During the course of a typical 12-hour shift, and depending on the unit, the bedside nurse may encounter hundreds, if not thousands, of alarms generated by patient monitoring equipment. From chirping ventilators to beeping infusion pumps to chiming heart rate monitors, the barrage of noise is so ubiquitous that some nurses even dream about alarms in their sleep.
The alarms are designed to catch a patient in crisis—to signal a dangerous heart rhythm, or plummeting oxygen levels, for instance—and many times, they are lifesaving. But more often, the alerts are false, and the excessive cacophony of pings, rings, and chimes has given rise to a phenomenon known as “alarm fatigue,” whereby overwhelmed nurses and other caregivers become desensitized to the racket and tune it out like background noise.
“I worked in ICUs for 30 years and you truly almost don’t hear it,” says Marc Schlessinger, RRT, MBA, FACHE, a senior associate at the ECRI Institute, a non-profit that evaluates medical devices and works on patient safety issues. “You become so immune to it, that when it’s truly a critical alarm that you have to react to, you may miss it.”
That appears to be what happened two years ago at Vibra Hospital in San Diego when staff failed to respond to a patient’s ventilator alarm for 12 minutes.
According to a report released by California state health regulators, sometime in the early morning hours of May 4, 2014, a portion of the patient’s ventilator tubing became disconnected and a loud alarm began sounding. As the patient’s oxygen levels plummeted, dozens of pages were dispatched to a licensed vocational nurse on duty and a respiratory technician—but no one immediately responded.
The patient’s nurse, who was just 13 feet away at the nurses’ station, said she heard the ventilator alarm going off, but it didn’t occur to her there was a problem. “It was just a vent alarm, it’s not like the oxygen saturation alarm, so I didn’t think anything of it,” she told state regulators. By the time staff responded, the patient was blue and unresponsive. She died 28 days later.
Such incidents are all too common. According to the Joint Commission, alarm fatigue was the single most common factor contributing to 98 alarm-related sentinel events between 2009 and 2012, 80 of which resulted in death. A 2011 investigation by The Boston Globe, meanwhile, identified at least 216 deaths nationwide between 2005 and 2010 that associated with problems with monitoring alarms. Alarm fatigue, the Globe found, was often the root cause.
Tackling the Problem
While there are no easy fixes, hospitals and researchers are taking steps to tackle the vexing problem.
Boston Medical Center (BMC) has dramatically reduced the number of nuisance alarms in its institution by better managing equipment default settings. After mining alarm data on a cardiac telemetry unit, BMC found that the vast majority of false alarms were generated by clinically insignificant changes in heart rate or rhythm that would set off two-beep “warnings” that would typically reset on their own. All told, these self-resetting alarms were generating 175,646 beeps per week.
To cut down on the noise, BMC eliminated the low-priority alarms and elevated more serious alarms to “crisis level,” which triggers three beeps and requires the nurses to review and respond each time it sounds. Other key changes included tweaking low and high heart rate parameters and empowering nurses to personally tailor alarm settings for patients. So far, the strategy seems to be working. Since implementing the changes hospital wide, BMC has reported a 60% drop in alarm noise, nurses seem less stressed, and patient satisfaction scores have improved.
Other institutions, meanwhile, have turned to central monitoring as a solution. At Nemours Children’s Hospital in Central Florida, pediatric med-surg patients are remotely monitored by a team of paramedics who track the patients’ vitals and alarms 24/7. They can visualize the patient in bed, if need be, via a high-resolution camera installed in each room.
If the paramedic detects that a child is in distress or sees a concerning trend, they can promptly alert the patient’s nurse, call a rapid response, or initiate a code blue. Or if an alarm sounds and they see that the patient is just jumping on the bed, they can let the nurse know that too, explains Daniela Melendez, nurse manager of Nemours’ Clinical Logistics Center. “There’s that peace of mind for that nurse that they didn’t have to stop what they were doing taking care of their current patient to go tend to something that really didn’t need their attention at that moment.”
Richard Fidler, a critical care nurse practitioner, nurse anesthetist, and assistant adjunct professor at University of California San Francisco School of Nursing, worries that too often the reflexive reaction to alarm fatigue is simply to silence the alarms. “They are just bothersome and most of the time, the only thing people know about interacting with the monitor and alarms is where is the silence button… The reaction isn’t why is it alarming, but how do I stop it?”
To help clinicians better sort through the data and the din, Fidler and his UCSF colleagues are working on designing a “super alarm” that could filter out irrelevant information, while at the same time recognizing and alerting caregivers to significant trends. Fidler provides the hypothetical example of patient who comes into the hospital with a heart rate of 65 bpm and develops a gastrointestinal hemorrhage. Over six hours, the patient’s heart rate climbs to 125. In today’s world, those heart rates probably wouldn’t trigger a single alarm, “though the patient is obviously headed south pretty quickly.”
Already, the UCSF team, which is led by biomedical engineer and associate professor Xiao Hu, has shown that they can accurately predict impending code blue events in ICU patients hours in advance by honing in on certain ECG changes that current monitoring can’t detect.
Tips to Reduce Alarm Fatigue
Until better technological solutions are widely available, experts offer these pieces of advice to hospitals and RNs seeking to reduce the problem of alarm exhaustion.
1. Reduce Nuisance Alarms.
ECRI’s Schlessinger says the number one thing hospitals can do is decrease non-actionable alarms. “A perfect example of a non-actionable alarm would be a ventilator where you have one or maybe two high pressure alerts and you’re not going to get off your chair and do anything, because truly nothing needs to be done,” explains Schlessinger. “A similar alarm would be a transient heart rate alarm, or a low pulse ox. A non-actionable alarm is something that truly corrects itself in a matter of seconds with no intervention required.”
2. Tailor Settings.
Many clinicians simply rely on the default alarm settings created by the manufacturer, but one size does not fit all. A patient with severe COPD, for instance, would have a dramatically different baseline EtCO2 and SpO2 levels than a patient without lung disease. Schlessinger says the ECRI recommends hospitals have a “policy that alarms be tailored to each patient—and it doesn’t matter if it’s a ventilator alarm, if it’s a heart rate alarm, pulse ox, whatever. It should be tailored to each patient’s individual needs.”
3. Ensure Good Electrode Contact.
Loose electrodes are a frequent cause of false alarms. Proper skin prep can greatly reduce artifact on electrocardiogram monitoring. Some institutions require the daily replacement of EKG electrodes to avoid problems.
4. Educate the Patient.
Nurses aren’t the only ones affected by alarm noise. Patients also get exhausted by the cacophony and slow staff response to alarms can add to their worry, says Fidler. “It may actually make them start wondering, ‘Is this not a good hospital? Are the staff not good? Why are they not coming in here when this thing beeps?” Whenever possible, explain to patients and their families why alarms are sounding and what they mean.
5. Avoid Over-Monitoring.
Consider whether your patient requires monitoring, what the appropriate level of monitoring might be and have a collaborative conversation about it. “This practice of putting a patient on a telemetry unit, or monitored unit, because they get a lower nurse-to-patient ratio has got to stop, because you’re contributing to alarm fatigue by putting people who don’t need monitoring on the monitor,” advises UCSF’s Fidler. “Conversely, I don’t want somebody saying ‘Oh, he [sets off] too many alarms, take him off the monitor.’”
6. Join Your Alarm Management Committee.
As of January, the Joint Commission requires every hospital to have an alarm management strategy in place and input from those on the frontlines of patient care is invaluable. If your hospital doesn’t have an alarm management committee, consider starting one. “Every new thing coming into the hospital has some kind of alarm attached to it. Even if it’s a power disconnect alarm—everything has some kind of alarm,” says Fidler.