Wake up! This is alarming!

ALARM FATIGUE

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ECRI Institute 2011

What is
Alarm Fatigue?
Alarm fatigue occurs when
clinical personnel fail to
respond appropriately to
alarms due to excessive or
inability to understand the
priority or critical nature of
alarms.
As a result, clinical
personnel will be
desensitized to alarms,
and will ignore them and
even turning them off.
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http://www.youtube.com/watch?v=9rdcso5cpN8
ECRI
Institute 2011

An Alarming Challenge
More and more devices with alarms
More and more patients are connected to
one or many alarm-based devices
150-400 alarms per patient per day can be
typical in a critical care unit
Alarm-based devices are not standardized
in many institutions
Flexible alarm setting features allow for
inconsistent use of alarms

Alarm Management is Complex

Culture Conundrum

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is !
I
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it
deal w

Its not
my job!

way
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This is ays done
a lw
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v

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w
.
things

just do
ld
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If the n
t have a
n
ld
u
o
w
e
w
,
their job
problem.

We dont have any problems.

Weve never had an alarm
event.
Why shou
ld I rush
to put
the leads
back on?
Theyre
just going
t o co m e o
ff again.

No foundation
for improvement
6

Its the vendors

fault!

ALARM FATIGUE
Why is it important?
The Food and Drug Administration
(FDA) received 566 reports of
patient deaths related to alarms on
monitoring devices from 2005
through 2008
The ECRI Institute has identified
alarm hazards as their number 1 top
hazard for 2012
JCAHO recognized Alarm Fatigue
as critical and integrated this into
their accreditation standards
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The Consequences are

Alarming

And Still in the News

Alarm Fatigue a Concern for New
Haven Hospitals. New Haven
Register, June 11, 2011
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A Typical Event
Patient admitted with chest pain and shortness
of breath---Was on a monitored unit. At 3:25 am,
patients nurse noticed the leads were off and on
checking on the patient found him in the
bathroom unresponsive. Resuscitation efforts
were unsuccessful. Monitor showed the leads
had come off at 2:32 am
Alarm Interventions During Medical
Telemetry Monitoring: A Failure Mode &
Effects Analysis, A Pennsylvania Patient
Safety Advisory Supplemental Review,
March 2008

Example of Alarm Fatigue

Ventilator-dependent patient frequent
coughing
Coughing triggers high-pressure alarm
Frequent response to alarm by nurse with
no real problem
Pressure alarm limit increased to minimize
the number of false-positive alarms
An accident waiting to happen
Patient movement crimps breathing circuit
Secretions clog the endotracheal tube
Inadequate ventilation (inhalation or expiration)
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Some Questions to Ask

Does the nurse understand the purpose of the
high-pressure alarm?
Was the nurses competence in ventilator use
validated?
Does the hospital have a policy for who can and
cannot set ventilator alarms?
Is there a policy on how ventilator alarms should
be set?
If so, is it generic or does it consider specific
circumstances?
Does the hospital have ventilator responsive-valve
features, which can reduce nuisance high-pressure
alarms?
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Causes
Studies have shown as many as
99% of ICU alarms are false or
non-critical alarms.
These are called nuisance alarms
and are the leading contributor to
alarm fatigue
Alarms fail to function as expected
It is difficult to distinguish which
machine's alarm is going off
Nurses may block out noise in
order to concentrate on current
task.
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NURSES PROBLEMS?
Nurses have an overabundance of
notifying devices (nurse calls,
pagers, phones, overhead pagers,
and monitor alarms)
Lower patient to nurse ratios
increase the number of relevant
alarms per nurse
Monitors with undirected alarms
alert all nurses instead of specific
nurses
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Problem Reporting Data

Underreporting
Some estimates suggest that the actual number
of alarm-related deaths is ten-fold higher or more
than what problem data shows

Ability to do analytics on data is very limited

I literally had to read every report (around 20) in
a recent problem reporting analysis

Actual reports often dont have much

information
Typical language (paraphrased) - During use of
device alarm did not sound and patient died
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15

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How can we improve?

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Assess if sufficiently staffed with

enough nurses
How many nuisance/false-positive
alarms are there in the unit per day
Tiered response system would
allow for quicker response time and
delegation
Set individual parameters
Actionable/tailored alarms would
create less nuisance alarms
The combination of all alerts to one
device, "Smart alarms" to monitor
multiple device in relation to each
other
Centralized monitoring with
allocated staff member to alarm
personnel
Pop up screens
EDUCATION & TRAINING!!!

References

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THANK
YOU!!!
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