Alarm Fatigue and Clinical Alarm Management in the Neonatal Intensive Care Unit: A Scoping Review of Quality Improvement Interventions, Outcome Metrics, and Implementation Lessons
Aditya Hemendra Bhatt, Somashekhar Marutirao Nimbalkar, Lalan K. BhartiBackground
Alarm fatigue in neonatal intensive care units (NICUs) may affect patient safety, staff well-being, and the developmental care environment. NICU alarm-management interventions have been reported across quality improvement (QI), before-after, randomized crossover, implementation, and observational designs, but outcome definitions, denominators, and safety measures remain heterogeneous.
Objective
To map NICU alarm-management interventions and related implementation studies, emphasizing intervention components, outcome metrics, alarm-burden outcomes, clinical safety measures, and implementation lessons.
Methods
This scoping review followed PRISMA-ScR guidance. PubMed/MEDLINE, Embase, CINAHL, and Cochrane Library were searched, with an updated search through June 2026. Eligible reports involved neonatal or newborn intensive care settings and addressed alarm fatigue, clinical alarm management, alarm burden, alarm thresholds, alarm delays, alarm routing, or related QI or implementation approaches. Two reviewers screened records and charted data. A protocol was predefined before screening but was not prospectively registered. Full database-specific search strategies are provided in Supplementary Appendix A. Owing to heterogeneity in designs, denominators, and outcome definitions, findings were synthesized descriptively and were not pooled.
Results
Sixteen studies/reports met inclusion criteria. The PRISMA-ScR flow diagram shows 20 records identified, 0 duplicates removed, 20 records screened, 3 excluded at title/abstract screening, 17 full texts assessed, 1 full text excluded, and 16 studies included. Included studies addressed alarm-threshold or parameter optimization, oxygen-saturation alarm strategies, staff education, protocol standardization, PDSA-based QI, alarm delay/filtering, handheld-device routing, and single-room NICU alarm workflows. Reported alarm reductions were directionally favorable in many studies, but denominators differed substantially, including total alarms, SpO 2 alarms, false alarms, non-actionable alarms, and alarms transmitted to handheld devices.
Conclusions
The NICU alarm-management literature describes cautiously favorable alarm-burden trends after carefully implemented, patient-tailored, multidisciplinary approaches, while reported monitored safety outcomes were generally maintained in published studies. However, most evidence is observational, before-after, or QI in design; therefore, conclusions should remain descriptive and cautious. Limitations include heterogeneous outcome definitions, English-language full-text restriction, and limited long-term and economic data. The evidence does not support ranking intervention combinations or making causal comparative-effectiveness claims. Future work should use standardized NICU-specific alarm outcomes, predefined balancing safety measures, long-term sustainability assessment, and economic evaluation.