The method of arranging medical devices and those that recognize and respond to alarms is fundamental to alarm safety.
The following are the 4 models or methods for alarm vigilance and notification in use today. These models are: line of sight, out of sight, monitoring techs, and automated notification. Let’s look at each one in turn.
LINE OF SIGHT
Back in the day when electronic medical devices were first used in hospitals, patient care areas were organized as wards. Patients were arranged in beds around the perimeter of a larger room with caregivers stationed somewhere along the perimeter or in the center of the room. When medical device alarms were triggered, nurses could very easily determine which patient’s device was ringing and see the alarm indicators on the medical device. Thus nurses could quickly determine if the alarming patient was one of their patients, and of so, the audible and visible alarm indicators indicated the urgency of the alarm. Due to this physical arrangement, alarm volumes could be set at moderate levels so as not to overly disturb patients while being sufficiently loud for vigilant caregivers.
Since these early days, not much has changed regarding medical device alarm annunciation. Bedside medical devices continue to be designed with audible alarms combined with some sort of visual cue such as a color coded flashing light or enlarged text display. A careful reading of a medical device’s user manual will reveal that medical devices are still designed for ward style line of sight units rather than today’s ubiquitous private rooms.
These days there are still certain types of units that are laid out in a ward style format. When I had my colonoscopy (what fun), the pre/post procedure area was a classic ward with curtained off beds around the perimeter and a nursing station in the middle of the room. Surgical PACUs are often laid out this way, as are some smaller high acuity units.
Line of sight alarm vigilance and notification is a best practice. If you work on a unit like this, or are a patient on one, thank your lucky stars that you likely don’t have to deal with persistent alarm fatigue or safety issues. Ward style units rarely have alarm fatigue issues due to the proximity between caregivers, patients and their medical devices. The medical device alarms work as designed in an environment in which they are intended to be used.
OUT OF SIGHT
This model deals with nursing units made up of private rooms, some of which always seem to be at the end of long halls. The key difference between this and the previous model is proximity between the caregiver and patient. When patients are in private rooms they are out of sight except when the caregiver is in a patient’s room — patients may also be down the hall, around a corner and behind a closed door. The privacy afforded by private rooms is highly valued such that the private room concept has been extended to EDs and critical care areas and is not going away. But the lack of proximity between the caregiver and patient is why these units are often the ones with the most alarm safety issues.
To bridge this new proximity gap between caregivers, patients and their medical devices, many techniques have been used to extend the medical device to be closer to the caregiver. Common methods for extending medical device alarms include:
- Turning alarm volumes up to maximum,
- Distribution of audible alarms via overhead PA systems,
- Applying acoustic treatments throughout the unit to better convey the sound of alarms,
- Message panels that cycle through the text descriptions of all active alarms, showing alarm description and patient room, and
- Slave displays and duplicate central stations sprinkled throughout the unit.
The above mitigations are less than ideal in that they do not provide the kind of immediacy found in the line of sight model of alarm vigilance. Caregivers may now be able to hear an alarm anywhere in their 36 to 60 patient unit, but they remain at a loss as to whether one of their patients is alarming and why. It is also important to note that these mitigations for out of sight alarm vigilance are also noted as the causes or major contributors to alarm fatigue.
Often these adaptations are not available from the medical device manufacturers and must be designed and implemented by the hospital. This is an unanticipated cost and puts the hospital in the position of having to modify FDA regulated medical devices.
Ironically, alarm safety issues on out of sight units have been exacerbated by the growing trend to monitor more patients and to monitor them anywhere in the hospital. This additional monitoring has been adopted to improve patient safety, yet for a variety of factors, can result in increased alarm fatigue.
With the proliferation of private rooms the design of nursing units has changed a lot over time, unfortunately how medical devices annunciate alarms has not. In fact, one could say that hospitals are using medical devices on out of sight units “off label” from the manufacturers intended use.
Out of sight alarm vigilance and notification as described above is a standard practice if only because so many hospitals take this approach to alarm notification in units with private rooms. Fortunately, the next two methods are both best practice approaches to alarm notification.
A less common mitigation of out of sight monitoring is the use of monitoring techs to provide the kind of direct oversight of monitored patients that are available in line of sight units. In this case, the monitoring techs are sitting right in front of the medical devices (central stations, actually) rather than looking at them across a room.
The use of monitoring techs mitigates the proximity issues that come with out of sight private rooms, without causing the alarm fatigue and safety issues associated with increasing audible alarms, message panels, etc. This monitoring tech oversight entails two key functions: they filter out all the nuisance and false/positive non-actionable alarms, and they ensure that actionable alarms receive a timely and effective response. Combined, these two capabilities have a huge impact on improving alarm safety. The end result is that caregivers only deal with actionable alarms, and out of sight nursing units maintain their quiet healing environment.
Monitoring techs are deployed in either a distributed fashion, putting small numbers of techs on individual units to over-watch that unit’s patients, or the techs are consolidated in a central monitoring “war room” where all patients are monitored from this central location. For notification of alarms, some hospitals have deployed dedicated red phones on nursing units covered by central monitoring and nurses know when the red phones ring a serious alarm has been detected. Another common monitoring tech-caregiver communications method is to use nurse carried wireless phones or Vocera badges.
A key reason the use of monitoring techs is not more prevalent is cost and overhead. Besides the costs associated with having to pay incremental head count that is not used in conventional out of sight units, many hospitals struggle with managing this specialized role. These management issues start with simply finding qualified (i.e., certified) candidates. In large urban areas this is not an issue, but in smaller markets this can be a significant issue. Hospitals often end up partnering with a local entity that can train and certify prospective monitoring tech employees. Sometimes hospitals have to develop their own education and certification capabilities to ensure an adequate stream of job candidates. Another common challenge is turnover. Watching 16, 30, up to 60 patients’ waveforms for 8 to 12 hours is stressful, and some techs burn out. The monitoring tech role could also be characterized as an entry level clinical job where competent and ambitious monitoring techs inevitably move on to bigger and better things.
Another issue with monitoring techs is that they can easily mask problems with the clinical practice of alarms. This clinical practice pertains to the proper prep, placement, maintenance and replacement of sensors applied to the patient. Another key aspect of this clinical practice revolves around the logistics of the sensors themselves. Sensors must be sourced from quality manufacturers, packaged and stored in a way that sensors are in peak condition when applied to patients. Poor clinical practice with sensors results in an increase in leads-off conditions and false/positive alarms that contribute to alarm fatigue. One of the saving graces of monitoring techs is that they can manually filter out these false positive and nuisance alarms and only report actionable alarms to caregivers on the units.
The use of monitoring techs is a best practice.
Starting with Emergin, in the early 2000’s, we saw the emergence of messaging middleware, software that interfaced with various systems, moving data between these systems and users, automating workflow. A key workflow that emerged was alarm notification.
These systems capture alarm data from medical device and nurse call systems (and optionally other systems), identify the patient, look up the responsible caregiver for that patient and send the alarm to the appropriate caregiver. Should the caregiver be unavailable, these alarm notification systems will automatically escalate the alarm to the patient’s backup caregiver. Alarm notification systems typically support multiple levels of message escalation.
Many alarm notification systems also transmit contextual information along with the alarm. This can be a portion of the waveform or trend associated with the alarm event, patient vital signs, and other clinical data from medical devices or the EMR. These alarm notification systems use mobile apps running on smartphones to convey alarms and automate workflow with caregivers. Automated alarm notification systems can provide the immediacy between the caregiver, their patients and connected medical devices that does not exist in out of sight units, at a cost that is substantially less than using monitoring techs.
Alarm notification systems are also a best practice. Every out of sight care delivery area should have either monitoring techs or an alarm notification system to ensure reliable alarm notification without causing alarm fatigue.
From a safety standpoint, monitoring techs have the advantage of being able to cover for poor alarm clinical practice. While alarm notification systems necessitate good alarm clinical practice, they have the advantage of coordinating and automating a myriad of point of care workflows besides alarms, such as the integration of nurse call response. Too many point of care activities are manual, and as such are impossible to measure and track. A messaging middleware solution provides that data capture capability providing a new set of management information to improve patient safety, outcomes and workload balancing across staff.