**8. Quality improvement**

Considering the potential for very serious clinical consequences of AF, quality improvement measures have been proposed to help reduce both nonactionable alarm occurrences and the incidence of AF. Successful quality improvement projects must address multiple facets of the overall problem, including root causes that lead to AF (**Figure 6**). For example, poor usability and lack of user-centered devices have the potential for elevating clinical personnel stress levels, creating unnecessary workload and interjecting workflow inefficiencies into an already tense environment [81].

Potential solutions for reducing the incidence of AF include multipronged approaches consisting of staff education, equipment (hardware and software) enhancements, and implementation of more efficient clinical protocols or guidelines [82–84]. From an educational perspective,

**Figure 6.** The different aspects of alarm fatigue that can be addressed through different quality improvement approaches (source: Ref. [80]).

it is important to ensure adequate staff education, equipment training, and closer team collaboration to improve patient safety within the existing framework [8, 85]. In addition to staff education, hospital policies have been developed and implemented to more clearly define which staff members are able to change alarm settings, as well as how such changes should be made and documented. Many of these polices have also delegated the responsibility of performing clinical alarm monitoring rounds to a staff member in order to allow for continued review of the application of patient monitoring systems [86–88].

To address the issues of staff workload, two potential approaches have been proposed. The first approach consists of secondary notification systems. The second option involves the use of dedicated staff to oversee alarms. A secondary notification system involves a specialized network interface that algorithmically facilitates the decision process regarding which alarms will be further communicated or escalated to pertinent downstream clinical staff. Further, this system would also enable the automatic escalation of an alert to another clinician, should the primary recipient fail to acknowledge the alarm within a designated timeframe. The use of staff to oversee alarms, while an expensive option, can give additional support to care providers in the form of dedicated personnel whose responsibility is to continuously monitor patient data trends and alarms from a central station [58].

No matter the solution, all the quality improvement processes require a multidisciplinary approach to address the causes and effects of AF. Only through collaborative efforts can substantial change be accomplished to reduce the number of alarm-related events in health care. In addition to the quality improvement measures taken by hospitals, technological advances have also led to more efficient and practical application of patient monitors in the clinical setting. These advances are directed at the reduction of nonactionable alarms with the goal of decreasing the alarm desensitization associated with AF. The importance of adequate information technology support, including better device designs, must be emphasized. As increasingly efficient and complex monitoring equipment is introduced into the clinical realm, certain phenomena, such as the emergence of "unpredictable code," may adversely affect computer performance (including the ability to effectively recognize important data patterns) and lead to clinical alerts being missed despite the fact that alert-specific data were clearly and provably present [89].
