EXECUTIVE SUMMARY

Clinicians are still overwhelmed with excessive alarms. There has been little progress in reducing the threat to patient safety.

• The rate of improvement is not keeping up with the increasing number of alarms.

• The vast majority of alarms are false or not clinically significant.

• Hospitals must address alarm fatigue so clinicians do not ignore the alarms.


Alarm fatigue still is a serious threat to patient safety and years of effort have yielded minimal improvement, experts say. Some effective strategies have been identified, but the problem could worsen before a real solution is found.

Diminishing the cacophony of alarms is proving to be more difficult than first imagined, says Paul Dexter, MD, research scientist with the Regenstrief Institute, an informatics and healthcare research organization, and associate professor of clinical medicine at Indiana University School of Medicine, both in Indianapolis.

“It’s a very active issue. There have been efforts to improve the situation but it is likely, in many ways, to only get worse,” Dexter says. “I don’t think the rate of improvement is matching the influx of all the new alerts, reminders, and alarms coming our way. We have tried to improve the precision and specificity of the alarms, but so far that is not enough.”

Most efforts involve trying to make the alarms and reminders more patient-specific, Dexter says. The patient history also can be factored in to the way alarms work, he notes, so that if a clinician has overridden an alert a number of times, that particular alert might be disabled or made less intrusive.

The adoption of such strategies is inconsistent across hospitals and health systems, Dexter says. Part of the problem is that device vendors tend to err on the side of safety, partly because of their own liability concerns, and encourage the widest use of their databases to detect allergy conflicts, for example, he says. It is up to the healthcare providers to tailor the use of the machine to their own needs, he says.

“You should take the vendor’s package of drug interactions and have clinicians assess what is right for your institution and your patients,” Dexter says. “If you don’t and you go with the vendor’s default settings for everything, you can end up with an overwhelming number of alarms and reminders. That can prompt people to turn off the functionality entirely, which is the wrong solution.”

Dexter urges hospitals to monitor and catalog alarms on particular units because you cannot effectively reduce the burden without knowing exactly what clinicians are subjected to on a daily basis.

“It’s the only way to know what’s really happening and to find a way to isolate those alarms that are most problematic,” Dexter says. “You can find those alarms that are overridden on a regular basis, and then there should be a very good reason to keep that alarm as-is or else you need to stop that alarm from interfering with patient care.”

New Guidelines Can Help

The American Association of Critical-Care Nurses (AACN) in Aliso Viejo, CA, recently issued a Practice Alert on the issue, titled “Managing Alarms in Acute Care Across the Life Span: Electrocardiography and Pulse Oximetry,” which outlines evidence-based protocols and clinical strategies related to alarm management. (See the story in this issue for more on the Practice Alert.)

Alarms can be detrimental to patient safety if they are not managed properly, says Nancy Blake, PhD, RN, NEA-BC, CCRN, FAAN, former nursing director at Children’s Hospital in Los Angeles, former board member with AACN and a member of the Association for the Advancement of Medical Instrumentation Alarm Coalition.

“While clinical alarms are meant to alert the clinician to a potentially harmful event for the patient, they are not without problems. If any of the monitors with integrated alarms aren’t used properly, they can become more of a hindrance to the clinician in performing their patient care duties,” she says. “Over the years, the growing number of alarms have contributed to sensory overload, and the clinicians have become desensitized to the alarms because of alarm fatigue. This alarm fatigue has contributed to delayed response to the alarms, which is a patient safety issue as clinicians could be missing a potentially critical event that triggered the alarm.”

Research has indicated that a range of 89% to 99% of alarms are false or clinically insignificant, Blake says. There are alarm parameters that are unique to every patient population, so it is important to look at the issue across the lifespan of the patient, she notes. It is important to ensure that the alarm settings are appropriate for the patient population.

The Joint Commission developed a leadership standard that requires the organization’s leadership to work with clinicians to develop structures and processes to manage alarms, Blake notes. This standard reinforces that alarm management affects the entire organization and is not an individual clinician problem.

“The Joint Commission realized that without a comprehensive approach, bedside clinicians alone are unable to fix this issue in organizations. It also ensures that the key decision-makers, when it comes to equipment, policies, and procedures, fully understand and are actively involved in solving this issue together as part of the team,” she says. “This has made alarm management an organization priority over the last few years, causing organizations to change the way they manage alarms from an organizational perspective and making it a high priority patient safety issue.”

Find Best Practices

By setting up teams to work on this issue and making this a joint problem to solve, an organization can truly examine its own issues and events and create a unique process based on evidence to help decrease or eliminate alarms that may be clinically insignificant or not actionable, Blake says.

The AACN Practice Alert also looks at best practices from using the equipment correctly or as intended by the manufacturer, to how the skin is prepped prior to placing the ECG electrodes, Blake notes. It suggests how often the electrodes must be changed daily to decrease the number of false alarms and technical alarms that are not due to a patient event.

“As hospitals strive to be high-reliability organizations and decrease patient harm while in the hospital, the AACN Practice Alert can assist in not only changing organization practice, but also developing unit-specific practices, organizational policies and procedures, ongoing education, and safe bedside practices to check the alarms at patient handoff, which supports excellence in practice,” Blake says. “Implementing the recommended practices and understanding the entire issue around managing clinical alarms will improve patient safety.”

The very high rate of false or clinically insignificant alarms is difficult to reduce, notes Bette McNee, RN, NHA, clinical risk management consultant at insurance broker Graham Company in Philadelphia. From the 89% to 99% found in research, even a concerted effort to address alarm fatigue typically reduces that number only about 50%, McNee says.

“Any nurse working in this area will still tell you that these alarms are still a diversion in their efforts to provide good patient care,” McNee says. “They have to keep their sensitivity up and respond to these alarms, even when a far majority of them are false. They have to step away from documentation and other patient care to check them out.”

In terms of improvements, the low-hanging fruit includes things like setting parameters specific to each patient, rather than having a machine default to a generic range of readings for all patients, she says. That kind of improvement is necessary, but only gets you so far in tackling the problem, she says.

Real improvement will come with building algorithms that consider various vital sign readings before triggering an alarm, McNee says. The goal should be to get the technology to work for the healthcare staff, having the machine do some of the initial thinking to realize that the one abnormal reading does not actually require the nurse’s intervention, she says.

“We’ve seen hospitals trying to go more toward wireless and silent alarms, and we’re seeing hospitals involve IT more to address technical alarms,” she says. “Some of these alarms are for technical issues like loss of Bluetooth connectivity or a low battery, so hospitals are diverting those nonclinical alarms to the IT department, which helps relieve some of the fatigue for nurses.”

Hospitals must continue to seek solutions, McNee says, because otherwise nurses will be tempted to silence the alarms instead of responding to each one, which can be deadly.

“Unfortunately, when people don’t know how to adjust them or nothing is done to reduce the alarms, nurses have been known to silence them. There have been deaths attributed to nurses silencing alarms because they just had so many alarms they didn’t know what else to do,” McNee says. “Unless hospitals put in some innovative solutions, the risk is still there to silence the alarm and move on.”

SOURCES

• Nancy Blake, PhD, RN, NEA-BC, CCRN, FAAN, The American Association of Critical-Care Nurses, Aliso Viejo, CA. Phone: (800) 809-2273.

• Paul Dexter, MD, Research Scientist, Center for Biomedical Informatics, Regenstrief Institute; Associate Professor of Clinical Medicine, Indiana University School of Medicine, Indianapolis. Email: prdexter@regenstrief.org.

• Bette McNee, RN, NHA, Clinical Risk Management Consultant, Graham Company, Philadelphia. Phone: (215) 701-5429. Email: bmcnee@grahamco.com.