Excessive patient monitoring alarms are no longer just one of those unavoidable annoyances of working in the hospital. Alarm fatigue has been recognized as a major patient safety issue, and healthcare facilities have been told to do something about it. But what should they do?
Patient monitors are supposed to represent a technological advance in patient care. They are intended to signal to the caregiver that some aspect of the patient's vital functions requires some attention. False alarms are common, but every once in a while the alarm heralds a life-threatening condition. Efforts to globally reduce the number of daily alarms, such as building in longer alarm delays, can have unintended consequences. A better approach is to evaluate the specific causes of each type of alarm that occurs in the patient population; whether action is needed; and what adjustments, configurations, or algorithms could safely prevent unnecessary alarms. It's a huge undertaking.
These investigators have taken on this challenge for the adult ICU population. "Our study is the largest prospective study to date on the alarm fatigue problem," said Drew. "Our job as clinical scientists is to inform and work with industry to improve these algorithms. Because computer devices have the potential to be more reliable than humans, an opportunity exists to improve these monitor devices to reduce the problem of alarm fatigue. We are also working with monitor manufacturers to share our insights about how monitors could be more interactive to help nurses tailor the alarms better for individual patients so the one-size-fits-all approach that results in too many alarms is avoided."
The solutions suggested by these data include some that can be applied by nurses and other clinical staff, and others that should be attended to by monitor and software engineers. "Smart" physiologic monitoring devices can, and must, do much more to improve workflow for nurses and make care safer for patients.
Clinical decision support is woefully underused in this arena. Patients are sicker and more complex than ever before, and they require individualized approaches to everything, including alarm management. We traditionally try to standardize as much as possible to avoid errors, but as these data show, one consequence of standardization is a whopping 2.5 million alarms in a single month! Even 187 audible alarms per patient per day is way too many to expect nurses to respond, assess, and take corrective action on every single alarm. As Drew explained, "We analyzed nearly 13,000 arrhythmia alarms and found that 88% of them were false alarms. This is like hearing a car alarm go off incessantly in your neighborhood. How often do you respond to a car alarm by calling the police? Everyone assumes that a real car burglary is not going on but rather, the neighbor has a car alarm that is triggered too easily."
With so many nuisance alarms, patient conditions that do require a response can go undetected. Clinical monitors have to become smarter to improve efficiency as well as safety. For example, monitors should be able to track nuisance alarms on a specific patient and provide prompts to suggest actions for the user to eliminate these unnecessary alarms.
Drew and colleagues provided a list of "device improvements" that could significantly reduce unnecessary alarms in the ICU setting from such conditions as persistent atrial fibrillation, artifact mimicking ventricular arrhythmias, wide QRS or pacemaker spikes triggering ventricular arrhythmia alarms, ST-segment alarms that do not reflect true myocardial ischemia, and flat-line respiratory waveforms causing apnea and respiratory rate alarms. Alarms that are not presently configurable should be made so, and monitor enhancements could eliminate many false alarms altogether.
The findings of this study also support some immediate actions that hospitals can take to alleviate alarm fatigue. Drew suggested that hospitals "review their alarm settings, both the hospital default settings and the settings that nurses at the bedside configure for the individual patient. Our article gives practical advice about how to reduce the excessive number of alarms. For example, we discuss what settings are safe to change from an audible alarm to a text message alarm."
Drew and colleagues also provided direction from nurse researchers for clinical nursing research that is sorely needed in the area of alarm and electrode management. Does changing electrodes at certain frequencies reduce nuisance alarms? Is it possible to measure and display impedance, and could a trend of increasing impedance signal electrode failure? What are the ideal techniques for skin preparation before electrode application to optimize electrode function?
This was a very impressive study. The findings and the practical suggestions offered by these investigators should prove valuable to clinicians working to improve alarm management in the adult ICU.
Medscape Nurses © 2014 WebMD, LLC
Cite this: Laura A. Stokowski. Alarm Fatigue? Smarter Monitors Needed - Medscape - Nov 13, 2014.