Alarm fatigue has garnered a lot more attention in recent years and that attention has led to a meeting of the minds to find ways to remediate the problem, educate clinicians and find technology solutions. Medical device alarm management has become the focus of a number of special groups working to uncover solutions to this dangerous problem.
The term alarm fatigue refers to the potential for a clinician’s response to be guided by a repetition of false alarms that creates a numbness to responding. Like the boy who cried wolf, the repeated false alarms instill a sense of nonreaction. The sheer number of false alarms presents a risk to the presence of legitimate alarms if a clinician is overwhelmed and ignores a given occurrence.
ECRI Institute had named alarm safety as the number one technology safety hazard for six years running. The problem with alarm management has been on the ECRI list, within the top portion of concerns, since the list’s inception in 2007.
In 2014, The Joint Commission selected alarm management as a national patient safety goal.
The resulting anxiety and stress resulting from repeated false alarms can have a deleterious mental impact on nurses, as well as the patient and their family. The alarms can be both annoying and frightening. There is also a problem with who is assigned to respond to each alarm. This is sometimes not always clearly delineated.
While much of the cacophony of alarms emanate from physiologic monitoring systems, there are others that add to the problem, that also cannot be ignored. ECRI has singled out ventilator alarms as an example of an important alarm that falls outside vitals monitoring.
Topic number three on the 2017 ECRI Institute Top 10 Health Technology Hazards describes the risks associated with ventilator alarms. And, on ECRI’s list for 2018, in the fourth position is; “Missed Alarms May Result from Inappropriately Configured Secondary Notification Devices and Systems.” This is another form of the alarm management problem.
No hospitals are immune.
AAMI launched the National Coalition for Alarm Management Safety, a group of experts who had their initial meeting in April of 2014 to address the issue.
Alarms can be a part of ventilators, infusion pumps, feeding pumps, nurse call systems, notifying of bed exits and more. The alarms can alert clinicians to a deteriorating state of a patient or simply signal that a medical device is not functioning properly.
A thorough alarm assessment should be routine at any institution that employs them.
Escalation patterns need to be followed and done so quickly. The algorithms developed for middleware need to be at the level of the alarm. The middleware can be the means of control and there must be redundancies built into every alert because Wi-Fi may become disconnected and signals to phones may fail.
In 2014, the National Association of Clinical Nurse Specialists (NACNS) Alarm Fatigue Task Force published “Alarm Fatigue Strategies to Safely Manage Clinical Alarms and Prevent Alarm Fatigue,” a guide to manage alarms and reduce alarm fatigue. The task force believes nurses must have strategies and guidance for effective alarm management.
That task force was chaired by JoAnne Phillips, MSN, RN, CCRN, CCNS, CPPS.
That same year, The Joint Commission announced a national patient safety goal (NPSG.06.01.01) on clinical alarm safety for hospitals.
The problem is that the alarm management, and solutions for reducing false alarms, is a complex and multifaceted challenge that includes user input, staff obligations, recognition of all alarms when some may be muted.
The problem has also been addressed by members of the Society of Critical Care Medicine, held in collaboration with the Surgery Patient and Safety Committee.
Work done by Maria M. Cvach, DNP, RN, FAAN, director of policy management and integration at the Johns Hopkins Health System and Bradford D. Winters, MD, PhD, FCCM, associate professor, anesthesiology and critical care medicine and surgery at the Johns Hopkins Hospital, has been particularly enlightening in understanding the problem and remediation approaches.
Beyond the work done by The Joint Commission, Johns Hopkins, NACNS and ECRI, to address alarm fatigue and management, is the attention it has received from AAMI.
“AAMI pulled together a cross disciplinary team to develop an alarm compendium for hospitals and health systems as a best practices guide to help navigate the complexities of alarm management,” says Samantha Jacques, PhD, FACHE, director of clinical engineering for the Penn State Health System.
“The compendium gives real world examples used by other hospitals that can be implemented to reduce alarms such as alarm reports, education and competencies, and applications of tools such as failure modes effect analysis. The compendium also provides default parameter settings for multiple facilities of varying sizes and complexities,” Jacques adds.
Some best practices include the adoption of some basic procedures.
“Successful alarm management would continue to require a dedicated multi-stakeholder/interdisciplinary alarm management committee that routinely meets to (1) review reports of adverse events and near misses, (2) audit alarm data, and (3) assess and revise (if necessary) the facility’s alarm management policies. Staff would also need education and retraining on using these tools,” says Priyanka D. Shah, MS, project engineer in the health devices group at ECRI Institute.
“Continuous staff education and receiving feedback from frontline staff about their concerns would also factor into alarm management,” she says.
What have been the newest approaches to alarm management that can help nurses? Much of it centers around education; both from vendors and from research.
“The key issues that we are working on to help nurses; 1. Standardizing onboarding and ongoing education. I have asked several key vendors if they have any data that says that their educational strategies are effective – can the nurses demonstrate safe use of the technology – they have all said no. This is more of what could help nurses, we are still working on how this should be structured,” says JoAnne Phillips, coordinator, nursing quality and patient safety for the University of Pennsylvania Health Systems.
Phillips is a member of the AAMI Foundation’s National Coalition for Alarm Management Safety and is working on education for nurses on alarm management.
She says that the regulatory influence of the national patient safety goal has brought this issue to the forefront for leadership.
“Because adverse outcomes – that we are aware of – are rare, it has been difficult to justify the organizational commitment to the resources needed to adopt a standardized approach to alarm safety (which includes education). There are really no tools to measure alarm fatigue or the negative influence of nuisance alarms on staff and patients,” Phillips says.
Her third point is that there has been a tremendous uptick in literature on alarm safety.
“It has been mostly PI projects, but that may be the best evidence that we will be able to get. There are several new publications that have addressed alarm safety competencies for nurses. Our task force is putting together a framework for organizations to use for alarm education,” she says.
She adds a fourth point.
“There are several published resources available for nurses – one of the key resources is from NACNS (National Association of Clinical Nurse Specialists). It is a toolkit that provides nurses with a series of alarm-related resources,” Phillips says.
What Intervention can HTM take?
Although the many physiologic alarms impact nurses the most, the HTM department has the medical device knowledge to help in monitoring the technical alarms as well as helping with the patient-specific alarms. This provides an opportunity for HTM to show empathy for nurses and align themselves with their clinical colleagues to help mitigate alarm fatigue in any way they are capable of assisting.
“With the onset of The Joint Commission National Patient Safety Goal on Clinical Alarm Management, hospitals were tasked with creating protocols to reduce alarm fatigue by decreasing the total number of false and nuisance alarms,” says Seth Blanchard, biomedical site coordinator, clinical engineering at WakeMed Health and Hospitals in Raleigh, North Carolina.
“HTM departments were in turn tasked to educate clinical leaders/staff with the capabilities of alarm management within the technology used for the monitoring, diagnoses and treatment of patients,” he says.
“This process not only saw HTM and clinical staff collaborate on ideas for nuisance alarm reduction, but also established momentum to bring the number of nuisance alarms down by introducing scheduled reporting of mined clinical and technical alarm data,” Blanchard adds.
Shah says that some of the steps that HTM can consider to help their clinical counterparts include active participation and involvement in the alarm management committee that may already be in place at the hospital.
“This will help ensure that HTM is up to date of the alarm management policies and potential issues reported by the clinicians,” she says.
She recommends that HTM professionals routinely check the configuration settings during inspections and other times they come in contact with devices that generate clinical alarms (e.g., patient monitors, ventilators, infusion pumps, etc.).
“If an ancillary notification system (middleware solution) and end-user communication devices (e.g., smartphones, tablets, etc.) are used, ensure that these systems are properly networked and configured,” Shah adds.
How frequently do clinicians review device defaults? Can clinicians discern between technical and physiological alarms? Those are some areas where HTM professionals can ascertain the understanding that their clinical colleagues have.
“Clinical engineering departments can educate and collaborate with their clinical partners to help address alarm management. There is still so much misinformation and misunderstanding as to how systems work that education is always appropriate,” Jacques says.
“Clinical users may not completely understand how the local alarm relates to one that occurs on the central station, or how that feeds into a multi-parameter alarm (like a sepsis alert) or how those relate to secondary device notification,” she adds.
She says that understanding the ecosystem can help clinicians make smarter decisions about what alarms should go where and who should be responding to them.
“Once those decisions are made, clinical engineering departments can then collaborate with the clinical teams to update and implement those decisions. Ongoing monitoring is key to assure that decisions made are reducing alarm burden while not affecting quality of patient care,” Jacques adds.
There have been innovations in recent years that have helped reduce the number of false alarms.
“Some innovations/advancements in the recent past that have helped facilities mitigate instances of false alarms include alarm analysis/auditing tools, either offered by medical device vendors (e.g., patient monitors, secondary notification systems, etc.) or developed by the hospital. These tools facilitate alarm data collection and analysis,” Shah says.
“For example, obtaining a measure of the number and types of alarms that activate per bed per day within a care area. The more data you can collect (and make sense of), the better you can target strategies to improve alarm management and reduce false alarms,” she says.
Shah says that certain alarm customization features offered by patient monitoring vendors, for instance, potentially also help in reducing [the] number of false alarms. These features include setting configurable delays for certain parameters (in case the condition auto-corrects), ability to set alarm limits specific to the patients’ recent vital signs, patient profiles based on a patient’s age and disease conditions.
She says that improving staff education for effectively configuring and addressing alarms can help.
Jacques says that since the compendium was released in 2015, several papers have been released in BI&T that expand on this work, including:
“Hospitals and health systems now have a myriad of tools to use to work toward reduction of alarm fatigue. These tools are making it possible for systems to rapidly implement changes to enhance the environment, reduce alarm fatigue and improve patient safety,” she says.
A more individualized approach and making more use of middleware are two factors.
Shah says that alarm management is a constant work in progress with multiple areas to focus on. ECRI Institute has observed and heard some member hospitals focus on key trends when it comes to alarm management.“Patient specific alarm customization: There is literature that suggests that [a] minority of patients are typically responsible for [the] majority of alarms within a care area.
Customizing alarms and ensuring that there are specific alarm management policies in place to cater to tailoring of alarms specific to each individual patient will facilitate alarm management,” Shah says.
She says that the goal with alarm management is to get the right information to the right clinician in a timely manner.
“Tools and features that [help] facilitate clinicians to achieve this would be one of the areas of focus moving forward,” Shah says.
“Secondary notification system/middleware system is one solution that offers the ability to apply facility-defined algorithms to filter incoming alarm messages such that only actionable alarms are sent to the clinician and other end users. We have seen increased hospital interest for implementing such systems since they integrate alarms from multiple medical devices and hospital information systems and send it directly to end-user communication devices,” Shah adds.
There is more to be done to bring the volume down in hospitals and ease the nerves of those who have to respond to large numbers of alarms daily. With the help of HTM, manufacturers and the results of studies that seek to address the problem, a sense of peace may be on the horizon for those feeling the fatigue.
AAMI Alarm Compendium:
The document can be accessed at: http://s3.amazonaws.com/rdcms-aami/files/production/public/FileDownloads/Foundation/Reports/Alarm_Compendium_2015.pdf
ECRI Institute Alarm Safety Resource Center:
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