The Problem of Alarm Fatigue

Priority #1: The Problem of Alarm Fatigue wwhen entering a busy labor and delivery unit or neonatal intensive care unit, the first thing people usually notice is the sheer volume of activity. Nurses hurry from room to room while beeps, bells and whistles ring out accompanied by the sounds of laboring women and crying babies. In the background, Brahms Lullaby plays over TANYA TANNER, PhD, MBA, RN, CNM the loudspeaker, signaling yet another birth. This cacophony of sound has been compared to sounds heard in a carnival or casino and can result in a phenomenon known as alarm fatigue (Welch, 2012). In 2011, the ECRI Institute (an independent nonprofit organization dedicated to using evidence to improve the safety, quality and Abstract Up to 99 percent of alarms sounding on hospital units are false alarms signaling no real danger to patients. These false alarms can lead to alarm fatigue and alarm burden, and may divert health care providers attention away from significant alarms heralding actual or impending harm. As the health care environment continues to become more dependent upon technological monitoring devices used for patient care, nurses must become aware of the possibility and consequences of alarm fatigue and ways to prevent it from negatively affecting their practice, as well as the possible consequences for patient care. DOI: 10.1111/1751-486X.12025 Keywords alarm burden alarm fatigue patient safety http://nwh.awhonn.org 2013, AWHONN 153

Priority #1: cost-effectiveness of patient care) cited alarm hazards as the top technology hazard for 2012 (ECRI Institute, 2011). The Association for the Advancement of Medical Instrumentation (AAMI) is an alliance of more than 6,000 members united by the mission of supporting the health care community in the development, management, and use of safe and effective medical technology (AAMI, 2012). The AAMI has invited the health care community to embrace a mission for alarm safety that by 2017, no patients will be harmed by adverse alarm events (AAMI, 2011a). or assume that other staff members are already attending to the alarm (Cvech, 2012; Harris, Manavizadeh, McPherson, & Smith, 2011). Causes of Alarm Fatigue Alarm fatigue caused by alarm desensitization may result in slower nursing response time, and may cause nurses to ignore or override the alarm or to turn it off altogether. Between 2002 and 2004, half of the reported deaths related to clinical alarms were associated with human error (ECRI Institute, 2007). A recent Medsun Report (U.S. Food and Drug Administration, 2012) identifies the likely purposeful unplugging of an audio cable from a display unit, effectively silencing the alarms of an electronic fetal monitoring system. These human errors exemplify those described as being a major cause of hospital deaths in the landmark 1999 Institute Many devices regularly found in obstetric and neonatal units have alarms, including patient call lights, emergency call lights, electronic fetal monitors, infant warmers, ventilators, pulse oximeters, IV pumps and infant security systems all of which may alarm simultaneously Tanya Tanner, PhD, MBA, RN, CNM, is a course coordinator at Frontier Nursing University in Hyden, KY, and practices clinically at Aurora Nurse- Midwives at The Medical Center of Aurora in Aurora, CO. The author reports no conflicts of interest or relevant financial relationships. Address correspondence to: tanya.tanner@frontier.edu Defining Alarm Fatigue Although no current consensus definition exists, alarm fatigue occurs when nurses experience sensory overload leading to desensitization in an environment of many regularly occurring alarms (AAMI, 2011a). These alarms may reflect actual events requiring nursing attention or, as is the case with the large majority of alarms, may be false or nuisance alarms requiring no nursing action (AAMI, 2011a). False alarms may occur because of patient factors, such as alarms resulting from the inability of the external fetal monitor to accurately monitor fetal heart tones due to maternal obesity; equipment factors, such as alarms resulting from artifact on the electronic fetal monitor tracing and a combination of patient and equipment factors, such as frequent maternal position changes during labor that impair the ability of the monitor to accurately interpret fetal heart rate. These alarms then add to the existing strain, commotion and noise of the unit and can negatively affect patient safety and disrupt patient care (AAMI, 2011b; Healthcare Technology Foundation, 2011). Nurses may become desensitized to alarms as a result of excessive exposure and fail to hear the alarms of Medicine Report: To Err is Human: Building a Safer Health System (Kohn, Corrigan, & Donaldson, 1999). Many devices regularly found in obstetric and neonatal units have alarms, including patient call lights, emergency call lights, electronic fetal monitors, infant warmers, ventilators, pulse oximeters, IV pumps and infant security systems all of which may alarm simultaneously. This synchronized occurrence of alarms results in alarm burden, which can result in nurses giving attention to one alarm at the expense of another, more critical alarm (ECRI Institute, 2011). Evidence shows that 80 percent to 99 percent of alarms are false alarms for which no danger is posed to the patient (Cvech, 2012). False alarms are frequently triggered by erroneous or absent patient data (Walsh, 2012). These types of alarms can be caused by such events as patient movement or repositioning and by poor placement of sensors such as an external fetal heart rate monitor or pulse oximeter. Recurrent false 154 Nursing for Women s Health Volume 17 Issue 2

their facility had experienced an adverse event related to clinical alarm problems (Healthcare Technology Foundation, 2011). In early 2010, the Boston Globe brought the issue of alarm hazards to a public forum by reporting on a series of incidents in a Massachusetts hospital in which nurse desensitization to alarms contributed to a patient death (Kowalczyk, 2010). Reports addressing ICU alarm hazards abound in the literature; experienced labor and delivery nurses can usually recall at least one near miss or actual adverse event related to alarm systems of an electronic fetal monitoring system. Nurses in the NICU are also well-aware of the hazards of alarm fatigue and alarm burden. Priority #1: Responding to the Problem Long acknowledged to be a significant health care problem, the issue of alarm fatigue has recently alarms lead to a cry wolf scenario in which nurses simply ignore alarms or are slow to respond (Sendelbach, 2012). Another type of alarm is the nonactionable alarm, in which the alarm sounds appropriately but no nursing action is required to prevent patient harm (Walsh, 2012, p. 2). Examples of these alarms are short episodes of fetal heart rates outside of normal parameters, brief durations of maternal oxygen saturation recording at less than the normal settings on the monitor and short-term physiologic responses to nursing interventions such as suctioning. These alarms, while appropriate in response to the settings on the monitors, add to the alarm burden on the unit and may result in nurses overlooking another, more actionable alarm. The most important issue regarding alarms cited by respondents to the both the 2006 and 2011 Healthcare Technology Foundation Clinical Alarms Surveys was the presence of frequent false alarms reducing staff attention and capacity to respond. In the 2011 survey, 18 percent of respondents reported that Consider the whole environment when addressing alarm hazards; this includes assessing equipment, staffing and unit features affecting the overall setting reemerged as a serious patient safety hazard. In 2002, The Joint Commission published a sentinel event alert regarding deaths or injuries related to long-term ventilation (The Joint Commission, 2002). Of these incidents, the majority were in some way associated with alarm malfunction or misuse or inadequate alarm settings. Specific problems included alarms that were set incorrectly, silenced, turned off or inadequately tested. These findings led to the inclusion of clinical alarms in The Joint Commission s 2003 National Patient Goals (NPSG) and 2005 Environment of Care Standards (Harris et al., 2011). The Joint Commission has once again proposed that alarm system management become April May 2013 Nursing for Women s Health 155

Box 1. Seven Clarion Themes Identified at the 2011 Summit on Clinical Alarms 1. Deepen all stakeholders understanding of use environments. 2. Improve alarm system management. 3. Innovate to improve alarm system integration. 4. Reconcile challenges and differences in use environments. 5. Strengthen medical electrical equipment standards and contracting language to promote success in all intended use environments. 6. Clarify regulatory requirements. 7. Share illuminating practices and lessons learned with all stakeholders. a 2013 NPSG (Sendelbach, 2012). In late 2011, a summit was convened by the AAMI that included The Joint Commission, the U.S. Food and Drug Administration, the ECRI Institute and the American College of Clinical Engineering (ACCE). The summit report declares, Medical alarm systems are out of control. Clinicians are fatigued, confused, and overloaded with sensory alerts or left in the dark without actionable information from this cacophony of sounds and signals (AAMI, 2011a, p. 8). More than 300 stakeholders were brought together to develop key priorities and discuss alarm-related issues from a multidisciplinary perspective. Summit attendees discussed case studies, began to define best practices and identified opportunities to increase knowledge about alarm hazards. Seven themes emerged from the summit that included improving alarm system management and integration as well as increasing the understanding of all stakeholders about the issue of alarm hazards (Box 1). The ERCI Institute Top 10 Health Technology Hazards Report (ERCI Institute, 2011) recommends several actions to address the problem of alarm-related adverse events. Emphasis is placed on the bigger picture as opposed to isolated events. The report Source: AAMI (2011a). encourages facilities to consider the whole environment when addressing alarm hazards; this includes assessing equipment, staffing and unit features affecting the overall setting. Units are encouraged to develop alarm guidelines that reflect appropriate default settings, instruct staff how to use alarms including tailoring alarm settings for individualized patients and address the disabling or silencing of alarms. The report also discusses the importance of identifying who is responsible for responding to alarms and implementing a system to ensure that the correct staff member is appropriately alerted. Many recommendations have been made to address the issue of alarm hazards at the unit or facility level. The AAMI summit report (2011a) contains suggestions and examples of how individual units and facilities can and have implemented changes to their unique alarm hazards. Underlying all recommendations is the importance of addressing the problem from a multidisciplinary standpoint within a continuous quality improvement framework. Other evidence-based suggestions for addressing the problems of alarm hazards include using decentralized alarm monitoring rooms, evaluating delay settings to increase the amount of time between sensing an event and sounding an alarm, evaluating the effectiveness of alarm thresholds for the unit population, requiring alarm management education for staff and considering alarmrelated factors when selecting new equipment (AAMI, 2011a; Hannibal, 2011; Welch, 2011). Implications for Practice Alarm hazards will continue to be a challenge for obstetric and neonatal nurses well into the future. As practice settings continue to become more technology driven, nurses must respond to the call to ensure patient safety in the midst of an increasingly complex care environment. We must carefully consider the need to use technological monitoring, especially in low-risk populations (see Box 2). Such nursing decisions will decrease the quantity of alarms and the resulting alarm fatigue and burden. Conclusion When using technological monitoring, nurses must ensure that appropriate and individualized alarm settings are set. Care must be taken to attend to alarms and not tune out persistent sounds that may signal danger. To Box 2. Some Ways to Reduce Alarm Fatigue Use intermittent fetal auscultation with low-risk laboring women to reduce electronic fetal monitor-related alarms. Implement policies that encourage oral hydration instead of routine intravenous hydration in low-risk laboring women to avoid pump alarms. Advocate for skin-to-skin contact as the preferred method for warming infants instead of the routine use of baby warmers; this reduces alarms related to the warming device. 156 Nursing for Women s Health Volume 17 Issue 2

Get the Facts Association for the Advancement of Medical Instrumentation www.aami.org www.aami.org/publications/summits/2011_alarms_summit_publication.pdf ECRI Institute www.ecri.org/forms/pages/alarm Resource.aspx www.ecri.org/documents/monitor%20 Alarm%20_Poster%20Presentation.pdf date, little research has been conducted in the area of alarm hazards and obstetric or neonatal populations. While much of the ICU-based literature may be effectively applied to these populations, inquiry into the risks and effective interventions for alarm hazards in obstetric, nursery and NICU settings is crucial. NWH Refernces Instrumentation (AAMI). (2011a). AAMI Clinical Alarms: 2001 Summit. Retrieved from www. aami.org/publications/summits/2011_alarms_ Summit_publication.pdf Instrumentation (AAMI). (2011b). Alarms pose challenges to healthcare facilities. Retrieved from www.aami.org/publications/alarmhorizons/ articles/alarms_pose_challenges_5.pdf Instrumentation (AAMI). (2012). Welcome to AAMI. Retrieved from www.aami.org/about/ index.html. Cvech, M. (2012). Monitor alarm fatigue: An integrative review. Biomedical Instrumentation and Technology, 46(4), 268 277. ECRI Institute. (2011). Top 10 Health Technology Hazards for 2012. Health Devices, 40(11). 358 373. Retrieved from www.eri.org/2012_ top_10 _Hazards ERCI Institute. (2007). The hazards of alarm overload: Keeping excessive physiologic monitoring alarms from impeding care. Health Devices, 36(3). 73 83. Hannibal, J. (2011). Monitor alarms and alarm fatigue. AACN Advanced Critical Care, 22(4), 418 420. Harris, R. M., Manavizadeh, J., McPherson, D. J., & Smith, L. (2011). Do you hear bells? The increasing problem of alarm fatigue. Pennsylvania Nurse, 66(1), 10 13. Healthcare Technology Foundation. (2011). 2011 National Clinical Alarms Survey: Perceptions, issues, improvements, and priorities of healthcare professionals. Retrieved from www.thehtf.org/ documents/2011_htfalarmssurveyoverallresults.pdf Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (1999). To err is human: building a safer health system. Washington, DC: National Academies Press. Kowalczyk, L. (2010, April 3). Alarm fatigue linked to patient s death. The Boston Globe. Retrieved from www.boston.com/news/local/ massachusetts/articles/2010/04/03/alarm_fatigue_linked_to_heart_patients_death_at_mass_ general/?page=1 U.S. Food and Drug Administration. (2012). Medsun reports: Perinatal data system. Retrieved from www.accessdata.fda.gov/scripts/cdrh/ cfdocs/medsun/medsun_details.cfm?id=85551 Sendelbach, S. (2012). Alarm fatigue. Nursing Clinics of North America, 47(3), 375 382. The Joint Commission. (2002). Preventing ventilator-related deaths and injuries. Retrieved from www.jointcommission.org/sentinel_event_alert_issue_25_preventing_ventilatorrelated_deaths_and_injuries/ Welch, J. (2012, May/June). Alarm fatigue hazards: The sirens are calling. Patient and Quality Healthcare. Retrieved from www.psqh.com/ mayjune-2012/1291-alarm-fatigue-hazards-thesirens-are-calling.html Priority #1: April May 2013 Nursing for Women s Health 157