By Debra Wood, RN, contributor
April 11, 2013 - Although well intentioned, the constant beeping of alarms and an overabundance of information transmitted by medical devices such as ventilators, blood pressure monitors and cardiac monitors is putting patients at serious risk. So, the Joint Commission has issued a Sentinel Event Alert urging hospital leaders to take a focused look at alarm fatigue.
Ramón Lavandero, RN, MA, MSN, FAAN, said alarm fatigue can become a problem in critical care areas due to their abundance.
“Nurses in high acuity and critical care are especially subjected to alarm fatigue because of the abundance of alarm-sensitive technology they use when caring for patients,” said Ramón Lavandero, RN, MA, MSN, FAAN, senior director at the American Association of Critical-Care Nurses (AACN) and a clinical associate professor at Yale University School of Nursing in New Haven, Conn. “The Joint Commission’s Sentinel Event Alert crystalizes the seriousness of the problem, especially in high acuity and critical care where an abundance of alarm-sensitive technology has become an essential element of giving care.”
AACN’s Patient Safety Summit in May will feature an alarm fatigue session.
Linda D'Antonio, MSN, RN, CNL, said nurses become desensitized to all of the alarms going off.
“Nurses become desensitized to the audible alarm systems; there are so many that go off during shifts,” explained Linda D’Antonio, MSN, RN, CNL, senior faculty associate at the College of Nursing at Seton Hall University in South Orange, N.J.
As vendors have introduced new devices, there are more beeps and other sounds emanating from equipment, said Pat Adamski, RN, MS, MBA, FACHE, director of The Joint Commission’s Standards Interpretation Group, during an educational podcast released by the organization to inform clinicians.
“Patient safety is why alarms were developed, to alert nursing staff to something going on with a patient that requires immediate attention, but they can also cause a lot of issues,” she added, explaining that false alarms can pull a nurse away from a patient truly in need of immediate attention. Additionally, with so many alarms going off, nurses no longer hear them.
“They may be aware, but it no longer rises up to something they have to take care of immediately,” Adamski said.
Wendie A. Howland, MN, RN-BC, CRRN, CCM, CNLCP, LNCC, principal of Howland Health Consulting in Pocasset, Mass., blamed much of the problem on reductions in nurse staffing, from when a critical care nurse would always be available in a room with a critically ill patient, not the 1:3 or 1:4 nurse to patient ratios found today.
Wendie A. Howland, MN, RN-BC, CRRN, CCM, CNLCP, LNCC, considers alarm fatigue a staffing problem.
“Alarm fatigue is very real now, and things get missed, or no one is right there immediately to address an alarm,” Howland said. “This is criminal. Nurses are the best monitors there are.”
Thousands of alarms may go off every day on some units. With multiple alarms going off, it’s a challenge for nurses to determine which one is most critical to respond to, Adamski said. The sounds emitted by a bed alarm may sound similar to those from a ventilator or cardiac monitor.
The Sentinel Event Alert reported that an estimated 85 percent to 99 percent of alarms do not require clinical interventions, such as parameters set too tight, dried out electrodes or improperly positioned sensors.
Compounding the problem, in some cases, caregivers disable the alarms, turn down the volume or adjust the settings outside what would be safe. And those actions can have fatal outcomes.
The U.S. Food and Drug Administration (FDA) has received reports of more than 560 alarm-related deaths during the past four years, and the commission’s sentinel event database includes 80 alarm-related deaths and 13 serious alarm-related injuries from January 2009 through June 2012. Causes for those events reported to The Joint Commission include an absent or inadequate alarm system, 30 events; improper alarm settings, 21; alarm signals not audible in all areas, 15; and alarm settings inappropriately turned off, 36 events.
Quite troubling, the Sentinel Event Alert reports that alarm-related events are under-reported.
Joint Commission recommendations
To improve safety associated with alarms, The Joint Commission recommends:
- Establishing and adhering to a process for safe alarm management and response in high-risk areas
- Preparing an inventory of alarm-equipped medical devices used in high-risk areas and for high-risk clinical conditions, identifying the default alarm settings and the limits appropriate for each care area, and establishing guidelines for alarm settings that address management and response in high-risk areas
- Determining situations when alarm signals are not clinically necessary
- Inspecting and properly maintaining alarm-equipped devices
- Educating and training all clinical care team members in the management and response to alarms.
- Reducing nuisance alarms
- Reviewing trends in alarm safety and making changes when possible to improve
- Sharing alarm-related incidents and prevention strategies with the commission, the FDA, the Association for the Advancement of Medical Instrumentation and ECRI Institute, all of which are concerned with alarm safety.
The Joint Commission is considering creating a 2014 National Patient Safety goal for health care organizations that would address this issue.
Clinical surveyors will review monitored areas and whether clinicians respond in an appropriate way, Adamski said. They also will assess whether staff are running around and if workloads seem reasonable. In addition, they will ask about who can reset or turn off an alarm or change the parameters, what the policies are and clinicians’ competencies.
Howland suggested using fewer devices with alarms, with more RNs at the bedside.
“If there are enough nurses to monitor things like IV pumps, telemetry, SpO2 monitoring, and many other forms of continuous monitoring parameters, really caring for their patients instead of racing around completing tasks all day, a large number of those alarms would be addressed so fast no one would have the opportunity to become overwhelmed by the sheer number of them going off all at once.”
D’Antonio said hospitals should make alarm awareness part of the yearly competencies and add it to the daily goal sheet and to nurse documentation for every patient. Additionally, respiratory patients need to be checked at the same time by respiratory therapist and nurse to ensure competency.
Some hospitals, including a unit where D’Antonio has worked, have installed a visual alarm system, with flashing lights, to attract nurses’ attention. Others are turning to systems that send the alert directly to nurses’ phones.
Adamski suggested sending impartial observers to a unit to watch how staff responds to alarms. Clinical and physician leaders also could learn from that experience and see how ordering certain devices can contribute to the problem.
“Organizations should be establishing that alarm safety is a priority,” Adamski said. “It’s very challenging working in health care these days, and trying to help the staff put some framework around something as complex as clinical alarms can only help them.”
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