Lawmaker Implores HHS to Address “Alarm Fatigue”
Rep. Edward Markey (D-Mass.) has written a letter to HHS (Health and Human Services) Secretary Kathleen Sebelius imploring her urge the Institute of Medicine to address “alarm fatigue” reports the Boston Globe‘s “White Coat Notes.”
Alarm fatigue refers to the desensitization to audible and visual alarms that caregivers experience when they become overloaded with those alarms from numerous medical devices.
Details of the Letter
In his letter, Markey made reference to the Boston Globe story from February 2011 that first brought national awareness to alarm fatigue. That story reported that problems with health monitor alarms led to 216 or more deaths in the U.S. between 2005 to 2010.
Markey also cited a separate Globe story from December 2011 that reported that 119 deaths in the U.S. were connected to similar situations involving ventilator alarms since 2005.
Markey wrote that Institute of Medicine should “develop best practice guidelines for device manufacturers and health care providers to protect patient safety and avoid alarm fatigue and other alarm-related safety concerns” (Kowalczyk, “White Coat Notes,” Boston Globe, 12/15).
Markey wrote that these “best practice guidelines” should cover three areas:
- How device manufacturers can help reduce the number of unnecessary alarms and false positives;
- Steps hospitals can take to ensure that caregivers are trained to reduce alarm fatigue; and
- What the FDA (the body that regulates medical device manufacturers) can do to improve adverse event reporting
ECRI Institute Release Top 10 Health Technology Hazards for 2012
ECRI Institute has released its annual list of the top ten health technology hazards. The ranking for the 2012 list is as follows:
1. Alarm hazards
2. Exposure hazards from radiation therapy and computed tomography (CT)
3. Medication administration errors using infusion pumps
4. Cross-contamination from flexible endoscopes
5. Inattention to change management for medical device connectivity
6. Enteral feeding misconnections
7. Surgical fires
8. Needlesticks and other sharp injuries
9. Anesthesia hazards due to incomplete pre-use inspection
10. Poor usability of home-use medical devices
It is worth noting that this is the first time alarm hazards have taken the No.1 spot on the list. According to the publication, alarm-related adverse scenarios can occur due to a variety of factors, including:
1. Alarm fatigue, in which staff become overwhelmed by the sheer number of alarms. This can result in alarm desensitization, which in turn can lead to missed alarms or delayed alarm response. Consequently, staff may take inappropriate steps such as: a. Improperly adjusting alarm limits outside the safe and appropriate range for a particular patient in an attempt to reduce the number of alarms. If such modifications are made without careful consideration of the patient’s condition and the alarm’s function, the alarm may be set in such a way that it effectively becomes disabled. b. Turning down the volume of alarms to an inaudible level in an attempt to reduce alarm fatigue and reduce stress on the patient and family. 2. Staff being unable to distinguish the urgency level of alarms or tell which device an alarm is coming from. 3. Alarms not being restored to the active setting after being put on standby (e.g., while the patient has left the floor for testing). 4. Alarms not being properly relayed to ancillary notification systems (e.g., paging system, wireless phones), potentially leading to a failure to notify relevant staff. 5. A lack of adequate alarm-notification and -response protocols. 6. Failure to promptly troubleshoot and correct leads-off alarms or frequent nuisance alarms caused by artifact. ECRI Institute’s decision to move alarm hazards to the top of the list is a reflection of the growing national concern for alarm safety. Public interest in alarm safety has been growing since February 2011 when The Boston Globe ran a series of stories chronicling the issue of alarm fatigue and the dangers it poses to patient safety. Since then, National Public Radio has discussed the issue, both CBS and NBC have dedicated time to discussing the causes and risks of alarm fatigue, and in October, the Association for the Advancement of Medical Instrumentation (AAMI) co-hosted a conference with ECRI Institute to discuss the challenges of addressing alarm fatigue.FDA and Joint Commission to Address Alarm Fatigue
The Joint Commission, a national organization that accredits hospitals, has announced that addressing alarm fatigue is one of its highest priorities this year. The Joint Commission is planning to meet with the Food and Drug Administration over the next few months to develop a strategy for effectively addressing alarm fatigue.
The announcement comes just months after a Boston Globe investigation revealed that over 200 alarm-related patient deaths occurred between 2005 and 2010. In many of these cases, medical personnel either didn’t notice the alarms or failed to react with the urgency required—both typical signs of alarm fatigue.
“There is uniform agreement that this is a major problem,” said Dr. Paul Schyve, a senior vice president at the Joint Commission, in a recent telephone interview. And that problem may be even worse than reported. The health care industry often fails to report these types of incidents, leading some researchers to believe the number of alarm-related deaths is much higher.
Having Too Many Alarms Reduces Usefulness
Schyve said the issue is much more complex now than it was just 10 years ago, because medical device manufacturers have “put a lot more alarms’’ on their devices. He cited devices in intensive care units as an example, explaining that these devices now sound alarms not only when a patient’s heart rate has gone above or below a predetermined level, but also whenever the patient’s heart rate appears to be headed in the wrong direction, no matter if it is a life-threatening situation or not.
Not only are there more alarms on devices than there were in the past, there are more devices with alarms in patients’ rooms than ever before. Studies show that the vast majority of alarms are false, triggered by something as insignificant as the patient turning in bed or coughing. “If you have that many alarms going off all the time, they lose their ability to work as an alarm,’’ Schyve said.
Health care professionals and device manufacturers all agree that alarm hazards, particularly alarm fatigue, need to be addressed. However, no panacea has yet been found. Some industry experts say that device manufacturers need to redesign their devices so that they produce fewer false alarms. Others say that hospitals should hire extra caregivers to improve alarm response statistics.
“Sooner or later, there is going to have to be a meeting with the users of alarms and people who put the alarms on their equipment,’’ Schyve said. “Neither side alone is going to be able to figure out how to address this problem.’’
Alarm Integration As a Possible Solution
Often hospitals will provide extra training for nurses to try to reduce alarm-related incidents but “telling nurses and doctors to be more careful and reeducating them isn’t the solution,’’ says Dr. Peter Pronovost, director of the Quality & Safety Research Group at Johns Hopkins Hospital in Baltimore.
“In the ICU there is somewhere between 50 and 100 electronic pieces of equipment, and each of them has alarms. Each individual device maker makes its alarms the most annoying. It’s an arms race of alarms. No one has worked on integrating them. The FDA could require that all these monitors link into a common platform,’’ Pronovost said.
In a recent statement to the Boston Globe, the FDA said it is collaborating with the Association for the Advancement of Medical Instrumentation, a nonprofit education organization run by the health care industry and the ECRI Institute, a nonprofit health care research organization “on raising the awareness of these issues and challenging the industry and the Joint Commission to work with us on a strategic approach moving forward.’’
CBS Reports on Alarm Fatigue
Media awareness of alarm fatigue continues to grow. Following Liz Kowalczyk’s report for the Boston Globe, both NPR’s “All Things Considered” and NBC Nightly News have addressed alarm fatigue. Now CBS News has followed suit.
(You can view the CBS article here.)
In the article, Liz Kowalczyk and CBS News Medical Correspondent Dr. Jennifer Ashton both weighed in on alarm fatigue, discussing the problems caused by advanced monitoring devices and the questions patients and their families can ask to help reduce the risk of harm from alarm fatigue.
“Exact data is hard to come by. But many people who work in health care think (alarm fatigue is) getting worse… Nurses and doctors will tell you that the manufacturers also need to improve the technology, and reduce the huge number of false alarms, which play a major role in desensitizing nurses.” Kowalczyk said.
Dr. Ashton observed, “This is possibly an issue here where technology designed to make things safer and better may actually be doing more harm than good.” When asked who has the responsibility to monitor these alarms, she also touched on the dilemma caused by over-sensitive monitors. She remarked, “‘What do I do if this monitor goes off?’ They are so sensitive that, if the patient moves or coughs or sits up, they can go off. And you don’t want to silence an alarm. You want to know, ‘Who do I go to get if this alarm makes a noise?’”
“Remember – the nurses are not just following these monitors: They’re giving medications, they’re assisting doctors in procedures, changing dressings. They are incredibly busy. They often have many patients to care for. Nurses that I’ve spoken to find that it does kind of set up a ‘cry wolf’ scenario where these monitors go off, sometimes every 90 seconds. Just on one patient. And they’re constantly silencing them, taking them away from giving good patient care.” Ashton said.
NBC Nightly News Explores Alarm Fatigue
Continuing a string of recent stories on alarm fatigue in US hospitals that started with the Boston Globe and jumped to NPR, NBC Nightly News has picked up the story.
The segment covered some of the key contributing points to alarm fatigue, including the sheer number of patient monitoring devices in the modern hospital environment and the overwhelming number of false alarms that create a “boy who cried wolf” syndrome with nurses.
Robert Bazell of NBC news interviewed Louis Valerio, Executive Director of Cardiac Services, at Maimonides Medical Center of Brooklyn NY.
Bazell asked Valerio, “Isn’t it very easy for a human being to ignore one of these many beeps going on?”
“Absolutely I’m sure you’ve heard the term alarm fatigue or nurses being desensitized because there is so much noise and you just become immune to it.” Valerio responded.
Maimonides Medical Center has implemented several solutions to prevent the problems associated with alarm fatigue including constant staff retraining, and testing the team with intentional false alarms. They have also moved telemetry from the central nursing station to smaller “pod stations” where the nurses have fewer distractions.
The hospital has successfully decreased their average alarm response time from 8 minutes to less than 1 minute.
NPR Addresses Alarm Fatigue
Awareness of alarm fatigue continues to spread throughout the nation. On February 15, 2011, Michele Norris from National Public Radio’s program “All Things Considered” interviewed Liz Kowalczyk, a reporter on healthcare for the Boston Globe who has written a series of articles exploring the risks posed by alarm fatigue. Listed below are some highlights from the conversation.
LIZ KOWALCZYK: One of the cases that I wrote about involved an elderly woman at UMass Memorial Medical Center in Worcester, Massachusetts. She was in the hospital to get a cardiac catheterization. Her monitor sounded an alarm for about an hour, indicating a weak battery. And then for about 15 minutes, indicating a battery that was about to die. And no one responded to that alarm and she did have a heart attack. And because the alarm – the monitor wasn’t working, there was no alarm to alert staff to her heart attack.
MICHELE NORRIS: Do the devices themselves have problems or flaws that contribute to alarm fatigue?
Ms. KOWALCZYK: Well, I think you would hear a lot of nurses and doctors saying that they do. The big problem for nurses is that most – the vast majority of these alarms are false alarms. The machines are so sensitive, that they alarm when a patient coughs, they alarm when a patient turns over. And that contributes to alarm fatigue.
Ms. NORRIS: So, what can be done about this? How are hospitals responding?
Ms. KOWALCZYK: Well, I think there are some short-term solutions. Hospitals are trying, you know, one is to hire nurses or technicians whose sole job is just to monitor the monitors. Another solution hospitals are looking at is trying to reduce the number of people on monitors. There are a lot of patients on cardiac monitors who probably don’t need to be on cardiac monitors.
But, you know, there has to be systemic longer term solutions that are reached in cooperation with companies in terms of how these monitors work and trying to reduce the number of false alarms that they produce.
Liz Kowalczyk has written several articles on the topic of alarm fatigue. You can read each of them by following the links below.
Patient alarms often unheard, unheeded
For nurses, it’s a constant dash to respond to alarms
No easy solutions for alarm fatigue
The ECRI Institute Releases Annual Top Ten Health Technology Hazards for 2011
The ECRI has released its annual list of Top 10 Health Technology Hazards for 2011. “Radiation therapy overdose” was ranked at No. 1, and “alarm hazards” ranked in at No. 2.
The Complete Health Technology Hazards list:
- Radiation overdose and other dose errors during radiation therapy
- Alarm hazards
- Cross-contamination from flexible endoscopes
- The high radiation dose of CT scans
- Data loss, system incompatibilities and other health I.T. complications
- Tubing and catheter misconnections
- Over-sedation during use of PCA infusion pumps
- Needlesticks and other sharps injuries
- Surgical fires
- Defibrillator failures in emergency resuscitation attempts
“If a hospital or health system needs help prioritizing its technology-related patient safety efforts, our top 10 list is a good place to start,” says James P Keller Jr, Vice President, Health Technology and Safety, ECRI Institute.
“Radiation Therapy Errors” Top the List for 2011
“Radiation therapy errors” is new to the top of the list for 2011. Radiation therapy is used in about 50% of all cancer treatment cases. Due to the complexity of treatment coupled with high radiation dosages, the therapy has a high potential for serious errors.
The complexity of radiation therapy treatment leads to a relatively high probability of human error. As a result, 60% of radiation therapy errors are suspected to be caused by human error. Additionally, software errors can lead to radiation overdose, and death.
“Alarm Hazards” Remains at Top of List for 2011
“Alarm hazards” has remained number two on the list from 2010. Alarm hazards and fatigue have been growing in awareness since an unfortunate patient death at Massachusetts General Hospital in January 2010. Multiple nurses at MGH reported being unable to hear the patient’s cardiac monitor alarm as his heart slowly stopped beating over the course of 20 minutes. An investigation showed that someone had apparently turned off the cardiac alarm. Investigators cited “alarm fatigue,” which is a feeling of being overwhelmed by the sheer number of alarms until they seem unmanageable.
The desensitization to alarms caregivers experience when experiencing alarm fatigue can result in increased errors in care. As more monitors and alarms are added to modern hospital environment, alarm hazards will continue to pose a serious risk to patient care.
Alarm management technology, such as Dalcon Alert, has been developed to help combat alarm fatigue. Alarm management technology organizes and presents alarms to staff in a manageable format.
Developing Alarm Fatigue Solutions
While the patient death at Massachusetts General Hospital (MGH) is terribly unfortunate, the same incident could have happened at almost any other hospital in the nation. The ECRI ranked “alarm hazards” at No. 2 in its 2010 Top 10 Technology Hazards.
MGH’s senior vice president for quality and patient safety, Dr. Gregg Meyer, says, “People expect when a loved one comes to the hospital that they will be closely observed and monitored appropriately…[and that] any signals from those monitors will be responded to. I think that’s a very reasonable request on one hand. But on the other hand, when you put that into the context of a busy inpatient unit, it gets complicated very, very quickly.”
Overuse of Alarms Leads to Fatigue
Meyer admits that after reviewing monitoring guidelines, “we found that maybe we were overmonitoring people.” This is a common occurrence that contributes to alarm fatigue in many hospitals. While MGH searches for new ways to reduce alarm fatigue, Meyers asserts, “The reality of it is that no matter how attentive you are, all of us will experience some level of fatigue. And that device alarms can be a lifesaver, but not if they’re ignored.”
Maria Cvach, MSN, RN at Johns Hopkins Hospital in Baltimore has coauthored a study on alarm fatigue. She found that many alarms have great sensitivity but poor fidelity or specificity. She says this contributes to the vast amount of alarms in hospital wards (sometimes over 500 alarms per patient per day). Cvach says, “Even if you have the best technology out there, you’re going to get a lot of false alarms.”
Cvach says the key is making the alarms “actionable.” “You’ve got to set parameters to a point where people will act… We want to customize the alarm for [each] patient and make it a reasonable level that will prompt action,” Cvach says. This means hospitals must be willing to set alarms to lower sensitivity, so that when an alarm does go off, caregivers understand the urgency of the crisis.
Managing Patient Care Alarms
In addition to lowering the amount of alarms directed at caregivers, technology can be put in place to help track and manage alarms. Alarm management systems break down the “overwhelming barrage” of alarms into organized and reasonable bits of information that caregivers can easily digest.
Dalcon Alert includes an alarm management system that maintains a real-time alert queue at the nurses station. This “alarm master list” gives caregivers immediate knowledge of all active alarms, including information on alarm type and location.
Caregiver Alarm Fatigue
A subtle problem has been growing inside the modern hospital environment. The trend towards increased usage of alert/alarm generating patient monitors seems like a logical step towards better patient care. It certainly makes sense that the more caregivers can know about patients’ conditions the better they can react should an emergency arise. However, there have been multiple incidents that suggest that this is simply not the case.
The most high profile incident occurred in January when a patient at Massachusetts General Hospital (MGH) died of a cardiac arrest. As it turned out, the patient’s cardiac arrest monitor had been in alarm mode for over 20 minutes before the patient died, yet nurses failed to notice the scrolling tickertape notices in the hallway or the beeps in the central nursing station. In addition, an unknown person had completely turned off the separate audible alarm on the physical bedside monitor the night before.
So what exactly causes this disconnect between caregivers and monitoring technology? Alarm fatigue. As more monitoring devices are added into the hospital environment, each additional alert adds weight until nurses feel overwhelmed. As a result, caregivers experience alarm fatigue. Alarm fatigue is the condition where caregivers begin to give up trying to manage the onslaught of alerts, and start to ignore them instead. In extreme cases, such as the situation at MGH, caregivers begin turning down the volume of audible alerts or even turning off alerts completely.
Preventing Alarm Fatigue
Stopping alarm fatigue isn’t simple. Obviously, eliminating alerts/alarms isn’t an acceptable solution, since that would defeat the purpose of patient monitoring devices. Yet something must be done or the problem will only continue to develop as the hospital environment gets more complex.
The solution lies not in eliminating alerts, but in more efficient management of them. Without an automatic and organized approach to managing alerts, caregivers are forced to juggle them manually. Manual management of alerts can be effective, as long as the number of alerts stays at a reasonable level. However, as more alerts are added to the environment, an alert management system becomes more necessary.
Developing an Effective Alert Management System
Today, new technologies such as Dalcon Alert include an Alert Management System designed to help caregivers organize alerts. Dalcon Alert’s Alert Management System automatically tracks all active alerts. Active alerts are displayed on a large screen monitor at the nursing station and are automatically updated in realtime with alert type, location, and length of duration. The alert queue is designed to allow caregivers to quickly prioritize active alerts, and canceled alerts are automatically removed from the queue.
Reducing Unnecessary Alerts
In addition, Dalcon Alert allows nurses to receive alerts via text message to wireless phones. A successful Alert Management System involves quality design. As a result, caregivers should only be receiving relevant alerts.
For example, caregivers should only receive non-critical alerts from their assigned patients, not from each patient on an entire floor. Because Dalcon Alert utilizes wireless phones assigned to each caregiver, relevant alerts can be tailored to the individual caregiver.
Because all alerts are managed by the Alert Management System, non-critical monitoring devices can have their audible alerts turned down in order to reduce hospital ambient noise. Any reduction in hospital ambient noise has been shown to increase the quality of patient care significantly.
Hospital Noise Pollution a Growing Problem
One of the largest complaints of hospital patients and staff nationwide is the abundance of noise in the hospital. Uncomfortable and unsafe noise levels inhibit the healing process of patients that need it most.
In fact a recent study at Johns Hopkins University Hospital has shown that loud hospital environments can have a major negative impact on patients including:
• Elevated blood pressure levels.
• Sleep disruption.
• Decreased oxygen saturation.
• Decreased rates of wound healing.
The consequences of a loud environment on staff include emotional exhaustion and burnout as well as a raised risk of medical errors due to miscommunication. Recently, a patient at Massachusetts General Hospital died because his heart monitor had been turned off by a staff member. The investigators cited “alarm fatigue” as a cause of the problem. Alarm fatigue occurs when nurses become overwhelmed by the number and variety of alarms in the healthcare environment. As a result, nurses begin ignoring or even turning off alarms.
A Mayo Clinic study performed several years ago showed peak noise levels at night in one facility rising to 113 decibels, equivalent to a chainsaw or jackhammer.
Major sources of noise include hospital ventilation systems as well as overuse of the hospital paging system and an abundance of alarms. The Johns Hopkins study noted that though audible alarms were significantly quieter than other sources of noise, patients ranked them as being more irritating than more intense sources.
New Technology as a Solution to Hospital Noise Pollution
Dalcon provides solutions that, as a secondary benefit, help eliminate hospital noise pollution.
Dalcon Alert for Remote Patient Monitoring connects with various patient monitoring devices such as heart monitors, IV pumps, ventilators, pulse oximeters, and more. When a patient monitoring device triggers an alarm connected to Dalcon Alert, the system sends a text message to wireless phones (or pagers) held by hospital staff.
Because Dalcon Alert allows hospital staff to more efficiently manage hospital alarms, alarm fatigue is significantly reduced. Also, since Dalcon Alert incorporates wireless phones or pagers to be carried by hospital staff, use of the overhead pager can be dramatically decreased as well.
