Monday December 18th 2017

Sounding the alarm

Nurses, organizations work to address alarm fatigue

Patients and their families often say they can’t wait to get home so they can finally get some rest — in part because of all the beeps and buzzes coming from IV machines, cardiac monitors and other medical equipment. That cacophony of sounds also can have a negative effect on nurses and other health care professionals — a phenomenon known as “alarm fatigue” caused by sensory overload.

The tuning out, and in some cases turning off, of alarms is such a critical problem that The Joint Commission issued a sentinel event alert earlier this year warning health care providers of its prevalence and designating it as one of its “2014 National Patient Safety Goals.”

At the same time, the American Association of Critical-Care Nurses developed an AACN Practice Alert™, and more recently expanded its alarm safety resources with a new clinical toolkit on strategies to manage alarm fatigue, according to AACN Senior Director Ramón Lavandero, MSN, MA, RN, FAAN, who also is a Guam Nurses Association member. AACN is an organizational affiliate of the American Nurses Association (ANA).

“Bedside nurses often talk about how easy it is to become desensitized to the barrage of alarms,” said Sue Sendelbach, PhD, RN, CCNS, FAHA, director of Nursing Research and clinical nurse specialist at Abbott Northwestern Hospital in Minneapolis and an AACN and Minnesota Organization of  Registered Nurses (MNORN) member. “Many alarms have the same intensity and often sound the same. They also trigger so often that it’s impossible to know which one should have priority.

“That means the alarms designed to keep a patient safe are now becoming safety hazards themselves.”

ANA also has been working to disseminate information via social media and other communications vehicles to nurses nationwide about alarm fatigue and the recent sentinel event alert.

Sue Sendelbach

“It’s a big problem not just on critical care units but across the hospital wherever equipment is being used, such as in ERs or on med-surg units where people are undergoing dialysis,” said Marie Barry, MSN, RN, senior policy analyst in ANA’s Department of Nursing Practice and Policy. “And it’s everyone’s responsibility — from nurses to physicians to employers — to determine how we can manage alarm fatigue. We need to make sure we are using only the most necessary equipment for patients, as well as have appropriate staffing so alarms [signals] can be addressed promptly.”

And that requires big-picture thinking and strategies.

“We don’t want [to perpetuate] a shame-and-blame culture in which we say that when an adverse event occurs, it’s because someone just wasn’t paying attention,” said Jane Barnsteiner, PhD, RN, FAAN, a member of the commission’s Patient Safety Advisory Group and an MNORN member. “This is a systems issue and not only an individual clinician’s issue. So we need to look at what needs to be done to keep patients safe in a multifaceted way.”

The scope of the problem

According to The Joint Commission’s alert, the number of alarm signals for each patient each day can reach several hundred depending on the type of unit. That translates to “thousands of alarm signals on every unit and tens of thousands of alarm signals throughout the hospital every day.” Further, about 85-99 percent of the signals do not require clinical intervention, but rather they occur because sensors are not positioned correctly, default settings aren’t adjusted to individual patients, batteries are low, and often there are other mechanical issues.

Because of all the alarm beeps and dings, nurses and other health care professionals can become desensitized to them, which results in alarm fatigue. To reduce the sounds, which also can disturb patients’ sleep, clinicians may lower the volume on equipment, turn the alarms off completely or reset the default settings to potentially unsafe levels.

Ramón Lavandero

“I’ve even seen patients turn off the alarms themselves, such as those on IV pumps,” Barry said. “They don’t understand how dangerous that is — especially if they are on heparin or insulin drips, for example.”

Until a couple of years ago, there wasn’t sufficient evidence to issue an alert or recommend a national safety goal, said Barnsteiner, a professor of pediatric nursing at the University of Pennsylvania School of Nursing.

A review of the commission’s sentinel event databank between January 2009 and June 2012 revealed that there were 98 alarm-related events, of which 80 resulted in deaths, 13 in patients’ permanent loss of function, and five in additional care or longer stays. The alert also notes that these events are underreported in all health care settings.

Further, The Joint Commission alert reported that in a “Top 10 Health Technology Hazards” list compiled by the ECRI Institute, “clinical alarm conditions consistently appear as the first or second most critical hazard.”

Alarm fatigue can be seen as a symptom of technology run amok, a viewpoint that Barnsteiner shares with other professionals.

“The use of alarm technology has gone up so dramatically,” she said. “And there often is no way to distinguish whether it’s an IV going dry versus a patient going into cardiac arrest. There has been no coordination among companies that produce the various types of equipment regarding what should be a high alert or low alert [sound].”

And having too many different sounds also can be problematic.

“Science has shown that it’s difficult for a person to learn more than six different alarm sounds,” Sendelbach said. “And we don’t yet have conclusive studies to identify which alarm sound best captures a caregiver’s attention. Still, the number and variety of alarms continue to expand.”

According to the AACN Practice Alert, “the average number of alarms in an ICU has gone up from six in 1983 to more than 40 different alarms in 2011.”

Offering nurses, others guidance

The AACN alert offers specific actions that nurses and other professionals can take to better manage the array of alarms on any given unit, including some that are very specific. The alert calls for initial and ongoing education of health care professionals on devices with alarms, the need to establish interprofessional teams to address alarm-related issues, and the use of monitoring technology only for patients whose conditions require it.

Some specific nursing actions include providing proper skin preparation for ECG electrodes and changing them daily, as well as customizing delay and threshold settings on pulse oximetry monitors.

The Joint Commission alert also notes the importance of sharing alarm-related incidents and prevention strategies, as well as establishing cross-disciplinary teams to include clinicians, clinical engineering, information technology, and risk management to address alarm safety and fatigue on all units. It additionally describes a need to assess the acoustics in patient care areas to determine if critical alarm signals can be heard, as well as reducing nuisance alarm signals by changing single-use sensors if appropriate.

Another strategy detailed in both alerts — and stressed by interviewed nurses — notes the importance of tailoring all alarm settings and limits when possible.

All organizations should have specific standards on default settings for pediatric patients, adult med-surg patients and ICU patients, which will help reduce false alarms and positively impact alarm fatigue, Barnsteiner said.

When possible, device settings should be further individualized to a patient, Barry said. For example, a patient whose normal heart rate is 100 should be taken into consideration when alarm triggers are set.

“It all comes back to patient-centered care — making decisions based on that patient’s needs,” Barry said.

Barnsteiner also stressed the importance of having frontline nurses involved in determining all aspects of alarm management — from selecting equipment to creating guidelines and standards for their patient populations.

Nurses should be proactive in implementing innovative technology, because they know what can be helpful to their patients, Barry said.

“One of our ICUs and a progressive care unit started to address the problem even before the alert was issued,” said Stacy Jepsen, MSN, APRN, ACNS-BC, CCRN, who is a clinical nurse specialist at Abbott Northwestern, an MNORN member, and who with Sendelbach, helped develop the AACN alert. “It’s also a good example of how active involvement in a national nursing organization can benefit a nurse’s home hospital.”

To further reduce the threat of environmental alarms and improve patient safety, AACN developed an “NTI ActionPak,” a comprehensive, downloadable toolkit of evidence-based strategies, resources and best practices, according to Lavandero. The toolkit includes an overall guide for implementing change, a customizable gap analysis and change-readiness survey, journal articles, a PowerPoint presentation, and talking points for team huddles.

“Despite the unique differences in clinical practice settings, the one common bond that unites professional nurses is our desire to improve patient safety and increase workplace effectiveness,” said Dave Hanson, MSN, RN, CNS, NEA-BC, co-author of the NTI ActionPak. “Whether you’re a direct care nurse, educator, advanced practice nurse or leader, this toolkit has been developed to support the important work each of us does to ensure safe, quality and efficient care to patients.”

Barnsteiner maintains that there is no simple solution and called The Joint Commission alert a “stop-gap measure.”

“But we need the equipment companies working together to implement standards on alarm signals and how they operate,” she said.

Sendelbach agreed, saying, “This is an issue in which all players need to help seek and implement solutions. All players means health professionals, of course, but also expert organizations, technology manufacturers and regulatory groups.”

And that brings Barnsteiner to another point.

“Sometimes top administrators get the alerts and that information stays with them,” she said. “It’s important that the alerts get to the units and shared with staff providing patient care.”

— Susan Trossman is the senior reporter for The American Nurse.


More information on the commission’s alert and safety goals:

More information on AACN’s alert and toolkit:

Infographic courtesy of The Joint Commission

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