July 15, 2010 - Recently, a patient death at a prestigious Massachusetts hospital was attributed to a phenomenon known as alarm fatigue. How could this happen, many people wondered? How could the alarms on all the patient monitors have failed to alert a nurse that something was wrong?
But alarm fatigue is not uncommon, and patient safety experts have been concerned about the phenomenon for awhile.
Kathryn Pelczarski, director of ECRI Institute’s applied solutions group, recommends a tiered-response system for patient alarms.
As far back as 2002, the Joint Commission released a Sentinel Event Alert that revealed alarm malfunction and misuse are a significant root cause of ventilator-related deaths and injuries. The Joint Commission and the American Association of Respiratory Care both recommended that organizations address the problem by establishing better processes and procedures for testing, setting and responding to alarms, as well as training staff and providing adequate maintenance on the equipment.
ECRI Institute, a non-profit patient safety organization, recently ranked alarm incidents in the top 10 technology-related health hazards for 2010. Although the institute does not have statistics on how many incidents can be attributed specifically to alarm fatigue, alarm events in general can contribute to harm, even death, and should be taken seriously, noted Kathryn Pelczarski, director of the institute’s applied solutions group.
How alarm fatigue can happen
It’s not uncommon for a patient, especially in an intensive care unit, to be hooked up to a number of monitoring devices. Most, if not all, of those devices have alarms that are designed to alert the patient’s nurse that something is wrong. Ideally, the nurse responds immediately and a crisis is averted.
Trouble can arise, however, for a number of reasons: the alarms may not function the way they were supposed to; there may be so many alarms that it’s hard for a nurse to distinguish which alarm goes to which device; the alarms may all sound very similar if there’s no standard tone or decibel level to distinguish a particular type of device; the sounds of multiple alarms can be overwhelming; or as nurses try to focus on stabilizing a patient, they may even block out the noise without realizing it.
Some alarms are so sensitive that they sound even when nothing is really wrong, perhaps when a patient moves around or a lead slips off. These are often called nuisance alarms. When health care professionals get accustomed to such “false” alarms going off all the time, they might not respond to them as quickly, even in critical situations. Or they might not even hear them anymore.
“You become desensitized to the actual noise of it,” said Linda Bell, MSN, RN, clinical nurse specialist with the American Association of Critical-Care Nurses.
And that’s when alarm fatigue can set in.
The nurse’s role in prevention
Expecting a nurse to immediately respond to every single alarm every single time might sound like the only solution, but it’s not that easy.
What if a nurse is in the middle of administering medication when an alarm sounds? What if the nurse is already responding to an alarm for another patient?
Pelczarski advocates for the creation of a tiered-response system. The first person to respond to an alarm would naturally be the patient’s primary nurse, but beyond that, who will respond if that nurse cannot? That’s what needs to be determined in advance and set out in a plan.
“It’s all about delineating responsibility for alarm coverage and providing backup,” she said.
“The whole point is to make sure that the alarm is not missed,” she added.
According to Bell, it’s not just an individual issue, either; it’s not just the responsibility of the nurses providing the direct patient care. It’s an important patient safety matter that requires a group effort and commitment.
“This takes a village,” she said. “It’s everybody’s issue.”
Leaders’ roles in establishing effective alarm management
Kelly Graham, BSN, RN, patient safety analyst and consultant for ECRI, says that leadership must be involved in addressing alarm-related incidents.
Kelly Graham, BSN, RN, patient safety analyst and consultant for ECRI Institute, agreed that the issue has shared ownership. She noted that nurses and other caregivers can and should make extra efforts to remain vigilant, but efforts to address alarm-related incidents must go beyond the individual, and leadership must get involved.
Pelczarski recommends that hospitals and other facilities create a multi-disciplinary team to examine their own processes and develop policies and strategies. And she suggests that front-line staffers—the people who actually work with medical devices every day—be invited to participate.
“They’ll provide you insight on a particular concern or something that you wouldn’t necessarily have thought of without their input,” she said.
Bell agreed that it’s crucial to include the nurses who know first-hand what it’s like to work with equipment with a variety of beeping and blaring alarms. “Let’s have them be part of the conversation from the very beginning,” she said.
When it comes to implementing effective alarm management strategies, ECRI Institute recommends that leaders make sure that alarms on devices are actionable. Don’t just go with the default settings; tailor the settings on each device to make sure they are appropriate for the unit and for the patient, Graham said. That can potentially reduce the incidence of nuisance alarms.
Additionally, hospitals need to make sure they provide for regular and appropriate maintenance for these devices with alarms.
Also, the multi-disciplinary team needs to make sure that they choose strategies that can reasonably be implemented, Pelczarski added.
For example, in many hospitals, the labor and delivery unit might use one type of infusion pump, and the critical care unit might use another from a different manufacturer. While it might be very useful to have only one brand of medical equipment throughout a hospital so that nurses and other staffers only have to be familiar with one type, acquiring and deploying standardized equipment might have to be a long-term goal, not an immediate strategy.
Jerry Gervais, associate director for Joint Commission’s standards interpretation group, pointed out that medical equipment can be very expensive, so it’s not reasonable for most facilities to buy all new, uniform equipment all at one time.
Ongoing education and evaluation
Although most facilities can’t afford to buy the latest standardized equipment throughout every department, it is important to provide ongoing education on how to use the equipment that they do have.
Mary Carol Mooney, MSN, RN, senior associate director for The Joint Commission’s department of standards interpretation, noted that many hospitals require some nurses to float from unit to unit, and many also contract with agency nurses. Those nurses must also be trained to work with any and all equipment that they might be required to use.
“Organizations need to be very conscious of that, that whoever is in that unit has the appropriate training,” she said.
Once health care organizations have taken steps to address the issue of alarm management, they must track the results and analyze them. If a process or procedure is deemed to be less than effective, they should work together to determine a better one.
“You should always be looking for ways to improve,” Pelczarski said.
For additional information on this topic, nurse leaders may be interested in ECRI Institute’s web conference, “Clinical Alarm Fatigue: Strategies for Keeping Your Patients Safe and Your Hospital Out of the Headlines,” on July 21, 2010; registration deadline is July 19.
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