This article is reprinted with the permission of Patient Safety & Quality Healthcare (PSQH). Improving patient safety is one of the most urgent issues facing healthcare today. PSQH is written for and by people who are involved directly in improving patient safety and the quality of care.
According to ECRI Institute, an independent, nonprofit organization that researches the best approaches to improving the safety, quality, and cost-effectiveness of patient care, alarm hazards are the number-one health technology hazard for 2013.
In its report, Top 10 Health Technology Hazards for 2013, ECRI states:
Medical device alarms perform an essential patient safety function. Physiologic monitors, medical telemetry units, ventilators, infusion pumps, dialysis units, and a host of other medical devices sound alarms or issue alerts to warn caregivers of potential problems with the patient. The sheer number of alarms, however, has itself become problematic. The result is that caregivers can become overwhelmed trying to respond to the alarms, or they can become desensitized, which can lead to missed alarms or delayed response, placing patients at risk.
In a recent incident, a patient died “when nurses did not respond to alarms on his cardiac monitor.” Massachusetts General Hospital agreed, apologized to the patient’s family, and settled the case for $850,000. The Boston Globe reported, “Investigators concluded that alarm fatigue experienced by nurses working among constantly beeping monitors contributed to their inattention. Additionally, the volume for a separate audible crisis alarm on his bedside monitor had been turned off.”
“Alarm fatigue is a national problem. Excessive false alarms occur frequently and contribute to alarm desensitization, mistrust, and lack of caregiver response,” says Maria Cvach, MS, RN, CCRN (assistant director of nursing, clinical standards, The Johns Hopkins Hospital). “This may lead to staff disabling or ignoring alarm systems, which decreases patient safety.”
Cathy Carlson, PhD, RN (associate professor, Northern Illinois University School of Nursing & Health Studies) describes how she has seen alarms impact patient care, “It’s amazing what nurses can tune out. Nurses get very tired of having to go again and again into a patient’s room for false alarms. When this happens, caregivers may disable, silence, or even ignore alarms. These caregivers need to ask themselves what would happen if their patient experienced an adverse event or death, all because their failure to use a device or ignore an alarm. Instead of ignoring or not responding effectively to alarms, we need to use available technologies to reduce false alarms.”
Using The Johns Hopkins Nursing Evidence-Based Practice model, Cvach analyzed research and non-research findings published between January 1, 2000, and October 1, 2011, on alarm fatigue in “Monitor Alarm Fatigue: An Integrative Review”. Her research provides an excellent analysis of the evidence on key difficulties with alarm fatigue:
- Excessive alarms and effects on staff
- Nurse’s response to alarms
- Alarm sounds and audibility
- Technology to reduce false alarms
- Alarm notification systems
Here we focus on four technology recommendations for decreasing monitor alarm fatigue that are evidence-based, as documented in Cvach’s research.
1. Use Smart Alarms
“Smart alarms” can reduce the number of false alarms by taking into account multiple parameters, rate of change, and signal quality. Cvach explains further:
Rather than using raw data, technology can base alarms on physiologic trends detected over a period of time. Signal filtering, algorithms, and/or artificial intelligence systems process alarms using filters or morphologic and timing differences to reduce the number of alarms.
Carlson provides an example where use of “smart alarms” could increase the use of patient monitoring:
Some physicians are preferring to use an IV push to administer opioids for pain management rather than PCA [patient-controlled analgesia] because the IV push does not require a capnograph monitor. As false alarms are often going off, these physicians see monitors as a hindrance to patient care. Using an IV push, however, not only ties up valuable nurses’ time and resources, but PCA has been shown to have significant benefits including improved pain management, increased patient satisfaction, and better pulmonary function. Frankly, all patients receiving IV opioids should be monitored, but to use an IV push instead of PCA goes against the findings of many studies. For example, using a capnograph monitor with a smart alarm would decrease the incidence of false alarms and, for the physicians I mentioned earlier, increase the use of PCA over IV push.
Recently, she presented at the American Society of Pain Management Nursing, “ETCO2 and Opioids: Measurement of the Ebb and Flow”.
2. Use Alarm Technology that Incorporates Short Delays
Alarm technology that allows for short delays can decrease the number of ignored or ineffective alarms caused by patient manipulation. Cvach says that studies have shown the benefits of making sure monitors are equipped with short delays:
Patient care requires procedures such as suctioning, washing, repositioning, and oral care. Adding short delays can eliminate annoying alarms from sounding during these brief periods.
Carlson cautions that these delays must be of sufficient length:
Monitors can typically be shut off for brief periods during procedures, but not long enough in the opinion of some health professionals. Make sure delays are long enough to help with completion of patient care procedures. However, ensure that delays are not too long so as to jeopardize patient safety.
3. Standardize Alarm Sounds
Research shows that people respond to alarms in different ways. As Cvach explains:
Perceived alarm urgency contributes to the nurses’ alarm response, but nurses use additional strategies to determine response including the criticality of the patient, signal duration, rarity of alarming device, and workload. A caregiver’s “probability match” is the alarm response based on the perceived true alarm rate. If an alarm system is perceived to be 90% reliable, the response rate will be about 90%; if the alarm system is perceived to be 10% reliable, the response rate will be about 10%.
Nurses respond to alarms for different reasons, not just the fact that the alarm sounds. Nurses adjust the order of their activities by evaluating alarm urgency in relation to the patient’s condition and have a greater tendency to react to alarms of longer duration and considered rare. As workload or task complexity increases, alarm response and task performance deteriorates. Thus, signal duration is an important influence, but workload, patient condition, and task complexity may lead to other reaction strategies.
Standardizing alarm sounds may be an effective way to reduce the number of alarms that staff must learn.
4. Make Monitoring Problems Easy to Fix
Human factors research applies principles of psychology to designing products and creating work environments that boost productivity while minimizing safety issues. How equipment is designed affects how effectively caregivers interact with it to ensure patent safety and health outcomes.
“Animating steps on the monitoring equipment for troubleshooting alarms would be helpful in assuring best practice with equipment,” says Cvach.
Researchers Wiklund and Kendler in their paper “Complementing Medical Device Alarms with Animated Guidance” (2011) provide the following example:
For example, an alarm message on a therapeutic workstation might signal the presence of air bubbles in a blood-filled line and provide immediate, step-by-step instructions to remove the air from the blood and restart the therapy. The guidance might even take the form of repeatable animations.”
Improve Patient Safety Through Monitoring
Do not let false alarms prevent the use of monitoring. The purpose of patient monitoring is there is to improve patient safety. As Cvach explains, “Patients depend on us to keep them safe during medical procedures and as they recover. We must not stop using or fail to use monitors because of false alarms. Technology that integrates a number of vital sign monitoring or reduces the incident of false alarms should be used.”
For further information about implementing these solutions, please see the list below, which highlights the research cited by Cvach:
Use Smart Alarms
Schmid F , Goepfert M S , Kuhnt D , Eichhorn V , Diedrichs S , Reichenspurner H , et al. The Wolf Is Crying in the Operating Room: Patient Monitor and Anesthesia Workstation Alarming Patterns During Cardiac Surgery. Anesthesia and Analgesia. 2011; 112(1):78–83.
Burgess LP , Herdman TH , Berg BW , Feaster WW , Hebsur S. Alarm Limit Settings for Early Warning Systems to Identify At-Risk Patients. Journal of Advanced Nursing. 2009; 65(9):1844–52.
Gross B , Dahl D , Nielsen L. Physiologic Monitoring Alarm Load on Medical/Surgical Floors of a Community Hospital. Horizons (BI&T suppl). Spring 2011;29–36.
King A , Roderer A , Arney D , Chen S , Forino-Mullen M , Giannareas A , et al. GSA: A Framework for Rapid Prototyping of Smart Alarm Systems. Proceedings of the 1st ACM International Health Informatics Symposium. 2010.
Otero A , Felix P , Barro S , Palacios F. Addressing the Flaws of Current Critical Alarms: A Fuzzy Constraint Satisfaction Approach. Artificial Intelligence in Medicine. 2009; 47(3):219–38.
Use Alarm Technology that Incorporates Short Delays
Gorges M , Markewitz BA , Westenskow DR. Improving Alarm Performance in the Medical Intensive Care Unit Using Delays and Clinical Context. Anesthesia and Analgesia. 2009; 108(5):1546–52.
Standardize Alarm Sounds
Phillips J. Barnsteiner JH. Clinical Alarms: Improving Efficiency and Effectiveness. Critical Care Nursing Quarterly. 2005; 28(4):317–23.
Make Monitoring Problems Easy to Fix
Wiklund M , Kendler J. Complementing Medical Device Alarms with Animated Guidance. Horizons (BI&T suppl). Spring 2011; 67–71.