Too many alarms are not just irritating – they’re dangerous; here are some solutions
When caregivers are plagued with incessant waves of alarms and the continuous beeping of machines, they can grow desensitized to the noises and are more likely to ignore or miss important signals. A whopping 85-to-99 percent of alarms do not require clinical intervention, according to the Joint Commission, making alarm fatigue a top patient safety concern.
The commission received reports of 98 alarm-related “sentinel events” between 2009 and 2012, 80 of which resulted in patient deaths – and many such events go unreported. In Massachusetts, alarm fatigue caused at least 11 patient deaths between 2005 and 2011.
Alarm issues “vary greatly among hospitals and even within different units in a single hospital,” and “universal solutions have yet to be identified,” said the commission, which listed reducing alarm-related harm as a Top 10 goal for hospitals in 2017. Here, two providers in Massachusetts – Boston Medical Center (BMC) and Hebrew Rehabilitation Center – describe measures aimed at alleviating the problem.
A million alarms a week at BMC
BMC said it made progress in reducing alarm fatigue since 2012 after caregivers cut back on the number of alarms emitted by patients’ cardiac monitors. Alarm signals dropped from 1 million a week to about 400,000 across BMC through a multidisciplinary alarm management program.
“The key is to make all alarms meaningful and actionable,” said Deborah Whalen APRN, the clinical service manager for cardiology at BMC. “Alarms and their limits should be carefully selected by clinicians to ensure that only truly important clinical changes are signaled through an alarm. In addition, an alarm should bring staff to evaluate the patient when the alarm does occur.”
Before the changes, alarms would sound if a patient’s heart rate deviated even briefly from a pre-set range – typically 50 to 120 beats per minute - then automatically reset when the patient’s heart rate returned to the programmed range. Because the alarms did not require staff intervention, the ringing became more of a white noise than an emergency signal.
“For example, we have many patients on cardiac monitors whose heart rates drop to the upper 40s or low 50s when they sleep and that’s normal for them. A low heart rate limit of 50 would lead to excessive alarms,” Whalen said.
In an effort to cut down on unnecessary alarms that prove overwhelming for providers, Whalen’s team identified the most important parameters to be alarmed and heightened their status to a crisis level. Unlike the self-reset alarms, crisis alarms require staff to view and act in real time in order to silence the alarm.
They also trained two nurses to further customize settings for an individual patient if alarms are sounding that do not signal a clinically meaningful event. “We’ve really determined who has alarm ownership, so now nurses feel empowered to manage alarms,” Whalen said. “We’re putting alarm management in the hands of the people watching over the patients 24/7: our nursing staff.”
'It has greatly improved satisfaction'
After success in pinpointing best uses of cardiac condition alarms, BMC reduced their audible pulse oximetry alarms by 40 percent on two intermediate care units last year. Pulse oximetry settings were changed so that alarms emit when a patient’s oxygen level drops below 88 percent rather than 90 percent. Again, two chosen nurses have the ability to drop a patient’s trigger level to 85 percent if it would normally waver due to a condition like chronic hypoxemia.
Since the changes, Whalen said there have been no adverse events related to alarms. With the extra noise gone, call bells are more easily heard and there has been an increased responsiveness to call lights, she added.
“Staff and patients have noticed how much quieter it is and it has greatly improved satisfaction while maintaining patient safety,” Whalen said. “Technology is only as good as its processes – they must first be streamlined and controlled.”
Reduce alarm fatigue in your facility
Identify the most important alarm signals to manage based on:
Input from medical staff and clinical departments
Risk to patients if alarm signal is not attended to or if it malfunctions
Whether specific alarm signals are needed or unnecessarily contribute to alarm noise and alarm fatigue
Potential for patient harm based on internal incident history
Establish policies and procedures for managing alarms that address the following:
Clinically appropriate settings for alarm signals
When alarm signals can be disabled
When alarm parameters can be changed
Who in the organization has the authority to set and change alarm parameters
Who in the organization has the authority to set alarm parameters to “off”
Monitoring and responding to alarm signals
Checking individual alarm signals for accurate settings, proper operation, and detectability
Source: The Joint Commission (Hospital Accreditation Program National Patient Safety Goals, January 2017)
A long-term chronic care hospital’s approach
At Hebrew Rehabilitation Center (HRC) in Boston and Dedham, caregivers took a second look at their extensive use of pressure-sensitive alarms on the beds and wheelchairs of residents considered at risk for falling. In March of 2013, HRC began eliminating those alarms across its long- term chronic care and post-acute care units.
Karen Drake, a geriatric clinical specialist and certified lymphedema therapist, manages the post-acute rehabilitation therapy team at Hebrew Rehabilitation Center in Boston.
“We looked at the fall rates over the years and despite the high number of alarms, by the time they were answered the patient was on the floor,” she said. “There’s no research that shows that alarms bring efficacy, so do alarms really contribute to quality of life and make patients safer?”
Some research actually suggests alarms may be more harmful than helpful. Bozhena Kogan, director of nursing for HRC’s long-term chronic care hospital in Boston, found that alarms made patients nervous about moving around. The fear of setting off the alarms and creating a disturbance resulted in anxiety, incontinence, ulcers, muscle weakness, and other detrimental conditions.
“This project was all about a culture change,” she said. “We like to promote a home life environment and allow our patients to be comfortable, and we don’t have chair alarms in our houses.”
Prior to the alarm removal, almost 40 percent of the 600 patients had bed alarms, chair alarms, or both. In place of the alarms, staff introduced “purposeful rounding,” a more proactive and engaging approach to preventing falls. Nurses would check on patients regularly and ask if they needed to go to the bathroom, if they were in pain, or if they needed to be repositioned.
“Nurses are the ones identifying problems on the floor,” Drake said. “We had to change up the standard expectation and put nurses at the forefront, since people at the top do not experience firsthand the issues affecting patients.”
With only one patient having an alarm at the request of family, fall rates actually decreased following the removal and have remained stable. When patients do fall, huddles are initiated to analyze the fall and brainstorm new preventions.
“Just like when restraints were removed years ago, there was a fair amount of resistance against taking away alarms,” Drake said. “But now there have been absolutely no regrets in removing alarms – only feelings of positivity.”
Alarm fatigue events and responses
Alarm fatigue episodes can occur in all settings, as these serious reportable events (SREs) from Massachusetts institutions show:
Event: In 2013, a hospital patient grabbed the arm of a nurse who was responding to an alarm, “forcefully twisting it and momentarily pinning the nurse.” The bed alarm continued to sound. The RN was unable to turn it off because the patient grabbed her when she attempted to steady him. Other staff did not respond to the alarm - most likely because they felt it was ¨already covered¨ and did not realize that the RN needed help. In addition, the incident occurred at change of shift when staff was particularly busy completing documentation and other tasks.
Response: Alarm fatigue likely contributed to the lack of back up response from other staff. The hospital developed a new series of protocols, including training nursing staff on the correct way to use the alarm's double-tap feature to summon an immediate emergency response. Staff is also encouraged to test the double-tap function once per shift.
Event: In a 2013 case, a hospital investigation determined that the physical layout of a telemetry unit and its monitor configuration impaired the staff’s ability to hear and appropriately respond to clinical alarms in timely way.
Response: Trained telemetry monitor watchers were assigned to nursing stations to watch central monitors and notify patients’ nurses of alarms requiring immediate attention. Software was upgraded to allow push notifications from the telemetry unit to the nurses’ mobile devices so that concerning alarms can be immediately communicated when the nurse is with another patient and cannot hear the audible alarm.
Reducing alarm fatigue and desensitization in health care settings -- which the Joint Commission and other safety experts say is a complex and persistent concern.
Boston Medical Center and Hebrew Rehabilitation Center, both of which have reduced alarms by eliminating, recalibrating or disabling them depending on the condition and preferences of the patient.
Give nurses authority to customize settings for patients if monitors are sounding when they do not signal meaningful events. Consult with patients about their preferences; increase “purposeful rounding."
A consensus is growing that nurses and other front-line caregivers need more latitude to recalibrate or disable excessive alarms. Lines of authority over alarm management have to be clearly drawn.