On April 8, 2013, the Joint Commission published a Sentinel Event Alert on medical device alarm safety in hospitals. Once again, alarm hazards tops the ECRI Institute's 2013 Top 10 Health Technology Hazards. Alarm fatigue is unfortunately a topic that is evergreen because it has plagued hospitals for many years and shows little sign of abating. A search of the literature will show the most common consequence of alarm fatigue is a failure to rescue adverse event (in which
the vast majority 80% of patients die). A secondary consequence is on patient satisfaction; constant alarms audible throughout the unit make it difficult for patients to sleep.
The root causes of alarm fatigue can be divided into two areas: 1) nuisance alarms caused by false positive alarms, leads-off alarms (most often due to motion artifact, poor lead prep and/or low quality sensors), and alarms that are not clinically actionable (i.e., the alarm goes off and the nurse responds, but there's nothing for them to do), and 2) noise pollution resulting from annunciating all the alarms in a busy high acuity unit at sufficient sound levels to be heard throughout the unit.
Effectively managing alarm fatigue requires hospitals to do a number of somewhat complicated of things well. The Joint Commission Sentinel Event Alert, and AAMI's efforts on alarms tend to focus on these basics:
- Properly setting alarm limits,
- Buying quality physiological sensors, proper prep and placement of physiological sensors, and
- Making sure alarms from all monitored patients are audible in the nursing unit.
These clinical and operational best practices will reduce but never eliminate alarm fatigue, especially on busy high acuity units - to do that you need to mitigate the incessant noise from alarms going off across the unit - 24/7.
The Need for Alarm Notification
The patients in a typical high acuity unit generate a lot of alarms; the (thankfully) rare patient generates alarms continuously. Making sure all medical device alarms are audible throughout the nursing unit becomes a big part of the problem. The noise from all these device alarms is broadcast across the unit for everyone to hear and quickly becomes overwhelming, desensitizing caregivers and resulting in alarm fatigue.
In these situations, the ability to route alarms from the medical device directly to the responsible caregiver, and notifying them without exposing the rest of the nursing unit staff to every alarm, can have a huge impact on reducing alarm fatigue to a manageable level. (I currently track around 17 messaging middleware vendors who provide alarm alarm notification features.)
Monitoring Tech "War Rooms"
Some hospitals utilize monitoring techs to pre-screen alarms for caregivers in an effort to filter out false/positive nuisance alarms and to enable a reduction of alarm annunciation volumes in the unit. When this approach is used, monitoring techs watch remote central stations and notify the responsible caregiver when they see an actionable true/positive alarm. Monitoring techs are either gathered in a central location, often called a "bunker" or "war room," or placed within the unit they are supporting.
Using monitoring techs allows the nurses on the units to turn down alarm volumes and await notification from monitoring techs of alarms via "bat phones" placed around the units, Vocera badges or wireless handsets carried by the nurses. The problem with monitoring techs is that they're expensive. A 500 bed hospital can spend $2-3 million in operating costs annually on this approach. In many markets, finding and keeping these monitoring techs can be very difficult.
Compared to monitoring techs, an alarm notification solution automatically routes alarms to the caregiver responsible for the patient generating the alarm. These systems also automatically escalate notifications to backup caregivers ensuring a timely response to all alarms. One weakness of alarm notification solutions is that they cannot filter out false/positive nuisance alarms the way a trained and certified monitoring tech can. In the past, products like DataCritical's StatView, and similar products from Spacelabs and a few others - all now discontinued - displayed physiological waveforms of the alarming parameter associated with the alarm. This would enable the caregiver to quickly rule out false/positives and other nuisance alarms by looking at the same waveforms a monitoring tech would see. However, other than Welch Allyn's AcuityLink Clinician Notifier, none of the currently available alarm notification solutions include physiological waveforms.
When comparing the use of monitoring techs to purchasing an alarm notification solution, monitoring techs continue to have the advantage of being able to see the physiological waveforms associated with an alarm and make a determination as to whether the alarm is a false/positive alarm or not. Once alarm notification vendors implement support for waveforms (it's been done before, and cleared by FDA) this advantage of monitoring techs will be neutralized.
Given the ever present and increasing pressures on hospitals to control costs, I expect alarm notification systems to replace monitoring techs in the mid to long term.
Here are some additional links that may be of interest:
- ACCE page on alarm fatigue
- The ECRI Institute's Alarm Safety Resource page
- Mainstream news stories on the consequences of alarm fatigue, here and here
- A great story on alarm notification written by Jim Welch
- Another alarm notification story from the same magazine written by yours truly
- Philips Issues Alarm Notification Warning Letter: a surprising letter to customers in reaction to continued adverse events associated with alarm fatigue
The Joint Commission has published an infographic about medical device alarm safety that reinforces the root causes and consequences of alarm fatigue.
Sadly their recommendations/solutions in the infographic are totally inadequate. I would estimate that virtually 100% of hospitals and nursing units have already undertaken the activities on the Joint Commission's infographic list. In fact, their recommendations are just that, a list of activities, without the context of specific goals or objectives that must be accomplished to reduce alarm fatigue.
Eliminating alarm fatigue requires accomplishing three objectives: 1) greatly reduce nuisance alarms, 2) screen out false/positive alarms, and 3) route and manage alarms electronically to reduce noise pollution and ensure a timely alarm response. The 5 recommendations in the Joint Commission infographic are really just some of the activities required to implement the three objectives above.
And be sure to check out this ongoing discussion on alarm fatigue here under the Healthcare Technology Safety Institute's group page on LinkedIn.
Hi Tim, thanks for the great post. One point I am curious about:
“I currently track around 17 messaging middleware vendors who provide alarm alarm notification features.”
I would be interested in those 17 vendors/products you have inspected.