Hospitals mobilize to tackle alarm fatigue
At Bridgeport Hospital, "talking bed rails" programmed to speak to patients in the geriatric psychiatric unit are helping to reduce the number of alarms that sound when a patient at risk for falling tries to get out of bed.
At the Hospital of Central Connecticut in New Britain, health care professionals are adopting techniques from aviation safety experts to reduce the chances of a catastrophic event happening before a clinical alarm goes off.
These are among the many ways Connecticut hospitals are tackling a phenomenon known industry-wide as alarm fatigue.
Health care experts worry that medical devices with built-in alarms, such as heart monitors, infusion pumps and ventilators, designed to alert caregivers that patients are in danger could potentially put patients at risk because caregivers are desensitized by the sheer number of alerts and false alarms and fail to respond in a timely fashion. Research shows alarms in intensive care units are accurate less than 10 percent of the time, and 90 percent are false alarms.
Solutions for combating alarm fatigue range from alarm integration technology that sends alerts to a caregiver's telephone to the development of a new generation of "smart alarms," including ones designed to monitor multiple vital signs.
In Connecticut, a recent report from the state Department of Public Health on adverse events in hospitals noted that "alarm fatigue among hospital staff (non-response to alarms that are frequently inaccurate) is a serious problem."
"More alarms have crept into the clinical setting because they made sense, on the face of it. But in some cases, they've been pressed into service without evidence to support their use," said Dr. Steven D. Hanks, executive vice president and chief medical officer for the Hospital of Central Connecticut. "We need to optimize their use and value. If we don't tackle these issues, the alarms aren't going to help us."
A total of 216 deaths nationwide were associated with monitoring alarms from 2005 to 2010, according to data from the U.S. Food and Drug Administration. It's unknown whether any of these deaths occurred in Connecticut because the federal data is not state specific.
There are no reporting requirements in Connecticut specific to alarm fatigue, according to William Gerrish, spokesman for the state Department of Public Health. He added, "DPH is also working with patient safety organizations to better understand the impact of alarm fatigue, and identify best practice strategies that can be employed to reduce their impact on patient safety."
Alarm hazards topped the annual list of "health technology hazards" published by the ECRI Institute, a non-profit agency that assists hospitals, including some in Connecticut, with technology safety issues.
Patients need to be proactive
"Alarm fatigue is a huge problem that patients and their families should be concerned about," said Michael Wong, executive director of the advocacy group Physician-Patient Alliance for Health and Safety (PPAHS). "Patients should worry if caregivers are ignoring alarms on devices that help ensure patients are safe and leave the hospital alive."
"Patients believe that monitors are their lifeline in a crisis," added Jean Rexford, executive director of the Connecticut Center for Patient Safety. "Unfortunately, constant alarms can become background noise in very busy hospitals."
Connecticut consumers, however, "should feel confident that hospitals are taking a proactive approach to alarm safety," said Dr. Mary Cooper, vice-president and chief quality officer for the Connecticut Hospital Association. Alarm safety is among the topics under review by CHA's High Reliability Safety Culture Collaborative. The issue has garnered more public attention with the growing accumulation of medical devices in hospitals.
"Industry (officials) recognize that they can't put their staff in the position of having to discriminate among a hundred alarms, versus ten important ones," said Cooper.
The multitude of alerts also stresses patients, according to Hanks. He urged patients and families to question caregivers about the use of medical devices. "We need to do a better job of explaining how alarms work and what to expect if they go off,'' he said.
Bedside medical devices "provide an electronic safety net" that protects patients because caregivers can't be at the bedside round-the-clock, said Wong. "What are the odds of a nurse popping in at the very moment that a patient is experiencing difficulty? The odds are very poor. That's why this technology is absolutely necessary."
In addition, shorter hospital stays tend to mean patients who are hospitalized are sicker and require more medical monitoring, Cooper said. "Alarms are essential because they alert staff to changes in a patient's condition," she said.
A patient in an intensive care unit, for instance, may require numerous medical devices. Cardiac monitors check the heart's electrical activity. Physiologic monitors keep tabs on blood pressure, breathing, pulse, body temperature and more. Dialysis units remove waste and excess water from the blood in patients with failing kidneys. Infusion pumps deliver fluids, including nutrients and medications, into the body in controlled amounts. Mechanical ventilators assist patients unable to breathe on their own.
"Hospitals are facing challenges because the health care environment and the medical devices that manufacturers are developing are becoming more complex," said James Keller, vice-president of health technology evaluation and safety at the ECRI Institute.
Some critical care units experience as many as 350 physiologic monitor alarms per patient per day, reports the ECRI Institute.
"So many alarms are happening at once that a caregiver can become overwhelmed by the amount of information and miss a clinically important alarm," said Keller. "It's a serious problem because the number of devices with alarms has been growing over the years."
Compounding the problem is that many devices with built-in alarms do not differentiate between a technical problem and a change in a patient's medical condition that warrants immediate action, said Marjorie Funk, a nurse and professor at the Yale School of Nursing whose research has examined the appropriate and safe use of technology.
"The alarm on a cardiac monitor will go off when a patient's heart rate drops too low. But more often, it goes off because the electrodes (attached to the patient's skin) become loose," said Funk. "Hospital staff needs to maintain 100 percent sensitivity to alarms. But we need the alarms to be more specific" so that caregivers can differentiate between technical and medical problems.
Even simple steps, such as proper skin preparation so electrodes stay on the patient's chest during heart monitoring or changing the electrodes daily so they are sticky, "can make a difference in reducing false alarms," said Funk.
In some cases, alarm fatigue can lead to deadly consequences. Federal investigators determined that alarm fatigue played a role in the death of a heart patient at Massachusetts General Hospital in 2010 because nurses had disabled and ignored clinical alarms. In 2012, a Pennsylvania teenager who received opioids after a tonsillectomy died because the monitors attached to the girl had been muted for sound.
Cooper said disabling or lowering the volume on clinical alarms is not a problem in Connecticut hospitals.
"Hospitals are recognizing that they need to take a well-documented, standardized approach for alarm safety," said Cooper. To that end, The Joint Commission, the national organization that accredits hospitals, has proposed making alarm management a national patient safety goal.
Steps being taken
The use of central monitoring stations with monitor technicians, such as those in cardiac telemetry units where devices continuously monitor a patient's heart, can help reduce alarm fatigue, said Dr. Ryan O'Connell, vice-president for performance and risk management at Bridgeport Hospital. "Trained technologists in the central monitoring station keep their eyes on the monitors 24/7 to anticipate problems," he said. "This decreases the need for a number of alarms to go off."
In addition, some doctors at Bridgeport Hospital carry iPhones with software that prioritizes patients "from most to least acute" based on their current condition. "Doctors can adjust their rounds to focus on those who are most at risk," said O'Connell.
Some hospitals use alarm integration technology that gathers information about alarms from multiple medical devices at the bedside or central monitoring stations and then transmits these alerts to a caregiver's telephone or pager, according to Rikin Shah, senior associate at the ECRI Institute. "This adds another tier to a hospital's alarm notification system," he said.
Under development are a new generation of "smart alarms" that can spot and alert caregivers of changes in a patient's condition that are cause for concern. "Medical device manufacturers are developing smarter alarm systems that can indicate when a patient is trending in a certain direction," said Keller.
For example, caregivers set alarm parameters on each monitor that checks for vital signs, such as blood pressure, heart rate, respiration rate and more. A smart alarm that detects that a patient's pulse rate and body temperature are increasing — changes that "might be associated with an infection" — will send a "clinically relevant alarm" to the caregiver "that something may be wrong with the patient," said Shah.
"Essentially, smart alarms try to think like a caregiver," said Shah, "but we're not there yet."
This story was reported under a partnership with the Connecticut Health I-Team (www.c-hit.org).
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