Table 9. Key Insights into the Problem of Alarm Fatigue and Recommendations.

Conditions Causing Excessive Alarms	Suggestions for Device Improvements
1. Alarms are not tailored to the individual patient	• Have monitor prompt more appropriate alarm settings; e.g., “Mean HR = 130; do you want to increase high HR setting?”
2. Persistent atrial fibrillation	• Have monitor trigger alarms only upon new onset or termination of atrial fibrillation
	• When there are repetitive audible alarms, have monitor prompt “Do you want to continue to hear Afib alarms?”
3. Artifact mimics VT or VFib	• Have arrhythmia algorithm use all available ECG leads to identify a non-artifact lead
	• Make it easy to view and print out all available ECG leads at the time the alarm was triggered
4. Low amplitude QRS causes pause, asystole, & bradycardia false alarms	• Have arrhythmia algorithm use all available ECG leads to identify QRS complexes
	• Detect QRS if ≥1 lead has peak-to-trough amplitude of ≥0.15 mV as allowed by the AAMI standard, especially if rate matches SpO2 or arterial pressure waveforms
5. Wide QRS due to BBB or pacemaker rhythm triggers ventricular arrhythmia alarms	• Have monitor detect high frequency pacemaker “spikes” without clinician having to tell the monitor the patient has a pacemaker
	• Have monitor algorithm identify P waves to distinguish sinus rhythm with BBB
6. VT alarms not “actionable”	• Make VT alarm delays configurable according to criteria for documentation (≥10 seconds) or treatment (30 seconds) established by hospital preferences & practice guidelines
	• Use VT rate, invasive arterial pressure and SpO2 to identify hemodynamically significant (symptomatic) VT
7. Electrode failure causes poor signal quality	• Have monitor measure each electrode’s impedance and indicate when one is failing so electrode can be changed
8. ST-segment alarms are not truly indicative of myocardial ischemia	• Make ST alarm delays configurable according to criteria for ischemia (lasting 1 minute) to prevent brief “spikes” in ST amplitude from triggering alarms
	• Define ischemia only when present in 2 contiguous limb leads in order of aVL, I, minus aVR, II, aVF, III)
9. Flat-line respiratory wave-form cause false apnea & RR alarms	• Have monitor automatically search for best available ECG lead to measure/display respiration waveform
	• Investigate ECG-derived respiratory measurement to replace impedance method

Afib = atrial fibrillation; AAMI = Association for the Advancement of Medical Instrumentation; HR = heart rate; BBB = bundle branch block; VT = ventricular tachycardia; VFib = ventricular fibrillation; RR = respiratory rate.