Alarm fatigue – it’s a well-known issue in
nursing. A recent search of CINAHL
Complete yielded 153 results with the key words “alarm fatigue,” and that was
with results limited to full-text articles.
Alarms are a critical piece of patient safety (AHC Media, 2018); they
alert a nurse to a patient’s changing condition. However, when nurses become tired of hearing
those alarms, problems can quickly result.
What
is Alarm Fatigue?
Alarm fatigue results when a healthcare provider
delays response to an alarm – or fails to respond at all – due to the
ever-present nature of alarms on a unit (Carcerei de Oliveira, Barbosa Machado,
Duque dos Santos, & Bicalho de Almeida, 2018). This delay is not due to provider burnout or
maleficence; in cases of alarm fatigue, the provider felt the alarm was
probably false and thus did not hurry to respond. AHC Media (2018) notes that nuisance alarms –
those where there is no problem with the patient – remain a common problem and
decreasing them is easier said than done.
Alarms are set with specific parameters, and alarm technology has not
advanced to the point where, for example, the heart rate monitor can determine
that an infant patient is crying and therefore the tachycardia is not clinically
significant. Alarm fatigue research
focuses on healthcare providers, but it is not limited to them – as a pediatric
home care nurse, I started my shift many times to find a pulse oximeter monitor
silenced or a ventilator’s alarm speaker taped over by a caregiver. In fact, Respironic’s SmartMonitor manual warns
caregivers not to block the speaker (Respironics, n.d.). One respiratory therapist from a Chicago-area
company for durable medical equipment (DME) even warns nurses to check for
alarms that have been modified for “silencers” when receiving a ventilated
child from home.
So what can be done about alarm fatigue? Clearly, getting rid of alarms is not the
answer. While nuisance alarms are a
problem – it’s speculated that around 95% of alarms are not clinically
significant (AHC Media, 2018), in critically ill and medically complex
patients, every alarm could be a real event.
AHC Media (2018) notes that solutions are slow in coming; even
concentrated alarm fatigue efforts have only reduced that to about 50%. Clearly, nurses have to respond to every
alarm, every time…but when there is a feeding pump alarming at the same time as
two pulse oximetry alarms and a ventilator, it can be a bit of a choice – where
do I go first?
This brings up a second issue, one that corresponds
with alarm fatigue. While nurses are
often quite good at identifying exactly which device is alarming because of the
sound, how does one know what patient to go to when hearing a single alarm down
a hallway of patients? If a patient is
in crisis, every second counts – and the time spent “following the sound” can
delay a response even by a nurse not suffering from alarm fatigue. Furthermore, an informal survey of nurses on
one pediatric unit revealed that, sometimes their alarm fatigue led them to
thinking of an alarm as a device causing a problem, rather than a patient
potentially in crisis. And, in support
of addressing the larger and oft-studied issue of alarm fatigue, I present a
potential solution to this second issue: alarm specificity.
Alarm…Specificity?
What started as a joke among nurses on one
transitional care unit now may be one piece of the puzzle in solving the
problem of blaming an alarm on a device rather than immediately being concerned
for a patient. Wireless alerts do exist
that can send an alert to a nurse’s mobile device (AHC Media, 2018), but what
of units in which the nurses do not carry work phones? What about transitional and teaching units
where caregivers are being taught proper emergency response?
“Wouldn’t it be great if this thing just said the
patient’s name?” one nurse asked.
Another nurse, caring for a patient whose monitors had
a different manufacturer, commented that she appreciated the different tone of those
alarms. “I know it’s my patient right
away.”
This technology already exists. The website ReadSpeaker.com explores
countless uses of text-to-speech technology, and digital assistants like Siri
prove that a device can certainly be taught to talk. A simple name would not be enough of an
alarm, but coupled with the alarm’s distinctive pitch, HIPAA concerns, of
course, could be a problem for announcing a patient’s name. As could the technological challenge of reprogramming
a device each time a new patient is using it.
The solution to that is also simple: a code word or even a room number
could replace a name.
Imagine that you are a nurse on a busy unit, with two
ventilated patients in adjacent rooms.
The ventilator alarms with a piercing shriek, as usual, interrupted by –
Alert, 104, Alert, 104 – and now you
know that you should respond to room 104 rather than 102. It’s a few seconds and steps saved, but one
never knows when a patient may desperately need those seconds.
This
Sounds Expensive
The biggest question, of course, then becomes the cost. Text-to-speech software varies in cost, from
hundreds to thousands of dollars (Fearn & Turner, 2019). Other measures have focuses on cutting costs
by limiting the duration of time a patient remains on monitors with alarms – as
clinically appropriate (Chen et al., 2017).
This would of course, continue, along with the importance of maintaining
patient-specific parameters rather than generally accepted alert levels
(Williams, 2018). Angel et al. (2018)
noted the high costs of resuscitation of patients in sepsis – imagine not only
the financial cost of a resuscitation, but potential litigation if an alarm was
missed due to fatigue or even searching for the source.
Maybe
We Can Make Alarms Sound Nicer Instead?
Alarms, unfortunately, cannot be “gentle.” They might be ignored entirely if that were
the case! Nurstoons artist Carl Elbing (2000)
humorously speculated what that might be like…
A patient I once cared for had a bed alarm that played
a merry electronic version of Yankee Doodle, to be “patient-friendly.” It soon had to be replaced with a standard, screeching
bed alarm, because the musical alarm quickly resulted in the patient getting up
to hear the music!
Humor aside, there are very real implications to be
considered in making alarms less “annoying.”
Patient specificity and nurses silencing alarms in advance of events
that would set them off, like suctioning (Williams, 2018) can help to reduce
the number of alarms. However, Williams
(2018) notes that reducing nuisance alarms is only one part of the alarm
fatigue issue. Caregivers cannot be
educated that it is vital to respond to all
alarms and then see nurses failing to do the same. For the home care environment, where there is
only one patient, user-specific alerts are admittedly not critical; the
technology could be adapted to allow the option of a “standard” alarm or a specific
one when the device parameters are set.
However, on a teaching or transitional unit, this technology could also
aid caregivers – should they respond to that alarm or can they carry on with
what they were doing, knowing it is not their loved one?
Do
We Have to Replace All Our Equipment?
No! This is not
a scorched-earth solution.
For the good of our patients, we need this adaptation
to be made. When the American Heart
Association mandated that CPR mannequins have feedback devices to monitor
compression performance, there was an immediate response to make new mannequins
with the technology included (Channing-Bete, 2019). However, existing mannequins were not
obsolete – these same companies developed after-market adapters to make the
mannequins compliant. The same could be
done with devices already on the market if alarm specificity is demanded. New devices could have the feature built in,
with adaptations made to existing equipment.
Once we have it, we can study it and provide evidence that this will, as
predicted, lead to quicker response times and reduced alarm fatigue. But the first step is getting it out
there. Join me in the quest for more
specific alarms!
