Bedside alarms reduced up to 74% in some units

(Editor’s note: This is part 2 of a two-part series on alarm fatigue. In last month’s issue we discussed how to reduce alarm fatigue. In this month’s issue, we tell you how The Johns Hopkins Hospital reduced alarms up to 74% in some areas.)

A group of nurses, physicians, and engineers at The Johns Hopkins Hospital have significantly reduced the number of distracting, non-critical bedside alarms in some of the hospital’s noisiest areas — up to 74% in some cases — in an improvement that has been linked to patient safety.

For its efforts in reducing bedside alarms, ECRI Institute awarded The Johns Hopkins Hospital its Health Devices Achievement Award for 2012.

The effort is an example of how a methodical and carefully analyzed research process can be applied to alarm management and result in a significant improvement in patient care, says Maria Cvach, MSN, RN, CCRN, assistant director of nursing clinical standards at Johns Hopkins and leader of the hospital’s alarm improvement efforts since 2006. “This project came about because, like a lot of healthcare organizations, we were concerned about how to improve safety with clinical alarms,” she says. “One of the top reasons for missing an alarm is alarm fatigue. There are too many alarms, and people are just desensitized to the amount of noise. They either hear it and ignore it, or they don’t hear it and don’t take action.”

Ironically, improvements in monitoring have led to the need to reduce the number of alarms, Cvach explains. “In healthcare we have created the perfect storm with all of these monitoring devices,” Cvach says. “Monitor alarm systems are set to be very sensitive and unlikely to miss a true event, but result in too many false positives.”

Baseline measures revealed the scope of the challenge for Johns Hopkins’ Alarms Management Committee: One 12-day alarm system analysis registered 58,764 alarms, an average of 350 per patient per day. In addition to noise reduction, the quality-improvement project sought to prevent alarm fatigue. “Frequent alarming can cause a ‘cry-wolf’ effect,” Cvach explains.

By collecting baseline measurements, defining and validating appropriate alarm settings, and working with each unit to develop an alarms improvement plan, the multidisciplinary team safely reduced the cacophony from monitors hospitalwide. Reductions ranged from 24% to 74% across units.

Andrew Currie, MS, CBET, Hopkins’ director of clinical engineering, says, “Patients and staff need a quiet environment. We are trying to reserve noisy alarms for the most important, actionable events. In some cases, units switched some lower-priority alarms to visual rather than auditory notifications.” Currie co-chairs the alarms committee with Cvach and Adam Sapirstein, MD, associate professor in the Department of Anesthesiology/Critical Care Medicine in The Johns Hopkins School of Medicine and also a faculty member in the Johns Hopkins Armstrong Institute for Patient Safety and Quality.

The coordinators of the effort say that partnering with leaders on each unit was essential to their success, because improvements needed to be tailored to individual settings. Currie says, “A one-size-fits-all approach would not have received the kind of support we needed to address this problem.”

Before setting out to alter alarm settings, the committee analyzed and rated each alarm based on importance and risk to ensure back-up notification systems were in place for the most critical alarms. Cvach says, “For high-priority alarm conditions, redundancy is important. Our units need multiple ways to ensure audibility of alarm signals and patient safety.”

The group’s other efforts include testing new equipment, assessing alarm management alternatives, developing new policies, creating and assessing training efforts, and considering new alarm technologies. Three postoperative care units, including an outpatient cardiac unit, are reviewing alarm management alternatives, Cvach says.

All hospital units have instituted processes including altering their alarm parameters, so they are receiving only “actionable” alarms, Cvach says. The units also implemented secondary alarm notification, so they are advised of alarms if they aren’t at the bedside, she says.

A pilot study tested use of an alarm integration system to send high priority alarm signals to cell phones or pagers carried by nurses, who, with the press of a button, can escalate the alarm to a back-up if they’re unable to respond. On one unit, high priority messages are sent to a pager that each nurse carries. On another unit, there is a single pager for the charge nurse. The investigators compared the frequency and duration of alarms. “We found a significant difference in the alarm frequency and duration when each nurse carried a pager versus just the charge nurse,” Cvach says. “There was a 23% reduction in average alarm duration time when each nurse carried a pager. When just a charge nurse carried a pager, we still saw a reduction, but just a 13% reduction in average alarm duration time.”