By: Kathleen Gaines BSN, RN, BA, CBC
Constant beeping – medication pumps, monitors, beds, ventilators, vital sign machines, and feeding pumps – are alarms that are all too familiar to nurses, especially in the intensive care unit. Research indicates that 72% to 99% of all alarms are false which has led to alarm fatigue. Unfortunately, due to the high number of false alarms, alarms that are meant to alert clinicians of problems with patients are sometimes being ignored. Assuming that an alarm is false puts patients in harm’s way and could lead to medical mistakes.
The American Association of Critical Care Nurses defines alarm fatigue as a sensory overload that occurs when clinicians are exposed to an excessive number of alarms, which can result in desensitization to alarm sounds and an increased rate of missed alarms.
The Joint Commission (TJC) has been trying to combat alarm fatigue since 2013. In 2013, there were numerous reported sentinel events, which led the TJC to issue an alert on alarms and then made alarm management a National Patient Safety Goal starting in 2014. Each year since, it has continued to be a National Patient Safety Goal because there continue to be sentinel events related to alarm management and fatigue.
A Few Scary Facts About Hospital Alarms
Alarm fatigue is one of the most troubling and highly researched issues in nursing. Over the last decade, research has found the following staggering statistics related to alarm fatigue and false alarms:
- The Food and Drug Administration reported more than 560 alarm-related deaths in the United States between 2005 and 2008.
- Between January 2009 and June 2012, hospitals in the United States reported 80 deaths and 13 severe injuries.
- One study showed that more than 85 percent of all alarms in a particular unit were false.
- A hospital reported an average of one million alarms going off in a single week.
- A children’s hospital reported 5,300 alarms in a day – 95% of them false.
- A hospital reported at least 350 alarms per patient per day in the intensive care unit.
2019 National Patient Safety Goals
Reducing the harm associated with clinical alarm systems continues to be a national patient safety goal. The Joint Commission continues to encourage healthcare systems to put policies in place to decrease the burden of unnecessary alarms on staff. The Joint Commission issues the following safety guidelines for all hospitals in their annual report:
- Leaders establish alarm system safety as a hospital priority
- Identify the most important alarm signals to manage based on the following
- Input from the medical staff and clinical departments
- Risk to patients if the alarm signal is not attended to or if it malfunctions
- Published best practices and guidelines
- Establish policies and procedures for managing the alarms identified and address the following:
- When alarms can be disabled or changed
- Monitoring and responding to alarm signals
- Checking individual alarm signals for accurate settings, proper operation, and detectability
- Who can set alarm parameters
- Who can change alarm parameters
- Who can turn alarm settings to “off”
- Educate staff about the purpose and proper operation of alarm systems
Contributing Factors to Alarm Fatigue
In the original sentinel event alert, The Joint Commission identified numerous factors that they believed contributed to alarm fatigue in the hospital setting. These included:
- Alarm parameter thresholds were set too tight
- Alarm settings not adjusted to the individual patient’s needs
- Poor EKG electrode practices resulting in frequent false alarms
- Inability of staff to hear alarms or detect where an alarm is coming from
- Inadequate staff training on monitors and alarms
- Inadequate staff response to alarms
- Alarm Malfunction
Recommendations and Solutions
While there is no universal solution to alarm fatigue, hospitals are taking individual approaches to combat it. The Joint Commission stresses in the 2019 National Patient Safety Goals that there needs to be standardization but can be customized for specific clinical units, groups of patients, or individual patients.
The Association for the Advancement of Medical Instrumentation released recommendations to combat alarm fatigue including:
- Have an alarm-management process in place.
- Review and adjust default parameter settings and ensure appropriate settings for different clinical areas.
- Determine where and when alarms are not clinically significant and may not be needed.
- Create procedures that allow staff to customize alarms based on the individual patient’s condition.
- Make sure all equipment is maintained properly.
Nursing associations have also released recommendations to combat alarm fatigue. The most striking and was the recommendations released by the American Association of Critical Care Nurses in May 2018. The Practice Alert outlined evidence-based recommendations to reduce alarm fatigue and false clinical alarms. Recommendations released for nurse leaders included:
- Organize an interprofessional alarm management team.
- Develop policies/procedures for monitoring only those patients with clinical indications for monitoring.
- Develop unit-specific default parameters and alarm management policies.
- Provide ongoing education on monitoring systems and alarm management for unit staff.
While recommendations for bedside clinicians included:
- Providing proper skin preparation for and placement of ECG electrodes.
- Using proper oxygen saturation probes and placement.
- Checking alarm settings at the beginning of each shift.
- Customizing alarm parameter settings for individual patients in accordance with unit or hospital policy.
Electronic charting systems, such as EPIC, have the ability for providers to place an order for alarm limits for each individual patient based on age and diagnosis. It also allows nurses to document each alarm limit every shift and if it is outside of the ordered parameters. It will also trigger a computer warning to the staff as a reminder to have the orders changed if the alarms are not set correctly. Some hospitals have tagged this as meaningful use so that it is a requirement for staff for each patient during every shift.
A contributing factor to alarm fatigue is the amount of noise the alarms produce. Constant beeping and alarms throughout the unit can cause nurses to miss their own alarms or change the settings to improper parameters in order to avoid the noise. The World Health Organization recommends noise levels of 35 decibels (dB) during the day and 30 dB during the night.
Advances in technology have increased the use of visual and/or vibrating alarms to help reduce alarm noise. Hospitals can implement functions on their monitors to pause alarms for short periods when providing patient care, turning a patient, and/or suctioning. These may all trigger patient alarms but if a trained healthcare professional were at the patient’s bedside pausing alarms would help reduce the alarm noise.
Boston Medical Center switched cardiac monitor thresholds from “warning” to “crisis” and as a result reduced the noise levels from 92 dB to 70 dB. In doing so, nurses had quicker reaction times to alarms and patients were less disturbed.
Success through Change
Hospitals throughout the country have been able to successfully combat alarm fatigue. The Cincinnati Children’s Hospital Medical Center in Cincinnati, Ohio specifically focused on reducing the number of alarms in the bone marrow transplantation unit. A multi-disciplinary team including nurses, physicians, nursing assistants, medical engineers, and family representatives met to devise a plan to reduce the number of alarms in the unit on a daily basis.
After making a variety of changes, the unit was able to drastically reduce the number of alarms from 180 to 40 per patient per day, and the number of false alarms fell from 95% to 50%.
Boston Medical Center was able to reduce the number of alarms by 60% by altering the default heart rate settings based on each patient’s condition. They also implemented the following mnemonic to help prevent alarm fatigue and increase patient satisfaction and outcomes:
- Alarm sensitivity
- Sounding notification
- Significant need to monitor
- Evaluate the situation
- Timely response/technology training
Alarm fatigue is a serious concern in hospitals around the country and The Joint Commission will continue to address this in their annual national safety goals. Until the number of false alarms decreases and there are no patient safety events, focus needs to remain on alarm fatigue.