Alarm fatigue is an issue that many hospitalists wrestle with (or ignore) on a daily basis. “We would often sit in the middle of all these alarms continuously ringing. [They were] just always going off,” said Eric Awtry, MD, inpatient medical director of cardiology at Boston Medical Center (BMC).
The Joint Commission has made alleviating alarm fatigue a National Patient Safety Goal. Phase I of its campaign began in January 2014 and required hospitals to establish alarms as a priority and identify the most important alarms to manage in their facilities. In Phase II, beginning in January 2016, hospitals will be expected to implement policies and procedures to remedy the problem.
The Joint Commission and other experts are concerned that the constant din of alarms in today's hospitals results in difficulty in detecting alarm signals, high noise levels, and staff desensitization to important alarms, among other issues.
Fixing this will require a multidisciplinary effort that includes hospitalists, according to experts. “It has to be the physicians, the nurses at the bedside, the clinical nurse specialists, the monitor techs, and biomed,” said Sue Sendelbach, PhD, RN, director of nursing research at Abbott Northwestern Hospital in Minneapolis, who has studied and published about alarm fatigue.
In many hospitals, a handful of alarms make up the bulk of unnecessary alerts. Experts say alarms for cardiac monitors rank near the top, along with those for blood pressure and oxygen saturation.
Researchers at the University of California, San Francisco (UCSF), investigated the causes of alarms in the ICU in an article published in the October 2014 PLOS ONE. Unnecessary alerts resulted mostly from “inappropriate alarm settings by the clinical staff, certain patient conditions such as having a pacemaker or a bundle-branch block, and algorithm deficiencies by the monitor manufacturers,” said study author Barbara J. Drew, RN, PhD, a clinical professor of cardiology at UCSF.
In addition to cardiac monitors, bed alarms and IV pump alarms add significantly to the total number of alarms a floor experiences. “Almost any equipment connected to the patient now has an alarm,” said Deborah Whalen, MSN, MBA, clinical service manager of cardiology at BMC.
When the din of alarms becomes the norm, ignoring them is an unfortunate side effect, one that may put patient care at risk. “Where there is a really critical alarm, it may well be missed because either people have become immune to responding to it or there's so much other noise you don't actually even recognize that there's an important alarm going off,” Dr. Awtry said.
Much of the research conducted around alarm fatigue focuses on the ICU. However, Dr. Drew believes the issue may be an even bigger problem on general medicine floors. “Patients on medical floors are more active,” Dr. Drew said. Walking down the hall or even using the bathroom can cause a false arrhythmia alarm.
Intensive care units have another advantage over general medicine wards, and that's an increased ratio of nurses. “Most of the monitoring that's occurring right now is occurring actually outside ICU settings, where the staffing ratios are 1-to-5 and 1-to-6 patients,” Ms. Whalen said. In addition, non-ICU patients may be farther from a nurses' station and not as easily seen in their individual rooms compared with the typically good lines of sight in the ICU.
There are established ways to reduce unnecessary alarms, experts say—”things like the clinically appropriate settings for the alarms, when they can be disabled, when parameters can be changed, who can change parameters and who can set parameters, monitoring the whole process, checking individual alarms for accurate settings, proper operation,” said Maureen P. Carr, project director of standards and survey methods in the Division of Healthcare Quality Evaluation at The Joint Commission.
In addition, resources are available from the Association for the Advancement of Medical Instrumentation (AAMI), which has compiled an alarms best practices library, and the ECRI Institute, which provides research and advice to help hospitals address alarm safety concerns.
At Abbott Northwestern Hospital, an interdisciplinary team (technicians, nursing staff, cardiac surgeons, hospitalists, and intensivists) reviewed alarm data from machines in the ICU. Duplicate alarms were identified and eliminated, as were those that were incorporated into other indicators, such as for couplet arrhythmias.
“The drop in alarms was 80% to 90%, and we've maintained that,” said Sharon Wahl, MSN, RN, clinical nurse specialist at Abbott Northwestern. The program was implemented almost 2 years ago and continues to be spot-checked several times each year.
In a pilot project at BMC, alarm data showed 90,000 audible cardiac monitor alarms per week on a 24-bed medical cardiology unit, so a multidisciplinary team decided to target cardiac monitor alarms as the major contributor to alarm fatigue. “Prior to the pilot there were 4 levels of alarm: message, advisory, warning, and crisis. Data showed it was the [self-resetting] warning alarms that led to the majority of alarms on this unit,” Ms. Whalen said.
The BMC team set out to eliminate warning alarms and make all important alarms “crisis alarms” that could not reset. The main concern was inadvertently making the environment less safe, but crafting the right alarm defaults insured this would not happen, Ms. Whalen said.
All clinically significant alarms were elevated to crisis alarms, including upper and lower heart-rate violations. Heart rate limits were slightly adjusted to 45-130 beats per minute (from 50-120 beats per minute previously) to better reflect values at which nursing staff should reevaluate a patient for clinically significant changes.
Also, 2 RNs were empowered to change alarm status or rate limits and to notify a physician of changes if the violation was not a clinically significant change from the patient's baseline. For patients with normally occurring rhythm disturbances such as chronic atrial fibrillation, order sets prompted downgrading this alarm to “advisory” on admission. This ensured staff would still be alerted as needed, but repeat alarms would be avoided, Ms. Whalen said.
Within 2 weeks of the program's launch, alarms had fallen by 89% without any apparent negative effects. “You can alter the false alarms but still maintain—in fact, I think improve—safety of the patients even though you're taking away almost 90% of the alarms,” Dr. Awtry said. The initiative was rolled out hospital-wide, reducing 1 million audible alarms per week to 400,000 per week.
While this project did use the resources of a large academic medical center, smaller facilities might actually find it easier to collect the necessary information about their alarms “because there are going to be smaller amounts of data,” said Ms. Wahl.
Those data should be shared with the clinicians on the front lines. “By showing their own personal data from the unit, it really helped make it meaningful to them,” said Stacy Jepsen, MS, a clinical nurse specialist in critical care at Abbott.
Regardless of whether the datasets are small or the budgets are large, addressing alarm fatigue is a complex venture that requires a variety of input. “A lot of organizations are probably putting together multidisciplinary teams to have a joint approach to this,” Ms. Carr said. “That would include physicians, nurses, and the people who manage technology.”