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Clinical Alarm Management and Response (3.5.3)

Clinical Alarm Management and Response (3.5.3) - Policies, Clinical, UW Health Clinical, Medical Records and Communication, Patient Assessment


Policy Title: Clinical Alarm Management and Response
Policy Number: 3.5.3
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: January 1, 2016


To provide guidance to healthcare professionals (HCP) regarding clinical alarm safety and management.


A. Clinical Alarms:
i. Clinical alarms are intended to alert healthcare providers of a change in patient condition, or when
equipment requires attention.
a. Clinical alarms indicate the patient is at actual or potential risk and requires attention.
b. Examples of clinical alarm equipment:
1. Physiology monitoring devices
2. Continuous pulse oximeter monitors
3. Bed and/or chair alarms
4. Infusion pumps
5. Ventilators
6. Non-invasive Positive Pressure Ventilation Devices
7. Gas Analyzer
B. Nuisance Alarms:
i. Alarms that do not measure an actual patient condition change or require action for the patient
(non-actionable alarms).
ii. Two alarms that measure the same thing (duplicate alarms).
iii. Alarm limits that are not adjusted for patient condition.
C. Alarm Equipment Signals:
i. “Enable” or “On” is defined as a signal that is active and will create an audible or visual alert if
patient value is outside of set parameter.
ii. “Disable” or “Off” is defined as an alarm signal that is not active so that an audible or visual alert
would not sound regardless of patient condition.


A. HCPs should monitor and respond to clinical alarms for which they are directly responsible and receive
training and/or show competency related to the device.
B. HCPs should consider patient safety the top priority when adjusting or modifying alarms.
C. It is recommended that:
i. Alarms are confirmed as on and audible as clinically indicated when assuming care of the patient.
ii. Physiologic parameters are evaluated at least twice per day for inpatient units.
iii. “Discharge” or “End Case” on the bedside, central or transport monitor must be completed after
every patient encounter to reset default parameters if patient received continuous cardiac
D. Alarm signals may be temporarily paused, silenced or delayed to allow for patient care. When leaving the
patient, alarms should be returned to on and audible.
E. Unless there are specific parameters ordered alarm parameters may be adjusted to trigger an alarm
indicating a change in patient condition or operational abnormality based on physiologic status or clinical
area. If an adjustment is made to an alarm setting by a HCP not responsible for caring for the patient, it is
the responsibility of the person making the change to alert the assigned HCP caring for the patient.
F. Disabling alarm signals:
i. A nuisance alarm may be disabled as long as there are sufficient alarms enabled to alert the HCP
to a change in patient condition.
ii. Additional policies may reference alarm settings for specific devices or clinical situations.
G. Alarm parameter settings
i. Default alarm parameters and settings are set according to UW Health clinical experts’
recommendations in conjunction with manufacturer’s recommendations and supporting evidence.
H. Clinical Equipment Alarm Settings:

Policy Title: Clinical Alarm Management and Response
Policy Number: 3.5.3

i. Will be serviced and preventive maintenance performed according to manufacturer’s
recommendations by Clinical Engineering.
ii. Alarm operation will be verified by Clinical Engineering when equipment is placed in patient use.


Author: Director, Nursing Quality and Safety
Senior Management Sponsor: SVP, Patient Care Services and CNO
Reviewers: Cardiology Clinical Nurse Specialist(s); Associate Nursing Informatics Specialist; Director,
Nursing Informatics; Physician Leadership; Clinical Engineering; Respiratory Therapy; Medical Director of
Patient Safety
Approval committees: Alarm Management Committee; Nursing Administrative Policy and Procedure
Committee; UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: December 21, 2015

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.


Jeff Grossman, MD
UW Health CEO

Teresa Neely

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee


-The Joint Commission 2014 National Patient Safety Goal on Alarm Management (NPSG.06.01.01).
-AACN Practice Alert. Alarm Management, 5/2013.
-Graham. K.C., and Cvach, M. (2010). Monitor alarm fatigue: standardizing use of physiological monitors
and decreasing nuisance alarms. American Journal of Critical Care, 19, 28-37.
-Gross, B., Dahl, D., and Nielsen, L. (2011). Physiologic Monitoring alarm load on medical/surgical floors of
a community hospital. Biomedical Instrumentation Technology, Spring, 29-36.

Version: Original
Next Revision Due: January 1, 2019