By Debra Wood, RN, contributor
May 31, 2012 - Beep, bleep, bong, beep, bleep--monitors and medical devices create a cacophony of sounds aimed at alerting nurses to changes in their patients’ conditions, but with the so many bells going off, nurses can become overwhelmed and tune out or turn off the devices.
Marjorie Funk, PhD, RN, FAHA, FAAN, said that alarm fatigue can lead to bad outcomes and suggested ways to minimize the risk.
“Devices with alarms beep endlessly, demanding our attention, but once the staff become overwhelmed by the sheer number of alarms, it has led to sentinel events,” said 2011 American Association of Critical-Care Nurses (AACN) Distinguished Research Lecturer Marjorie Funk, Ph.D., RN, FAHA, FAAN, a professor at the Yale University School of Nursing in New Haven, Conn., at the association’s 2012 National Teaching Institute and Critical Care Exposition (NTI) in Orlando, Fla.
Funk offered as an example the case of a patient whose telemetry battery needed replacing, yet no one responded for 75 minutes, and when the patient went into cardiac arrest, no sound was made.
A Centers for Medicare and Medicaid Services (CMS) report in 2010 determined alarm fatigue was a contributing factor in the death of a cardiac patient at Massachusetts General Hospital in Boston. The patient’s alarm volume had been turned off but digital displays in the hallways showed “HR LO” after this person developed a lethal arrhythmia for 22 minutes and asystole for 17 minutes. Staff members found the person dead and were unable to resuscitate.
Other examples exist. A Boston Globe investigation turned up more than 200 alarm-fatigue related deaths since 2005.
Charlene Vennard, RN, said alarm-related deaths should not occur.
“Alarm-related deaths should not happen,” stressed Charlene Vennard, RN, at the NTI. Vennard works as a senior clinical applications specialist with Dräger, a medical technology company based in Carmel, Ind.
The ECRI Institute, a nonprofit organization dedicated to improving patient care, ranked alarm hazards the No. 1 health technology hazard in its 2012 annual report; the report also outlined the causes and offered a variety of recommendations to reduce the risk.
Vennard called alarm management a “huge responsibility” for nurses.
“Cardiac monitors are designed to be an adjunct, not replace what we do,” she said.
The sheer volume of alarms contributes to the problem. Everything from cardiac monitors to ventilators to patients getting out of bed triggers an alarm.
Marisue Rowe, RN, recommended the use of secondary alarm systems that can alert multiple people to the actionable event and send less important messages to support staff.
Marisue Rowe, RN, clinical program manager for Philips and a staff/charge nurse at Franklin Square Hospital in Baltimore, reported at the AACN NTI that an average 15-bed ICU has up to 100 alarm systems and 942 alarms per day.
A study at Johns Hopkins Hospital in Baltimore found an average of 350 alarms per patient per day, Funk said.
“When we have more than six alarms, we have an inability to distinguish what they are, and we become desensitized and no longer hear them,” Vennard said.
Nuisance alarms, whether false alarms or multiple alerts for the same problem, also increase the risk, Rowe said.
Vennard gave as an example setting the heart rate at 50 and bradycardia at a different rate, to avoid redundant alarms.
“The alerts have to provide the information you need to be useful,” Rowe added.
Another issue relates to high sensitivity at the expense of specificity, Funk said.
When devices “cry wolf” too often, Funk said, nurses will tune them out. A false alarm occurs when there is no triggering event, and a nonactionable alarm sounds correctly but for an event with no clinical relevance.
“When there are too many false alarms, we become desensitized, ignore it and think the monitor is working inappropriately,” Vennard said.
Nurse fatigue, workload and unit culture also affect alarm fatigue, Vennard added.
Facilities can develop an alarm management program, starting with an in-depth assessment of the current situation, examining the alarm environment and protocols, before establishing policies for alarm silencing, modification and disabling, ECRI outlined.
An alarm management task force would develop a formal strategy, including policies and procedures, such as whether nurses can change parameters.
Rowe recommended additional staff education about the monitors and other equipment with alarms to ensure every nurse fully understands how to operate them.
“Read the manual and become more efficient at managing alarms,” Vennard said.
Assess whether a patient really needs monitoring. Follow American Heart Association guidelines, Funk advised.
And when patients do require a monitor, set parameters appropriate to that patient’s needs, if allowed by the facility.
Funk advised deactivating alarms for premature ventricular contractions, since that is a condition that is not treated.
To avoid false alarms, Funk recommended protocols to ensure good signal quality, including preparing the skin, changing electrodes daily, and using good quality electrodes and lead wire.
Vennard agreed, adding that proper placement includes clipping hair, not using alcohol to clean the skin since it dries it out, but rather cleansing the area with a washcloth to “pink it up.” Do not use electrodes that are dried out, since they won’t transmit the signal well. Proper placement also is essential.
Smart monitors may screen out false alarms by putting the event through an algorithm before sounding, which one study found could decrease false alarms by 17 percent to 43 percent, Funk said. Such monitors also can detect artifacts and suppress the alarm.
Central monitoring with monitor technicians is another possibility for reducing alarm fatigue, but Funk said the ideal ratio of patients to techs has not been determined, and there are no definitive answers to the question of whether it is best to keep the monitoring on the unit or move it offsite.
Facilities also can consider secondary alarm notification systems, with software that receives the alarm information and alerts the correct person, Rowe said. For instance, some alerts, such as battery replacements, could be sent to a nursing assistant, reducing the number of sounds directed toward the nurse. Those sent to the nurse should be actionable alerts, such as asystole. Some secondary systems also can be configured to send the alert to a second or third back-up person.
Vennard warned nurses not to silence an alarm until they see what caused it, by checking on the patient. She also cautioned not to rely on secondary systems, and she encouraged nurses to include alarm limits in shift report and to check the settings when coming on duty.
“Patients die due to alarm mismanagement,” Vennard said. “It’s a huge responsibility.”
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