This report originally appeared in the July 2011 issue of DOTmed Business News

Hospitals have more technology than ever before and alarm fatigue is one unfortunate drawback that has arrived with it. Alarm fatigue means a nurse, experiencing sensory overload, either grows complacent when hearing an alarm, possibly assuming someone else will handle it; becomes so frustrated with a false alarm that he or she shuts it off or lowers the volume; or manages to mentally file it away as background noise, ignoring it altogether.

The label “alarm” fatigue is slightly misleading, since it’s not just physiological patient alarms contributing to the noise. In addition to the warnings (both real and nuisance) given off by ventilators and IV pumps, other devices like call bell systems and even cell phones or pagers add to the cacophony. And there’s yet another sound being added — public outcry.

The human toll
Alarm fatigue takes its toll on hospital staff. A false or nuisance alarm can be distracting and may lead to mistakes in patient care. It can also be stressful to patients trying to rest and recover from surgeries or illness. The constant concern that a vital alarm might go off can also cause stress and anxiety for nurses worried about missing an event that needs immediate attention. And there’s legitimate cause for concern.


Earlier this year, The Boston Globe published an investigative report about the hazards of alarm fatigue. The Globe tapped ECRI Institute, a nonprofit organization that researches the best approaches to improving patient care, to review the Food and Drug Administration’s database of adverse events involving medical devices. From that information, it was determined that a total of 216 deaths were, in part, due to alarm problems. The problems included an alarm’s volume turned down so low as to be inaudible; equipment being used improperly; alarm speakers being taped over to somewhat mute the sounds; and, in some cases, nurses admitting that the alarm warnings just became background noise that was ignored. Manufacturing issues were cited in just eight cases. Experts at ECRI believe the actual number of deaths due to alarm issues is much higher, but hospitals may underreport the causes.

Additionally, manufacturers are rarely chased down by the FDA to complete inquiries into the cause of death when it comes to alarm issues, so the eight cited cases may be lower than the reality.

Alarm fatigue can also financially impact facilities. Beyond the lawsuits brought on by bereaved family members, having nurses constantly responding to and investigating nuisance alarms lowers workplace efficiency.

The hazards on a one to ten scale
Alarm fatigue ranks high on the dangers to watch for among hospital staff. In fact, ECRI Institute ranked alarm hazards as number two on its “Top 10 Health Technology Hazards for 2011” list, just one space behind radiation overdose and other dose errors during imaging procedures.

Beyond deaths, it’s important to factor in the effects on quality of patient care and comfort. While reports of deaths serve to grab national attention, understanding how many nuisance alarms occur, or how many actionable alarms occur, but are not acted on immediately, helps to define the scope of the problem.

“It’s hard to say exactly, but between 150 and 400 alarms can occur per patient, per day and that’s just physiological alarms,” says Kelly Graham, patient safety analyst for ECRI Institute’s Patient Safety Organization. “The problem is determining which of those alarms are false or nuisance alarms and which you need to respond to,” she says.

Budget cuts, along with a continuing nursing shortage, have exacerbated the problem in some hospitals. For some nurses, the better part of a shift may be devoted to investigating one alarm after another according to Graham.

Solutions lead to problems
In trying to prevent alarms from going unheeded, some facilities have bedside alerts sent to the on duty staff’s mobile phones. But when everyone on duty gets the alert, there’s the risk that each individual will assume someone else on the shift will handle it. “In that case, these facilities have the best intentions, but it’s creating white noise in the background,” says Mark Meyers, senior associate of the applied solutions group with ECRI Institute. If the alarm is going to a specific person, there is a better delineation of responsibility,” he says.

The sensory overload can lead to desensitization and ultimately worsen the issue all the bells and whistles are trying to prevent. According to Meyers, alarm fatigue troubles are on a steady increase. “For example, as more alarms come in with different and new bedside devices, there’s more alerts being created, making the problem worse,” he says.


An emphasis on patient privacy is also adding fuel to the fire. The prevalence of private patient rooms is resulting in a loss of centralization for patients and an increased burden for staff as they now have to travel room to room to respond to alarms. “It’s a significant issue,” says Meyers. “In a NICU, in the past, a nurse could turn around and ask for help from a coworker and everything was right there. Now, with single patient private rooms that coworker may not be there to help. In private rooms, you have to consider the architectural layout as well as staffing patterns for an alarm management plan to be successful.”

Successfully alert
How hospitals deal with patient alarms can vary widely, according to Meyers. The approach can even differ from floor to floor in the same hospital.
This makes implementing successful strategies as hard as nailing hospital Jell-O to the wall. It’s not just the alerts that have to be considered. Based on Meyers’ experience conducting onsite patient safety reviews of alarm management systems, to be successful, a hospital needs to take into account its technology, culture, infrastructure and practice.

“For instance, with infrastructure, can a nurse see patients easily or do they have to walk to see them?” he asks.

Things that work for some hospitals won’t work for others. Some facilities have a centralized system with staff dedicated to watching alarms all day. Others have a decentralized system with certain staff responsible for certain areas. Meanwhile, alerting all valid shift staff to patient alarms actually might work for some small care areas, but this method is not generally recommended. However, for any alarm management method to be effective, guidelines must be established to determine which staffer should respond to the appropriate alarm. “So nurses should only be alerted to clinically actionable alarms,” Meyers says.

“Low battery alarms, on the other hand, might go to a different member of the staff,” Meyers adds.

In fact, hospitals operating efficiently shouldn’t be troubling staff with any low battery alarms at all —Meyers recommends changing batteries on a regular basis. Another way hospitals may avoid excessive and unnecessary alerts is to make sure the clinician adjusts monitors to each individual under their watch. For instance, a heart rate monitor on a marathon runner needs to be adjusted to take into account the much lower heart rate that might signal a problem in the average patient, says Meyers.

Guidelines, conferences and seminars
It’s not just ECRI Institute making the push to silence the problem of alarm fatigue. The Association for the Advancement of Medical Instrumentation also has it on the docket with a summit slated for October to be co-hosted with ECRI and the American College of Engineers. The Joint Commission has also taken an interest and, the public’s awareness has been growing, helped greatly by the Boston Globe article and subsequent coverage by other news outlets — which are all good things in Graham’s estimation. “The more the media covers the issue, the more people will become aware and by talking about it and keeping it in the spotlight, I think it’s a good first step,” she says.

Manufacturing solutions
For manufacturers, the best thing they can do is make sure they’re openly communicating with professionals in the field. By speaking with bedside clinicians, they’re better able to determine where their energy should be focused.

Comprehensive customer education on the proper use of the machines and the management of the different alarm functions also plays a significant role. With a working knowledge of what the alarms are giving off warnings about, hospital staff will encounter fewer nuisance alarms and will be more prone to pay attention to the actionable ones.

OEMs are of course exploring device connectivity possibilities, but as Meyers points out, to provide an effective solution, companies would almost need to check each individual device to see how they work together.

Still, that hasn’t prevented some manufacturers from trying to improve upon design in order to create a safer and more peaceful experience for health care workers and patients alike.

Spacelabs Healthcare is one company that’s taking the challenge. According to Katherine Stankus, director of global strategic marketing, one of the main detail elements in the design of the company’s new XPREZZON monitor, introduced at the National Teaching Institute and Critical Care Exposition held this May in Chicago, was influenced by the growing concern about alarm fatigue.

“In terms of design, we decided to try to put more emphasis on visual alerts,” Stankus says.

While the unit still does offer audible alarms, it also offers visuals delivered by alarm lights embedded into the sides and back of the display. According to Stankus, the lights are totally invisible when alarm conditions aren’t present.

“The color of the light indicates the severity of the alarm,” says Stankus. “Walking by, a nurse can see that an alarm is in progress and the severity of the alarm — cyan for a low priority, yellow for a medium, and red for a high priority.”

According to Stankus, having visual cues has the added benefit of allowing a care provider to immediately find the source of the alarm, even in a room with multiple patients and in the case of multiple patient alarms going off, the different light colors can help set priorities.

DOTmed Registered Patient Monitors Companies

Names in boldface are Premium Listings.
Domestic
David Stopak, A. Imaging Solutions, AL
DOTmed Certified
DOTmed 100
Mary Mitchell, Biomedical Equipment Solutions, CA
Doug Rabkin, Buckeye Medical, CA
DOTmed Certified
Mark Charaf, Global Medical Sales and Repair, CA
DOTmed Certified
DOTmed 100
Kenn Matayor, Jaken Medical, CA
DOTmed Certified
Arnold Wiesel, MFI Medical, CA
DOTmed Certified
Scott Neary, Midstate Biomedical Equipment Services, CA
Andrew Bonin, Pacific Medical, CA
DOTmed Certified
DOTmed 100
dario mondragon, pmi, CA
Sanjay Singh, Tenacore Holdings, CA
Judy Engle, Frontier Medical, Inc., CO
DOTmed Certified
Tom Yore, Ace Medical Equipment Inc, FL
Carlos Vargas, INCAV, FL
DOTmed Certified
ROBIN WYLIE, ACE MEDICAL EQUIPMENT INC, FL
DOTmed Certified
Leslie Roberts, Altra Medical, FL
James Fowler, BioMed Techs Inc, FL
Diego Orjuela, Cables and Sensors, FL
Woody Owen, Clinical Measurements Inc., FL
Moshe Alkalay, Hi Tech Int'l Group, FL
DOTmed Certified
Ronald Tarr, MEDELCO, FL
Clinton Courson, Quest Medical Supply, Inc., FL
DOTmed 100
Ted Turano, X-Stream Medical, IA
DOTmed Certified
Warren Zhu, EastShore Medical Supply , IL
DOTmed Certified
Richard Fosco, HealthWare Inc., IL
DOTmed Certified
Dennis Swaggert, Heartland Medical Sales/Service, KY
Kevin Blaser, Coast To Coast Medical, MA
Garret Purrington, Medical Equipment Dynamics, Inc., MA
Bob Gaw, PRN, MA
DOTmed Certified
DOTmed 100
Alda Clemmey, Saffire Medical, MA
DOTmed Certified
DOTmed 100
John Gladstein, Medical Device Depot, MD
DOTmed Certified
Tom Kohman, Universal Hospital Services, MN
Nasser Saleh, Worldwide Medical Equipment, MI
Michael Fitzgerald, MaxMed, Inc., MN
DOTmed Certified
DOTmed 100
Tom Kohman, Universal Hospital Services, MN
Thomas Pigg, Sedation Equipment & Supply, MO
Joe Brock, Troff Medical, NC
George Fraza, DMS Topline Medical, ND
DOTmed 100
Alison Fortin, Global Inventory Management LLC, NH
DOTmed Certified
DOTmed 100
Charles Attle, TCL Technical Services, NJ
Abe Sokol, Absolute Medical Equipment, NY
DOTmed Certified
DOTmed 100
Mohamed Osman, Biomed Sky-Tech, NY
Jeovanni Rivas, Biomedical Technical Specialties, NY
Robert Schirano, Finger Lakes Medical Supply LLC, NY
Rotimi Osibogun, Timi & Daughters Inc., NY
Victor Landeros, OMED, NV
Rachel Seifert, Reliance Medical Sales, OK
Edmond Bright, Elite Biomedical, TX
Janet Lessnau, Hyperbaric Clearinghouse, Inc, VA
Philip Mothena, Simple Solutions, Inc., VA
Andy Stevens, Counterpane Inc., WA
Dorothy Marshall, Spacelabs Healthcare, WA
Dean Johnson, BioTech Services, Inc., WI

International
matin saeed kondori, Safari Medical Requisites L.L.C, United Arab Emirates
Thomas Koenigbauer, MED & IT Trading, Germany
Kelly Huang, Uni-tech Medical Supplies, Inc, China
Elin Fong, Clayton Technology Company Limited, China
Kevin Ming, Healthpower Technology Ltd., China
Ricky Lu, Shenzhen Jumper Medical Equipment Co.,Ltd, China
Jose Pinto, American Medical Systems And Supplies, S.A, Honduras
Johannes Hendradjaja, PT Intimedika Puspa Indah, Indonesia
Jimmy Wu, Bio-Technology Management & Services Pte Ltd, Singapore
Mensure Chang, Rayway Systrem Technology Inc, Taiwan