Bells and dings are sounds frequently heard coming from a slot machine paying out to a very happy casino guest. Interestingly, these same sounds are just as prevalent in a hospital environment. At any given moment in a hospital, the bells and alarms cascade across the care setting signifying to the bedside caregiver that his/her patient's condition has deviated from the norm.
What happens, though, when clinicians become desensitized to these sounds? And how do we as healthcare leaders ensure that our clinicians are responding quickly to life critical alarms?
Hospital Challenges: Alarm Fatigue & Desensitization
No one denies that the creation of medical device alarms have helped save patient lives when clinicians respond appropriately to these warranted notifications. The issue, however, resides when these devices generate an overabundance and redundancy of audible notifications that ultimately create alarm fatigue and desensitization for nurses and other providers.
With my experience as an ICU nurse and continued collaboration with healthcare organizations across the country and internationally, it's becoming evident that everyone is facing the same issues of alarm fatigue and desensitization. While alarms are intended to alert caregivers of deviations from a predetermined "normal" patient status, the actual percentages of alarms that bear critical importance appears to be low. Nurses are faced with an increased workload and higher patient acuity; many can attest to situations where they found themselves responding to a patient's alarm, only to find that the patient's condition was stable and the device was alarming on "artifact," i.e., extraneous or irrelevant data. As these alarms continue to increase throughout a shift, the noise becomes overwhelming, resulting in alarms being disabled, silenced or even ignored all together and resulting in a death or demise of a patient that could have been preventable.
Fatal consequences of alarm fatigue have started to make headlines. Factors contributing to these adverse outcomes are being examined and different healthcare bodies are taking notice. The ECRI Institute (formerly the Emergency Care Research Institute), an independent nonprofit healthcare research and consulting organization, has currently ranked alarm hazards as #2 in the "ECRI Institute's Top Ten List of Health Technology Hazards for 2011." The institute reported that nine deaths involving physiologic monitor alarm fatigue have occurred since June 2004 in the state of Pennsylvania alone.
Additionally, device manufacturers nationwide filed 216 reports with the FDA on monitor alarm-related deaths between January 2005 and June 2010.1 Likewise, using information provided by the Department of Health and the Centers for Medicare and Medicaid Services, the Boston Globe reported that there were at least 15 deaths during a 6-year span in Massachusetts related to missed alarms or physiologic monitor problems.2
A research study presented by the International Anesthesia Research Society also measured the volume of alarms coming from devices within the University of Utah Hospital's medical ICU. After over 200 hours of observation was completed, the study found that only 5.3 percent of alarms were effective and patient-related, and 17.7 percent were effective and technically-related. Over 36 percent of alarms were deemed ineffective and over 40 percent were altogether ignored by caregivers.3
Many healthcare organizations also experience inefficiencies with how alarms are relayed to caregivers, often resulting in delayed response times. In some hospitals, technicians are required to monitor alarms from a central location and manually notify a caregiver when a response is needed. This inefficient process can also result in adverse consequences if a critical alarm or an emergency code is not responded to in a timely manner.
Combating the Issues
As the industry examines ways to combat the issues of alarm fatigue, desensitization and alert notification inefficiencies, one recommendation many healthcare organizations are adopting is a secondary alerting system. Such technology solutions should possess the following requirements to:
- Route alerts from the electronic medical record, medical devices and nurse call systems directly to a caregiver's mobile device.
- Provide an escalation path for alarms between clinicians when a patient's primary caregiver is not available so that the alarm notification can be routed to another provider to respond.
- Embed a customizable rules engine that ensures these systems aren't adding to the overabundance of additional alarms firing to clinician. This built-in logic aids healthcare organizations in managing which alarms are critical and should be routed to caregivers for a response, as well as which are informational and do not require an immediate reaction. Rule-based alarms filter out much of the noise that would otherwise interrupt nursing workflows.
- Supply the system the rationale to route the notification to the correct caregiver. For example, most alarms coming from nurse call systems are typically non critical and can be routed to a nursing assistant's device to take action. Technology should be focused on driving the appropriate caregiver to the patient's bedside.
- Match the audible alarms sounds from the medical devices to the end user device such as a phone. This ensures the same consistent sound that the clinician is already accustomed to hearing for a particular device alarm is the same sound on the receiving device, helping to improve the clinician workflow and response time.
Benefits of Alarm Management Systems
Hospitals across the country have started recognizing these systems are a way to fight the challenges of alarm fatigue and desensitization. A 540-bed adult specialty healthcare hospital went live in December 2008 using Cerner Corp.'s CareAware Alertlink technology. This facility has seen over 6.97 million medical device alarms processed since the hospital went live. Of these alarms processed, only 81,256 (1.12 percent) were sent to the mobile phones carried by the caregivers. Use of customizable rules has allowed this healthcare organization to decrease the risks associated with alarm fatigue and improve their awareness to life critical alarms.
An onsite time and motion study measured the effect of secondary alerting at another facility and found that approximately 30 percent of all device alarms are being escalated by caregivers via the mobile devices. This enhanced escalation capability has led to improved response times by 45 seconds. For critical alarms and emergency codes, this improved response time means the difference between life and death for many patients.
As we continue to be entrenched within the era of healthcare reform, all organizations will need to find a way to do more with less capital and human resources. Along with reform, these hospitals will be faced with an increasing demand for services with the aging of the Baby Boomer generation. To meet these challenges, hospitals can no longer afford to operate and do business like they've done in the past. Healthcare organizations must look toward automation and innovative technology to help support the workflow and processes of the clinician to positively impact patient outcomes. By appropriately connecting alarm management systems to aid in the broken workflow, the technology enables the caregiver to better manage the vast number of medical device alarms.
Ashleigh George is an advisory sales executive at Cerner Corporation.
1. "Guidance and Tools to Help Healthcare Facilities Improve Alarm Safety." Alarm Safety Resource Site. ECRI Institute, 2011. Web. 1 June 2011.
2. Kowalczyk, Liz. "Patient Alarms Often Unheard, Unheeded." Boston.com. Boston Globe, 13 Feb. 2011. Web. 1 June 2011.
3. Gorges, Matthias, Boaz A. Markewitz, and Dwayne R. Westenskow. "Improving Alarm Performance in the Medical Intensive Care Unit Using Delays and Clinical Context." Anesthesia & Analgesia 108.5 (2009): 1546-552. International Anesthesia Research Society, May 2009. Web. 1 June 2011.