Improving the Safety, Effectiveness, and Efficiency of Clinical Alarm Systems: Simulation-Based Usability Testing of Physiologic Monitors
Authors: Sowan Azizeh K , Staggers Nancy , Berndt Andrea , Austin Tommye , Reed Charles C , Malshe Ashwin , Kilger Max , Fonseca Elma , Vera Ana , Chen Qian 
Published: February 2021

Background
Clinical alarm system safety is a national patient safety goal in the United States. Physiologic monitors are associated with the highest number of device alarms and alarm-related deaths. However, research involving nurses’ use of physiologic monitors is rare. Hence, the identification of critical usability issues for monitors, especially those related to patient safety, is a nursing imperative.

Objective
This study examined nurses’ usability of physiologic monitors in intensive care units with respect to the effectiveness and efficiency of monitor use.

Methods
In total, 30 nurses from 4 adult intensive care units completed 40 tasks in a simulation environment. The tasks were common monitoring tasks that were crucial for appropriate monitoring and safe alarm management across four categories of competencies: admitting, transferring, and discharging patients using the monitors (7 tasks); managing measurements and monitor settings (23 tasks); performing electrocardiogram (ECG) analysis (7 tasks); and troubleshooting alarm conditions (3 tasks). The nurse-monitor interaction was video-recorded. The principal investigator and two expert intensive care units nurse educators identified, classified, and validated task success (effectiveness) and the time of task completion (efficiency).

Results
Among the 40 tasks, only 2 (5%) were successfully completed by all the nurses. At least 1-27 (3%-90%) nurses abandoned or did not correctly perform 38 tasks. The task with the shortest completion time was “take monitor out of standby” (mean 0:02, SD 0:01 min:s), whereas the task “record a 25 mm/s ECG strip of any of the ECG leads” had the longest completion time (mean 1:14, SD 0:32 min:s). The total time to complete 37 navigation-related tasks ranged from a minimum of 3 min 57 s to a maximum of 32 min 42 s. Regression analysis showed that it took 6 s per click or step to successfully complete a task. To understand the nurses’ thought processes during monitor navigation, the authors analyzed the paths of the 2 tasks with the lowest successful completion rates, where only 13% (4/30) of the nurses correctly completed these 2 tasks. Although 30% (9/30) of the nurses accessed the correct screen first for task 1 and task 2, they could not find their way easily from there to successfully complete the 2 tasks.

Conclusions
Usability testing of physiologic monitors revealed major ineffectiveness and inefficiencies in the current nurse-monitor interactions. The results indicate the potential for safety and productivity issues in completing routine tasks. Training on monitor use should include critical monitoring functions that are necessary for safe, effective, efficient, and appropriate monitoring to include knowledge of the shortest navigation path. It is imperative that vendors’ future monitor designs mimic clinicians’ thought processes for successful, safe, and efficient monitor navigation.