out that it was necessary to strengthen the safety and alarm management of medical devices and encourage the monitoring and reporting of medical device‐related adverse events. Adverse events can cause patients to suffer functional impairment or prolonged hospital stay. The results of this study showed that 52.39% of ICU nurses believed that the incidence of alarm‐related adverse events had decreased since the implementation of the alarm management programme in the 2019 patient safety goal. However, our findings showed that 24.35% of ICU nurses' wards had experienced alarm‐related patient adverse events in the past 2 years, which was quite different from the results of Casey et al. (2018). These researchers investigated 166 ICU nurses from six hospitals in Ireland in 2018, and all of them reported that they experienced adverse alarm‐related events. In the survey of HTF in 2016, 60% of medical workers said that their institutions had experienced adverse alarm‐related events (Ruppel, Funk, et al., 2018). This might be due to the larger sample size of this study and the differences in medical background and ICU working environment in different countries. At present, there were few studies on adverse alarm‐related events in our country. It is recommended that managers should establish and implement alarm management programmes according to the relevant requirements of equipment alarm management in patient safety goals, encourage active reporting of alarm adverse events, and reduce the occurrence of alarm related adverse events.

4.9. Limitations

The Hawthorne effect may exist in this study by collecting alarms through the observation method, but there were still cases where the alarms were not heard and missed. At the same time, this study only conducted a questionnaire survey in one region. In the later stage, when conditions permit, the intelligent alarm collection method of equipment background can be adopted to fully explore the occurrence of clinical alarms in the ICU, and the survey can be expanded to further investigate nurses' perceptions and practices regarding clinical alarms in different regions of the country.

4.10. Implications

This study conducted an observational study to confirm it and the results of this study help ICU managers and nurses to understand the situation of physiological monitor alarms occurrence, which lays the data foundation for the development of alarm management measures and further research. In this study, the US. HTF 2016 Clinical Alarms Survey was introduced and translated into Chinese, which not only provides alternative assessment tools to enrich the research on clinical alarm management in China but also investigates ICU nurses' perceptions and practices of clinical alarms to explore the factors that may hinder and promote nurses' recognition and response to alarms. The results of this study are of great significance for formulating or optimizing alarm management strategies, improving the quality of alarm management, nursing and the safety of patients.

5. CONCLUSION

This study found that physiological monitor alarms occurred frequently in the ICU, and it was necessary to develop effective or optimized alarm management measures to further reduce the occurrence of alarms. An online survey of 1191 ICU nurses showed that showed that ICU nurses thought they were sensitive to alarms and responded quickly, but there were still cases where the alarms were not heard and missed, and the large number of nuisance alarms disrupted the care of patients. It is suggested that the use of smart alarm systems and alarm notification systems, develop alarm management projects and educate and train staff to improve the safety of alarm management. Although there are some differences between the results of this survey and the results of foreign studies, it is still imperative to formulate and effectively implement clinical alarm management measures for medical devices, which are expected to have a certain reference role for peers.

AUTHOR CONTRIBUTIONS

Study design: Caiping Song, Lei Wang, Wei He, Yulu Chen, Qiuping Wu, Xin Du, Qin Li. Data collection and analysis: Lei Wang, Wei He, Yulu Chen, Qiuping Wu, Xin Du, Qin Li. Manuscript preparation and revising: Caiping Song, Lei Wang.

FUNDING INFORMATION

None.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

ACKNOWLEDGEMENTS

Sincere gratitude is given to all nurses in the Department of Critical Care Medicine ICU, the Second Affiliated Hospital of Army Medical University. We would like to thank all respondents in this study. We also thank the nurses of Jing Wang, Mengyi Wang, Shuo Wang, Jiazhu Jin, Zhizhi Li for their assistance in data collection.

Wang, L. , He, W. , Chen, Y. , Wu, Q. , Du, X. , Li, Q. , & Song, C. (2023). Intensive care unit nurses' perceptions and practices regarding clinical alarms: A descriptive study. Nursing Open, 10, 5531–5540. 10.1002/nop2.1792

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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