For the fifth time since its inaugural publication in 2007, the ECRI Institute's Top 10 Health Technology Hazards list has identified alarm hazards as the No. 1 threat to watch out for in 2013.
Although monitor alarms are designed to help keep patients safe, the biggest risk they pose today is alarm fatigue caused by the sheer number of alarms bombarding hospital staff.
"According to the ECRI, alarm fatigue occurs when staff is exposed to an excessive number of alarms and that can result in sensory overload," said Sue Sendelbach, PhD, RN, CCNS, FAHA, director of Nursing Research, Abbott Northwestern Hospital, Minneapolis. "This sensory overload can cause staff to become desensitized to the alarms that may result in delayed alarm response or missed alarms."
"It is a big problem, and some people will characterize the problem as noise," said Marjorie Funk, PhD, RN, FAHA, FAAN, professor at Yale University School of Nursing and affiliated with Yale-New Haven Hospital, New Haven, Conn. "But it's really not just about the noise . alarm fatigue has led to sentinel events."
With hundreds of alarms ringing on a daily basis - most of them false or not actionable - it is easy to understand how nurses and other clinicians could easily succumb to alarm fatigue and delay their response or ignore alarms altogether.
According to Sendelbach, research has shown that people will respond only 10% of the time if the monitoring system is perceived to be only 10% reliable.
"Clearly, systems that have a high percentage of false alarms do not create a safe environment," she said. "In addition, it's been demonstrated that individuals have difficulty learning more than six different alarm signals. And, yet in an intensive care unit environment there can be up to 40 different alarms."
Once healthcare leaders understand alarm fatigue and its negative effects, they can educate their staff and implement precautionary measures to help reduce the overabundance of monitor alarms and the negative outcomes that often come with them.
Maria Cvach, MS, RN, CCRN, assistant director of ursing, Clinical Standards, Johns Hopkins Hospital, Baltimore, noted their medical progressive care unit initially registered more than 500 alarms per bed per day.
After staff identified this as a significant safety issue in 2006, Cvach and Andrew Currie, Johns Hopkins Hospital's director of clinical engineering, began a project that sought to uncover just what was causing so many alarms and what they could do about it.
The first hurdle was creating a system to measure the problem, and Cvach and her team found a way to log all of their monitor alarms and prioritize them into four categories - high, medium, low and technical.
Alarming Success: Hospital leaders at Johns Hopkins Hospital joined their Alarms Management Committee to accept ECRI Institute's 2012 Health Devices Achievement Award for their alarm improvement efforts.ADVANCE thanks Johns Hopkins Hospital.
"We looked at 18 days of data, and we got thousands and thousands of alarms," Cvach said. "What we found was that by and large, the bulk of alarms fell into the category of low priority alarms."
With this data in hand, the team turned their attention to alarm improvement initiatives, and they realized some of the most common sense solutions could have huge results.
For starters, they took a hard look at their threshold parameters and asked staff to help them identify when alarms were considered actionable.
"Every hospital can do this and not need a lot of human resources," Cvach said. "Just doing simple things like changing thresholds, getting rid of duplication and removing any kind of alarm that's not considered actionable, we were able to reduce our quantity of alarms by 43%."
Other alarm improvement initiatives they instituted included:
- Updating the electrode placement procedure - changing electrodes daily reduced alarms by 46%, Cvach said.
- Removing duplicative alarms.
- Implementing secondary alarm notification systems for each unit.
- Instituting a hospital-wide alarm committee to create a comprehensive policy that incorporates the best practices for alarm management, electrode application, lead monitoring and staff notification.
- Educating staff about monitoring equipment and alarm management policies.
- Reminding staff to customize monitors for each patient.
These simple changes combined to reduce alarms throughout the hospital - and reduced alarms on the medical progressive care unit alone from the overwhelming 500 per bed per day to under 100. "That was very significant, but it is still a lot of alarms," Cvach noted.
One innovation everyone agreed will one day change monitoring practices for the better is smart alarm technology.
No matter how helpful new thresholds and better alarm management protocols can be in reducing alarms, nurses today are still responding to events that have already happened - the patient's heart rate has already dropped, or they have already been disconnected from the ventilator.
"The fact of the matter is that you get a lot of alarms, and they are highly sensitive but have a very low specificity," Cvach admitted. "But technology needs to change, and it needs to be more predictive and less reactive. What we really need is smart alarms that are able to predict patient deterioration before it occurs."
Smart alarms can pick up on the earliest signs that occur in patients and warn the bedside staff before a negative event, fundamentally changing the scope of monitoring technology. Funk noted some of the newest monitoring technologies are already showing promise, if units can get their hands on them.
"A lot of that technology is already available, but only on the newer models," Funk said. "Until a unit gets newer monitors, they might not have access to that. Or maybe nurses don't know it exists."
But smart alarms are not the only advancement that might help mitigate alarm desensitization, according to Jean T. Avery, MBA, BSN, senior manager, Office of Policy Support, Dartmouth-Hitchcock Hospital, Lebanon, N.H.
"There are also opportunities for manufactures to improve the problem by standardizing the meaning of different alarm tones, having escalating alarms so that the alarm tone changes or the volume escalates," suggested Avery. "These manufacturing changes could assist the nurse with alarm identification."
Fewer, smarter, and more varied alarms are going to help the bedside staff remain alert throughout their shift, ready to respond at a moment's notice when the patient needs them the most.
As healthcare providers continue to look for both simple and technologically savvy answers to one of the biggest health technology risks, researchers are still grappling with the possible implications of such efforts.
"We need well-designed randomized, controlled trials to look at some of these initiatives," Funk admitted. "There has been research that describes how many alarms there are . but we really haven't tested interventions yet."
"We don't want to implement an intervention if it's not going to be safe or not going to be effective or going to be too costly," she continued. "It's a huge problem and we have to be very thoughtful about how we approach it."
Until the research supports changes to monitoring systems at large, facilities like Johns Hopkins Hospital still have plenty of simple and safe alarm management improvements that can significantly reduce alarms and work toward eliminating alarm fatigue.
"When you get rid of alarms you benefit your staff and you decrease the amount of desensitization so they are more apt to pay attention to the alarms," Cvach said. "But also you benefit your patients and their families because there is less noise."
"Alarms are the patient's safety net, and failed response to alarms can lead to patient harm," Avery concluded. "This is an important issue where clinicians, researchers and manufactures working collaboratively can make a difference!"
Rebecca Hepp is on staff at ADVANCE. Contact: firstname.lastname@example.org.