Clinical alarm systems safety has received immense attention from clinicians, patient safety organizations, and policy makers [1The Joint Commission. The Joint Commission announces 2014 National Patient Safety Goal. Available from: http://www.jointcommission. org/assets/1/18/jcp0713_announce_new_nspg.pdf Accessed April 1, 2016.-5FDA Patient Safety News. FDA Patient Safety News: Show #106. Silver Spring, MD: US Food and Drug Administration; 2011 Jan. Alarming monitor problems. Available from: http://www.fda.gov/ downloads/Safety/FDAPatientSafetyNews/UCM417915.pdf 2011. Accessed May 10, 2016.], especially after the U.S. Food and Drug Administration’s (FDA) report indicated 566 alarm- related patient deaths [5FDA Patient Safety News. FDA Patient Safety News: Show #106. Silver Spring, MD: US Food and Drug Administration; 2011 Jan. Alarming monitor problems. Available from: http://www.fda.gov/ downloads/Safety/FDAPatientSafetyNews/UCM417915.pdf 2011. Accessed May 10, 2016.]. The Joint Commission (TJC) in the U.S. attributed the majority of alarm-related deaths to alarm fatigue and subsequently issued a National Patient Safety Goal (NPSG) on clinical alarm systems safety [1The Joint Commission. The Joint Commission announces 2014 National Patient Safety Goal. Available from: http://www.jointcommission. org/assets/1/18/jcp0713_announce_new_nspg.pdf Accessed April 1, 2016.]. TJC required healthcare organizations to implement the NPSG in two phases: Phase 1, beginning January 2014, was to identify high priority alarms, and Phase II, beginning January 2016, was to implement policies and procedures for alarm safety and to educate clinicians on alarm management [1The Joint Commission. The Joint Commission announces 2014 National Patient Safety Goal. Available from: http://www.jointcommission. org/assets/1/18/jcp0713_announce_new_nspg.pdf Accessed April 1, 2016.]. In response to Phase II, this study assessed nurses’ perceived competence on physiologic monitors use in intensive care units (ICUs).

The FDA reported that physiologic monitors (also referred to as bedside or patient monitors), often used by nurses, were most commonly involved in alarm related-deaths [5FDA Patient Safety News. FDA Patient Safety News: Show #106. Silver Spring, MD: US Food and Drug Administration; 2011 Jan. Alarming monitor problems. Available from: http://www.fda.gov/ downloads/Safety/FDAPatientSafetyNews/UCM417915.pdf 2011. Accessed May 10, 2016.]. The majority of studies on alarm systems safety verify the high rate of alarms produced by physiologic monitors, specifically in ICUs [6Görges M, Markewitz BA, Westenskow DR. Improving alarm performance in the medical intensive care unit using delays and clinical context. Anesth Analg 2009; 108(5): 1546-52.
[http://dx.doi.org/10.1213/ane.0b013e31819bdfbb] [PMID: 19372334] -14Cho OM, Kim H, Lee YW, Cho I. Clinical alarms in intensive care units: Perceived obstacles of alarm management and alarm fatigue in nurses. Healthc Inform Res 2016; 22(1): 46-53.
[http://dx.doi.org/10.4258/hir.2016.22.1.46] [PMID: 26893950] ]. In fact, this rate reached 350 alarms per patient per day [3Association for the Advancement of Medical Instrumentation. A siren call for action: Priority issues from the Medical Device Alarms Summit Available from: http://www.aami.org/htsi/alarms/ pdfs/2011_Alarms_Summit_publication.pdf 2011. Accessed March 10, 2016.]. This high alarm rate can create alarm fatigue. Alarm fatigue occurs when clinicians ignore alarms from physiologic devices due to an excessive number of non-actionable or false positive alarms. Alarm fatigue can lead to unsafe workarounds, such as inappropriate disabling of alarms or unsafe adjustments to alarm limits, and was ranked by the ECRI Institute as one of the top 10 Technology Hazards [4ECRI. ECRI Institute Top 10 Health Technology Hazards Report for 2014. Available from: http://www.visimobile.com/ wp-content/ uploads/2013/12/6C-5-Top-10-Health-Tech-Hazards-2014-%E2%80%93-ECRI.pdf 2014. Accessed May 10, 2016.].

Alarm systems safety is complex. Beyond the mere high rate of non-actionable alarms, safety can be compromised as alarms often look and sound alike [9Sowan AK, Tarriela AF, Gomez TM, Reed CC, Rapp KM. Nurses perceptions and practices toward clinical alarms in a transplant cardiac intensive care unit: Exploring key issues leading to alarm fatigue. JMIR Hum Factors 2015; 2(1): e3.
[http://dx.doi.org/10.2196/humanfactors.4196] [PMID: 27025940] , 10Sowan AK, Gomez TM, Tarriela AF, Reed CC, Paper BM. Changes in default alarm settings and standard in-service are insufficient to improve alarm fatigue in an intensive care unit: A pilot project. JMIR Hum Factors 2016; 3(1): e1.
[http://dx.doi.org/10.2196/humanfactors.5098] [PMID: 27036170] ]. These similarities can decrease clinicians’ sensitivity to alarm urgency and affect clinicians’ responses to alarms. Moreover, such challenges raise questions about the usability of medical devices [9Sowan AK, Tarriela AF, Gomez TM, Reed CC, Rapp KM. Nurses perceptions and practices toward clinical alarms in a transplant cardiac intensive care unit: Exploring key issues leading to alarm fatigue. JMIR Hum Factors 2015; 2(1): e3.
[http://dx.doi.org/10.2196/humanfactors.4196] [PMID: 27025940] , 10Sowan AK, Gomez TM, Tarriela AF, Reed CC, Paper BM. Changes in default alarm settings and standard in-service are insufficient to improve alarm fatigue in an intensive care unit: A pilot project. JMIR Hum Factors 2016; 3(1): e1.
[http://dx.doi.org/10.2196/humanfactors.5098] [PMID: 27036170] ]. Recent studies in ICUs show that alarm safety is affected by multifactors such as unit layout, lack of policies and procedures on alarm management, poor usability of physiologic monitors, lack of standardized practices on alarm reduction strategies, and most important to the current topic, lack of nurse competence on physiologic monitors use [9Sowan AK, Tarriela AF, Gomez TM, Reed CC, Rapp KM. Nurses perceptions and practices toward clinical alarms in a transplant cardiac intensive care unit: Exploring key issues leading to alarm fatigue. JMIR Hum Factors 2015; 2(1): e3.
[http://dx.doi.org/10.2196/humanfactors.4196] [PMID: 27025940] -13Sendelbach S, Wahl S, Anthony A, Shotts P. Stop the noise: A quality improvement project to decrease electrocardiographic nuisance alarms. Crit Care Nurse 2015; 35(4): 15-22.
[http://dx.doi.org/10.4037/ccn2015858] [PMID: 26232798] ]. The need for system-based management strategies to improve alarm safety is well documented, especially in ICUs in which multiple monitoring devices are in constant use [1The Joint Commission. The Joint Commission announces 2014 National Patient Safety Goal. Available from: http://www.jointcommission. org/assets/1/18/jcp0713_announce_new_nspg.pdf Accessed April 1, 2016.-4ECRI. ECRI Institute Top 10 Health Technology Hazards Report for 2014. Available from: http://www.visimobile.com/ wp-content/ uploads/2013/12/6C-5-Top-10-Health-Tech-Hazards-2014-%E2%80%93-ECRI.pdf 2014. Accessed May 10, 2016., 9Sowan AK, Tarriela AF, Gomez TM, Reed CC, Rapp KM. Nurses perceptions and practices toward clinical alarms in a transplant cardiac intensive care unit: Exploring key issues leading to alarm fatigue. JMIR Hum Factors 2015; 2(1): e3.
[http://dx.doi.org/10.2196/humanfactors.4196] [PMID: 27025940] -13Sendelbach S, Wahl S, Anthony A, Shotts P. Stop the noise: A quality improvement project to decrease electrocardiographic nuisance alarms. Crit Care Nurse 2015; 35(4): 15-22.
[http://dx.doi.org/10.4037/ccn2015858] [PMID: 26232798] ]. On the other hand, although some system-based alarm management strategies achieved success in alarm reduction [14Cho OM, Kim H, Lee YW, Cho I. Clinical alarms in intensive care units: Perceived obstacles of alarm management and alarm fatigue in nurses. Healthc Inform Res 2016; 22(1): 46-53.
[http://dx.doi.org/10.4258/hir.2016.22.1.46] [PMID: 26893950] , 15Cvach MM, Biggs M, Rothwell KJ, Charles-Hudson C. Daily electrode change and effect on cardiac monitor alarms: An evidence-based practice approach. J Nurs Care Qual 2013; 28(3): 265-71.
[http://dx.doi.org/10.1097/NCQ.0b013e31827993bc] [PMID: 23187092] ], in other studies this success was not complemented with improvements in alarm fatigue or nurses’ attitudes toward alarm safety [9Sowan AK, Tarriela AF, Gomez TM, Reed CC, Rapp KM. Nurses perceptions and practices toward clinical alarms in a transplant cardiac intensive care unit: Exploring key issues leading to alarm fatigue. JMIR Hum Factors 2015; 2(1): e3.
[http://dx.doi.org/10.2196/humanfactors.4196] [PMID: 27025940] , 10Sowan AK, Gomez TM, Tarriela AF, Reed CC, Paper BM. Changes in default alarm settings and standard in-service are insufficient to improve alarm fatigue in an intensive care unit: A pilot project. JMIR Hum Factors 2016; 3(1): e1.
[http://dx.doi.org/10.2196/humanfactors.5098] [PMID: 27036170] ]. Nurses reported the need for more training on physiologic monitors [9Sowan AK, Tarriela AF, Gomez TM, Reed CC, Rapp KM. Nurses perceptions and practices toward clinical alarms in a transplant cardiac intensive care unit: Exploring key issues leading to alarm fatigue. JMIR Hum Factors 2015; 2(1): e3.
[http://dx.doi.org/10.2196/humanfactors.4196] [PMID: 27025940] , 10Sowan AK, Gomez TM, Tarriela AF, Reed CC, Paper BM. Changes in default alarm settings and standard in-service are insufficient to improve alarm fatigue in an intensive care unit: A pilot project. JMIR Hum Factors 2016; 3(1): e1.
[http://dx.doi.org/10.2196/humanfactors.5098] [PMID: 27036170] ]. It seems that the complexity of modern IT-equipped physiologic monitors requires structured individualized training focused on developing specific skill sets to navigate monitors and manage alarms [11Sowan AK, Reed C, Tarriela AF, Gomez TM. Flaws in clinical alarm safety studies: The value of mixed methods and objective alarm data. Crit Care Med 2015; 43(12): 206.
[http://dx.doi.org/10.1097/01.ccm.0000474648.68026.66] , 12Gomez T, Sowan AK, Tarriela A, Reed C, Stepanik K. Reducing non-actionable alarms of cardiac monitors as a strategy to improve alarm safety in a transplant/cardiac ICU. Crit Care Nurse 2015; 35(2): e72-3.].

Studies on nurse training on alarm management are a few and tend to be focused on limited skills related to frequency and best practice in electrodes change and customizing parameters to be patient-specific [14Cho OM, Kim H, Lee YW, Cho I. Clinical alarms in intensive care units: Perceived obstacles of alarm management and alarm fatigue in nurses. Healthc Inform Res 2016; 22(1): 46-53.
[http://dx.doi.org/10.4258/hir.2016.22.1.46] [PMID: 26893950] , 15Cvach MM, Biggs M, Rothwell KJ, Charles-Hudson C. Daily electrode change and effect on cardiac monitor alarms: An evidence-based practice approach. J Nurs Care Qual 2013; 28(3): 265-71.
[http://dx.doi.org/10.1097/NCQ.0b013e31827993bc] [PMID: 23187092] ]. None of the previous studies outlined nurse competence on physiologic monitors use. To guide our initiatives and achieve Phase II of TJC’s clinical alarm systems safety NPSG, we created and validated a structured list of required alarm management skills and surveyed ICU nurses on their competence level on using physiologic monitors.

In this study, we created and validated a set of competencies and surveyed bedside ICU nurses on their knowledge and perceived confidence in using physiologic monitors. Our initial intent was to gain information that would guide future in-service training on physiologic monitors use. Ultimately, we hope to develop a standardized self-assessment checklist that adult ICU nurses can use to evaluate and enhance alarm systems management and safety practices.

Excluding the 5 items under advanced/specialized functions subscale, 1 to 7 nurses (3% - 23%) reported a lack of skills or knowledge to perform one or more of the remaining 54 functions/features of the physiologic monitors. All of these items were rated as needed by the expert nurses who validated the survey, of particular interest, at least one fifth of the nurses reported a lack of confidence in 17 essential functions. Some of these functions were related to alarm management and appropriate monitoring, such as extending alarm pause time. Additionally, 9 (30%) nurses reported not using or had never heard of this particular function, indicating the need for future in-service. Extending alarm pause time is an important alarm management strategy to decrease the number of false alarms and alarm fatigue, especially for care procedures that last longer than 1 minute, which is the default setting of alarm pause in our system that can be extended to 5 or 10 minutes. On the other hand, some institutions may discourage extending the pause period for safety purposes.

There was also a reported lack of confidence in customizing default settings to be patient specific, recognizing when specific monitoring is needed for specific medical cases, and in eliminating redundant alarms when changing default settings. These skills are essential for safe monitoring and to decrease alarm fatigue and the overall number of alarms.

Our data also support the need to improve nurses’ skills on troubleshooting technical alarm messages and monitoring problems, when to contact service personnel and how to report device malfunctions. More than 20% of the nurses reported lack of confidence in these skills and up to 3 (10%) reported they had never used or heard of these functions. The narrative data also indicated the need for future in-service training on these skills. The absence of a standardized reporting system for device malfunctions is likely to contribute to this problem.

There are many types of Technical alarms. Examples of such alarms include “Empty Battery”, an alarm triggered because the remaining charge/power in the battery to operate the device is down to 10 minutes. This alarm cannot be paused or silenced and should be acknowledged by replacing the battery or connecting the device to the charger. To troubleshoot this particular alarm, nurses need to know how to identify the battery's power status of the X2 monitor from the display color, which is one of the front panel color indicators or LEDs (Item 11). Up to 11 (37%) nurses reported they had never heard of these functions. Other technical alarms include “ECG Leads Off”, which is triggered when leads are displaced or not all required leads are attached, and “Check Patient ID”, an alarm triggered when there is a mismatch in patient data between two monitoring devices connected to the patient. Nurses’ lack of competence in troubleshooting “Check Patient ID” technical alarm may explain nurses’ limited confidence in editing patient information after admission as well as resolving patient information mismatch (Items 4 and 5).

Troubleshooting monitoring problems is essential for alarm management. Most of the research on alarm management focuses attention on physiologic alarms [6Görges M, Markewitz BA, Westenskow DR. Improving alarm performance in the medical intensive care unit using delays and clinical context. Anesth Analg 2009; 108(5): 1546-52.
[http://dx.doi.org/10.1213/ane.0b013e31819bdfbb] [PMID: 19372334] -8Drew BJ, Harris P, Zègre-Hemsey JK, et al. Insights into the problem of alarm fatigue with physiologic monitor devices: A comprehensive observational study of consecutive intensive care unit patients. PLoS One 2014; 9(10): e110274.
[http://dx.doi.org/10.1371/journal.pone.0110274] [PMID: 25338067] ]. Little information is available on the rate of technical alarms, which also contribute to alarm fatigue [19Bonafide CP, Lin R, Zander M, et al. Association between exposure to nonactionable physiologic monitor alarms and response time in a childrens hospital. J Hosp Med 2015; 10(6): 345-51.
[http://dx.doi.org/10.1002/jhm.2331] [PMID: 25873486] ]. In a previous study [10Sowan AK, Gomez TM, Tarriela AF, Reed CC, Paper BM. Changes in default alarm settings and standard in-service are insufficient to improve alarm fatigue in an intensive care unit: A pilot project. JMIR Hum Factors 2016; 3(1): e1.
[http://dx.doi.org/10.2196/humanfactors.5098] [PMID: 27036170] ], Sowan and colleagues analyzed data logged from physiologic monitors in a Transplant Cardiac ICU for a 10-week period and found a total of 9224 technical alarms (unpublished results, personal communication with the authors), equivalent to a rate of 12.6 alarm/patient day, with the most common being ECG Leads Off (a total of 5552 alarms).

Lack of confidence in different skills may be related to lack of use (or rarely used functions), lack of training on physiologic monitors, and/or lack of usability of physiologic monitors. However, skills such as admit and discharge a patient, connect monitor cables, place electrodes, identify major hardware components, pause and silence alarms, know parameters’ display and the meaning of waves, view active alarm messages and differentiate priority, change alarm limits safely, easily and appropriately, and many other skills are all commonly used in any adult ICUs on daily basis and essential for safe and appropriate monitoring. Having nurses reported lack of confidence in these fundamental skills strongly supports the need for training and examining the usability of physiologic monitors. Our results suggest poor usability of some features of the monitors. For example, 4 to 5 (13% - 17%) nurses reported lack of confidence in navigating different monitors' screens easily and efficiently (Items 43 and 52). Other nurses reported they had never heard of or used these functions. Furthermore the lack of confidence of the nurses in identifying the difference between latching and non-latching alarms and the high reported percentage (40%) on never heard of this function can be related to the look-alike and sound-alike alarms [10Sowan AK, Gomez TM, Tarriela AF, Reed CC, Paper BM. Changes in default alarm settings and standard in-service are insufficient to improve alarm fatigue in an intensive care unit: A pilot project. JMIR Hum Factors 2016; 3(1): e1.
[http://dx.doi.org/10.2196/humanfactors.5098] [PMID: 27036170] ], another usability-related issue. Since ease-of-use is a fundamental usability attribute, these findings, and similar to previous findings [9Sowan AK, Tarriela AF, Gomez TM, Reed CC, Rapp KM. Nurses perceptions and practices toward clinical alarms in a transplant cardiac intensive care unit: Exploring key issues leading to alarm fatigue. JMIR Hum Factors 2015; 2(1): e3.
[http://dx.doi.org/10.2196/humanfactors.4196] [PMID: 27025940] , 10Sowan AK, Gomez TM, Tarriela AF, Reed CC, Paper BM. Changes in default alarm settings and standard in-service are insufficient to improve alarm fatigue in an intensive care unit: A pilot project. JMIR Hum Factors 2016; 3(1): e1.
[http://dx.doi.org/10.2196/humanfactors.5098] [PMID: 27036170] , 20Sowan AK, Reed CC, Staggers N. Role of large clinical datasets from physiologic monitors in improving the safety of clinical alarm systems and methodological considerations: A case from Philips monitors. JMIR Hum Factors 2016; 3(2): e24.
[http://dx.doi.org/10.2196/humanfactors.6427] [PMID: 27694097] ], further support the need to examine the usability of physiologic monitors.

In the narrative data, nurses asked to focus the in-service on functions review and appropriate navigation of the central-station monitor. They also wanted to understand the data transmission process from the bedside to the central monitor, and the limitations of the two monitors. Although many of the functions/skills included in the survey are applicable to bedside, central-station and transport monitors, the processes of completing tasks and screen navigation differ based on the monitor in use. For example, the steps to admit a patient are different when using the central-station versus the bedside monitor, requiring nurses to master multiple skill sets. Additionally, some skills are limited to specific monitors, such as clearing sectors, unit management of log alarm data, and locating equipment, which are limited to the central-station monitor. Our survey did not focus on the specific skills limited to the central-station monitor.

Although skills on the survey were applicable to all adult ICUs and some items were written in general terms such as “know different types of parameters display”, patients’ medical conditions require knowledge of case-specific parameters. Therefore, the suggestion to have unit-specific super users is vital. For example, Neuro ICU nurses reported a concurrent monitoring of 2 ICP readings, a parameter that may not be frequently monitored in other ICUs. Monitoring 2 ICP measurements requires nurses to pick an alternative waveform for the second ICP measurement. In this case, it is important to know the capabilities of the physiologic monitor in terms of the maximum number of waveforms that can be displayed. Our bedside monitors allow simultaneous display of 8 waveforms. So, for example, if nurses are monitoring the waves of Lead 1, Lead 2, Pulse, NBP (noninvasive blood pressure), CVP (central venous pressure), ABP (arterial blood pressure), Respiration, and one ICP, they need to eliminate one of these measurements to monitor a second ICP waveform. Nurses usually sacrifice the Respiration waveform. The nurse decision on the parameter to sacrifice should be carefully made based on the client condition and the possibilities for risking safety. This issue, for example, can be one of the critical unit-specific training aspects.

In regard to advanced functions, more than one third of the nurses were either not aware or not using the following features: sepsis protocol/guidelines, manual entry of data into the monitor, and drug calculator. Not using sepsis protocol can be related to the fact that a sepsis protocol is embedded into the electronic medical record (EMR), reducing the need for such feature within the physiologic monitors. On the other hand, this feature can be useful for hospitals with no e-protocol for sepsis and when complete interoperability exists between the EMR and physiologic monitors. Similarly, manual entry of lab data into the monitor may not be usable, specifically when there is no algorithm to connect lab data and the monitored parameters to help in clinical decision-making. Likewise, the use of drug calculator within the monitor can be inconvenient for nurses, given the availability and ease of access to pocket calculators, cell phones, and/or drug calculation apps. When hospitals select their physiologic monitors and medical devices, a thorough discussion with the vendor is recommended to ensure optimal use of advanced features of their products. Unfortunately, little research is available about the use of such features within the physiologic monitors.

Our survey includes skills required by all bedside ICU nurses based on our institution’s policies and procedures of safe monitoring. In other hospitals, some of these skills may be performed by nurse practitioners, super users, certified critical care nurses, or physicians. Therefore, adhering to unit policies and procedures is important when surveying nurses about their competence on physiologic monitors use. Additionally, a system for periodic assessment, training, and documentation of nurse competence on physiologic monitors use should be in place for safe monitoring.

In previous projects on alarm systems safety, assembling a multidisciplinary alarm management team, changing alarm default settings, having a unit policy on frequency of electrodes’ replacement, and providing standardized in-service nursing training on physiologic monitors use were insufficient to reduce alarm fatigue, despite a significant reduction of 25% in alarm rate [10Sowan AK, Gomez TM, Tarriela AF, Reed CC, Paper BM. Changes in default alarm settings and standard in-service are insufficient to improve alarm fatigue in an intensive care unit: A pilot project. JMIR Hum Factors 2016; 3(1): e1.
[http://dx.doi.org/10.2196/humanfactors.5098] [PMID: 27036170] ]. Lack of competence on physiologic monitor use is a root cause of alarm fatigue [9Sowan AK, Tarriela AF, Gomez TM, Reed CC, Rapp KM. Nurses perceptions and practices toward clinical alarms in a transplant cardiac intensive care unit: Exploring key issues leading to alarm fatigue. JMIR Hum Factors 2015; 2(1): e3.
[http://dx.doi.org/10.2196/humanfactors.4196] [PMID: 27025940] , 10Sowan AK, Gomez TM, Tarriela AF, Reed CC, Paper BM. Changes in default alarm settings and standard in-service are insufficient to improve alarm fatigue in an intensive care unit: A pilot project. JMIR Hum Factors 2016; 3(1): e1.
[http://dx.doi.org/10.2196/humanfactors.5098] [PMID: 27036170] ]. The educational aspect of this complex problem can be improved by focusing attention on the skills nurses need to effectively, efficiently and safely navigate physiologic monitors. Our competence list includes basic navigation skills for all adult ICUs. Detailing unit-specific skills can expand the list and super users should facilitate the competency process.

The findings of this study should be interpreted in light of the following limitations. Although we had a motivated sample, our sample size was small due to budget constraints. Including a larger sample of nurses would improve our knowledge about the essential skills in physiologic monitors use in adult ICUs and improve the generalizability of the study and survey. Extending the survey to pediatric and neonate ICUs may also be beneficial to understand unit-specific skills in monitoring pediatric and neonate patients. Although our survey was designed based on the features of Philips and General Electric Monitors, many items on the survey are applicable to all physiologic monitoring devices irrespective of the manufacturer. The main difference among physiologic monitors from different vendors can be related to the availability of advanced features (e.g., sepsis protocols). On the other hand, examining the survey against the functions of other monitoring devices may increase its generalizability.

This is the first study to create and test a list of competencies for physiologic monitor use. Rigorous, periodic and individualized training is essential for safe and appropriate use of physiologic monitors and to decrease alarm fatigue. Training should be comprehensive to include all necessary skills and should not assume proficiency on basic skills, such as admitting a patient to the monitor. Special attention should be focused on managing technical alarms. Increasing each unit’s number of super users is a recommended strategy for individualized and unit-specific training. There is a need for usability testing of complex IT-equipped medical devices such as physiologic monitors for effective, efficient and safe navigation.