Strategies for Managing Alarm Fatigue on the Floor

Alarm fatigue has moved to the forefront of hazards on the hospital floor. Nursing staff gets bombarded by hundreds or thousands of beeps, rings, whistles and pings emanating from bedside devices in a shift, and it can be difficult for them to distinguish the critical from the routine. An analysis of hospital alarms at Johns Hopkins Hospital counted a total of 59,000 alarms over a 12-day observation period, an average of 350 alarms per patient per day.1

Multiply that by several patients per nurse and it becomes a cacophony that's easy to tune out. The Food and Drug Administration database for cardiac monitoring devices for 2011 reported 565 incidents of patient harm due to alarm fatigue, 35 of which resulted in patient death.2

ECRI Institute lists alarm hazards as the top health technology hazard for 2015, as it has been in several previous years. The Joint Commission issued a National Patient Safety Goal for hospitals and critical-access hospitals to develop and implement alarm management strategies. In 2011 the Association for the Advancement of Medical Instrumentation (AAMI) held a summit with stakeholders from the FDA, the Joint Commission, the American College of Clinical Engineering and ECRI Institute that made recommendations that hospitals can employ to address alarm fatigue.1

In a national survey of 168 hospital personnel, 95% said they were concerned about the role alarm fatigue has in adverse events related to patient-administered analgesia.3 Alarm overload can have a significant effect on quality of care and outcomes, which are becoming more important as payment moves to a quality-based model. Alarm fatigue describes the desensitization to alarm signals that occurs when nurses become overwhelmed by their sheer number and then tune them out: studies have reported that 85% or more of alarms in hospital units are false.4 "Alarm [signals] should be about redirecting our attention from something that's less important to something that's more important," George Blike, Quality and Patient Safety Officer at Dartmouth-Hitchcock Medical Center, told the AAMI Summit.

The Joint Commission addressed alarm management in in its 2013 Sentinel Event Alert that cited 98 reports of alarm-related events between January 2009 and June 2012, 80 of which resulted in death, 13 in permanent loss of function and five in unexpected additional care or extended stays. Phase II of its National Patient Safety Goal takes effect January 2016, and hospitals "will be expected to develop and implement specific components of policies and procedures." Those policies and procedures must address the following:

• Clinically appropriate settings for alarm signals.
• When alarm signals can be disabled.
• When alarm parameters can be changed.
• Identify who in the organization has to authority to set and change alarm parameters, and turn them off.
• A plan to monitor and respond to alarm signals.
• A process to check individual alarm signals for accurate settings, proper operation and detectability.

In addition, organizations must educate staff and licensed independent practitioners about the purpose and proper operation of alarm systems for which they are responsible.

The evidence on return on investment in alarm management is sketchy at best. No studies have investigated the cost benefit of alarm management strategies. According to the American Association of Critical Care nurses, organization focus on alarm fatigue has been tied to improvements in patient satisfaction, clinical outcomes, relevance of clinical documentation, staff morale and effectiveness of the care team-but, again, no quantifiable data are available.

Potential Solutions for Alarm Fatigue

The AAMI summit developed a list of 10 actions healthcare organizations can take to improve alarm conditions. They included creating a cross-functional team with clinical leadership to address alarm fatigue across all environments of care, developing a continuous improvement process for constantly optimizing alarm configurations, and testing acoustics on clinical floors.1

Strategies to reduce alarm fatigue range from low-cost to no-cost approaches such as creating alarm management teams and re-evaluating alarm settings and eliminating self-resetting alarms to installing software to analyze alarm data and recalibrate alarm settings, which can cost six figures. Here's a look at some strategies that have hospitals and health systems have tried.

Eliminate self-resetting alarms.

In studying problems with alarm overload in the telemetry unit at Boston Medical Center, nurse investigators found that alarms with self-reset capabilities can result in an excess number of audible alarms and clinical alarm fatigue. The hospital instituted a pilot program to eliminate self-resetting alarms, and the total mean weekly audible alarms declined by 89% overall, staff and patient satisfaction scores improved, no adverse events related to missed cardiac monitoring events ensued, and the incidence of code blues decreased by 50%.5

Engage leadership in an inter-professional team.

Boston Medical Center formed an inter-professional team led by the chief medical officer to address the problem of alarm fatigue. Including senior management in addressing the issue of alarm fatigue is crucial. Better quality outcomes have been associated with hospital boards of directors who spend 25% of their time on quality issues and receive a formal quality performance measurement report.4
Use data to determine alarm settings.

Sue Sendelbach, director of nursing research at Abbott Northwest Hospital in Minneapolis, noted that alarm system configuration policy should be based on clinical evidence rather than accepting the manufacturer's default alarm configurations. Ironically, her review of strategies to eliminate alarm fatigue noted that minimal research has been conducted on appropriate alarm parameters.4

However, some anecdotal evidence has shown good results. Clinicians at Hoana Medical in Honolulu used physiological data from the general ward population to guide alarm settings and optimize false alarm rates.6 A pilot program at Johns Hopkins involved training nurses to individualize patients' alarm parameter limits and levels, and modifying monitor software to promote audibility of critical alarms. In this quality improvement project, critical monitor alarms were reduced 43% from baseline data.7

Sendelbach has cautioned that as default limits are widened, clinicians need to ensure that critical events are not missed and patients are not harmed.4

Middleware.

By definition, middleware is software that acts like a bridge between two different systems. In alarm management, middleware links alarms and alerts from various devices to the hospital communication system, which then sends signals to personal communications devices, namely smart phones.

Middleware can perform four critical functions in alarm management: help prioritize alarms, alarm escalation when a caregiver does not acknowledge the alarm within a certain time, route assignments (for example, by sending the message to one individual only), and help generate reports. Middleware comes with multiple implementation factors, such as what communication devices and medical devices it can interface with and whether it can interface with information systems.

Middleware also comes with a significant cost, upwards of $100,000, depending on the configuration. ECRI advises that a multidisciplinary team that includes clinicians, IT, facilities and biomedical engineering should lead middleware design efforts. Don't overlook simple things. For example, poor contact between ECG electrodes and skin has been known to contribute to artifacts. Something as simple as prepping the skin with fine sandpaper before placement of ECG electrodes can reduce artifacts. So can changing electrodes daily, as a quality improvement project at Johns Hopkins reported; this strategy led to a 46% reduction in the average number of alarms per bed per day.8

Meeting the Joint Commission National Patient Safety Goal will require a combination of these approaches to alarm fatigue. The lynchpin seems to be engagement of top-level hospital staff in the process. If they're not on board, bringing change to the patient care floors can be difficult.

Resources for Clinical Alarms Management

• Healthcare Technology Foundation: http://thehtf.org/clinical.asp
• Report from AAMI summit: http://s3.amazonaws.com/rdcms-aami/files/production/public/FileDownloads/Summits/2011_Alarms_Summit_publication.pdf
• 2015 Top 10 Hospital C-Suite Watch List, ECRI Institute: www.ecri.org/2015watchlist
• 2015 Top 10 Health Technology Hazards, ECRI Institute: https://www.ecri.org/Pages/2015-Hazards.aspx
• American Association of Critical Care Nurses Strategies for Managing Alarm Fatigue: http://www.aacn.org/dm/practice/actionpakdetail.aspx

REFERENCES:

1. Association for the Advancement of Medical Instrumentation. A siren call for action: priority issues from the Medical Device Alarms Summit, 2011. Available at: http://s3.amazonaws.com/rdcms-aami/files/production/public/FileDownloads/Summits/2011_Alarms_Summit_publication.pdf. Accessed March 26, 2015.

2. Welch J. Alarm fatigue hazards: the sirens are calling. Patient Saf Qual Healthc. 2012:9:26-33.

3. Wong M, Mabuyi A, Gonzalez B. First national survey of patient-controlled analgesia practices. Poster presented at Society for Technology in Anesthesia annual meeting, January 15-18, 2014, Orlando, FL.

4. Sendelbach S, Funk M, Tracy MF. Alarm fatigue: A patient safety concern. AACN Advanced Crit Care. 2013;24:378-386.

5. Whalen DA, Covelle PM, Piepenbrink JC, Villanova KL, Cuneo CL, Awtry EH. Novel approach to cardiac alarm management on telemetry units. J Cardiovasc Nurs. 2014;29:E13-E22.

6. Burgess LPA. Alarm limit settings for early warning systems to identify at-risk patients. J Adv Nurs. 2009;65:1844-1852.

7. Graham KC, Cvach MM. Monitor alarm fatigue: standardizing use of physiological monitors and decreasing nuisance alarms. Am J Crit Care. 2010;19:28-34.

8. Cvach MM, Biggs M, Rothwell KJ, Charles-Hudson C. Daily electrode change and effect on cardiac monitor alarms: an evidence-based practice approach. J Nurs Care Qual. 2012;28:265-271.