By Greg Freeman
EXECUTIVE SUMMARY
Nurses in an ICU successfully alleviated alarm fatigue with a bundle. The CEASE bundle focuses on changing electrodes and using appropriate monitors.
- Electrodes were changed at least daily.
- Monitoring was tailored to patients’ specific needs.
- Nurses consult physicians about appropriate levels of monitoring.
Alarm fatigue continues to plague clinicians and threaten patient safety, but nurses in the surgical ICU at Mayo Clinic in Jacksonville, FL, have reported good results with a tool to help staff maximize the benefits of clinical alarms.
The nurses used the CEASE bundle to improve alarm management practices and reduce their self-reported alarm fatigue.
“CEASE” is an acronym for Communication, Electrodes, Appropriateness, Setup, and Education. Nurses at Porter Adventist Hospital in Denver developed the tool.1 Stephanie Bosma, DNP, APRN, FNP-BC, a critical care nurse at Mayo Clinic, recently implemented it at the facility and published the results.2
Bosma and her colleague, Roberta Christopher, EdD, MSN, APRN, FNP-BC, EBP-C, NE-BC, CAIF, introduced the CEASE bundle to nurses during their regular staff meetings. Descriptions were placed around the unit for easy reference.
Bosma and Christopher surveyed 115 nurses working in the unit after the intervention and found greater alarm management competency and improvements in their perceptions of alarm functionality, settings, response time, and policy adherence. There was a statistically significant decrease in self-reported alarm fatigue. The CEASE bundle also influenced nursing practice.
“I had just started working in the surgical ICU at the Mayo Clinic, and I learned really quickly that alarm fatigue was super real. It was a bit overwhelming at first because I worked in the progressive care unit before then but the level of alarms in our surgical ICU was astronomical,” Bosma recalls. “Learning all the different alarms, the sounds, how to troubleshoot them, and how really to manage them all together was very challenging.”
Bosma wanted to find a way to help nurses reduce their alarm fatigue, realizing that feeling overwhelmed by the alarms was not merely a function of starting a new job in the ICU. All the nurses were suffering from alarm fatigue and worried it was detrimental to their patient care.
Change Electrodes More Often
Bosma’s research led her to the CEASE bundle, and she began a project to introduce it to her ICU. Bosma began by explaining what each element of the bundle means and how it can contribute to reducing alarm fatigue.
The first is communication between staff members regarding the alarm parameters and whether they need adjustment. That communication should be maintained during shift changes, too. Changing the electrodes daily and as needed is the second topic.
“A lot of times, electrodes are left on patients for an extended amount of time — they don’t need to be. As soon as one pops off, you get an alarm because one of the telemetry wave lines is flat. That’s never good,” Bosma says. “We focused on changing those electrodes daily, at least once a day, but also if you did a bath or changing event. We did the same with the continuous pulse oximeter — if the finger is wet and they come off or become a little loose, it looks like they’re desaturating but really they’re not.”
The nurses focused on standardizing the changing of electrodes and other monitors, Bosma says. Nurses assessed the appropriateness of monitors, the next element of the bundle.
“A lot of times, we would be recovering transplant patients fresh out of the OR. At first, they get intubated, and all the monitoring is very appropriate. They have catheters, they have arterial lines, and central lines,” Bosma explains. “But as the patient starts to get better, it’s up to the nurse to kind of assess, ‘Well, can we pull the arterial line now? Are they off vasopressor medication? What can we do to minimize the monitoring now that they’re more stable?’”
The nurses make a point of asking the physicians whether the patients need those lines anymore. If monitoring remains necessary, they look at customizing the alarm parameters to the patient.
Each patient is different, Bosma notes, so nurses talk with the physicians to see what level of monitoring is acceptable and when they want to be notified of changes. Sometimes, the ICU parameters will be tighter than in other settings, but the default set of parameters on each alarm is not always needed.
“Learning the patient and how you can adjust those parameters to notify you if something actually needs to be done is better than creating more false alarms,” Bosma says.
The education component of the bundle is about continuing education, which Bosma says is particularly important when a unit’s turnover rate is high. Her ICU gets a lot of new nursing graduates, so it is important to put a system in place to train them on the CEASE bundle. Education also is key when monitoring systems are updated or new monitors are introduced.
The bundle has been effective in alleviating alarm fatigue. Bosma recommends it for other hospital units. Implementing the bundle requires support from nurse management and hospital leadership.
“You can create a small team because it is sometimes challenging to educate 115 ICU nurses, making sure that people are getting their questions answered and they’re understanding the bundle,” Bosma says. “It is good to create an alarm management work group of at least five people.”
Bosma also recommends contacting the multidisciplinary team to let them know about the project, including respiratory therapists, physicians, and technicians.
“A lot of time, the patient care techs in the ICU do a lot of the work with helping change out those electrodes, the pulse oximeters, and things like that, so it’s important that you involve them in this effort and not make it only about the nurses,” Bosma says. “Getting buy-in from the top, creating a workgroup, and educating the multidisciplinary team would definitely be beneficial for implementation of the bundle.”
REFERENCES
- Lewis CL, Oster CA. Research outcomes of implementing CEASE: An innovative, nurse-driven, evidence-based, patient-customized monitoring bundle to decrease alarm fatigue in the intensive care unit/step-down unit. Dimens Crit Care Nurs 2019;38:160-173.
- Bosma S, Christopher R. Implementing a unit-based alarm management bundle for critical care nurses. Crit Care Nurse 2023; 43:36-45.
SOURCE
- Stephanie Bosma, DNP, APRN, FNP-BC, Critical Care Nurse, Mayo Clinic, Jacksonville, FL. Email: [email protected].
Nurses in an ICU successfully alleviated alarm fatigue with a bundle. The CEASE bundle focuses on changing electrodes and using appropriate monitors.
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