Alarm fatigue is a major healthcare burden, continually ranking at the top of patient safety concerns. Managing alarms in both the ICU and post-anesthesia care unit require proper protocols and technology to ensure patient outcomes as well as effective staff response.



Respiratory therapists are exposed to the near constant sound of beeps from the machines that monitor patients’ vital signs. These alarms, designed to alert clinicians when something goes wrong, may cause unnecessary distractions and lead to avoidable errors that can put patients at risk.

“It gets to be a cacophony of sound on a unit,” said Maria M. Cvach, DNP, RN, FAAN, director of policy management at Johns Hopkins Health System and Integration in Baltimore, Md. “By having all these unnecessary, low-priority alarms happen on the unit, it actually causes what I consider white noise.” After awhile of living with this constant noise, providers can tune it out.

“That’s when problems occur.”

Cvach, who has worked as a cardiac nurse in the intensive care unit for more than 30 years and who does consulting work with hospitals on how to prevent alarm fatigue, said that it is often the medium-priority alarms that are missed, potentially causing harm to patients. This is due to alarm fatigue, a condition among hospital staff in which they start to become desensitized to the alarms.

An independent nonprofit authority on medical practices and products, ECRI Institute listed the condition on its 2019 Top 10 Health Technology Hazards report. Hospital administrations are also aware of this issue. According to a national survey conducted by the Physician-Patient Alliance for Health & Safety, 19 out of 20 hospitals rank alarm fatigue as a top patient safety concern.

Since alarm fatigue has become a high priority in emergency rooms across the country, respiratory department managers and others who work in acute care settings are working to find solutions to decrease the number of adverse events related to alarm fatigue. But how do clinicians strike the proper balance between activating too many alarms, which can lead to alarm fatigue, and activating too few alarms, which can lead to hazardous conditions being missed? The ECRI Institute suggests that alarm customization is one practice that can help achieve this balance, but there are other ways that hospital leaders are taking action.

Develop an Alarm Management Protocol

Dave Crotwell, RRT-NPS, FAARC, director of respiratory care services at Seattle Children’s Hospital, suggests that department managers consider developing an alarm management protocol for their team of respiratory therapists.

At Seattle Children’s Hospital, Crotwell worked with an interdisciplinary team from across the hospital to come up with a plan for managing the issue. Ultimately, they developed high and low limit guidelines for each device’s alarm settings. “We went through a consensus process to set limits for safety and to prevent the frequency of alarms,” said Crotwell.

He also advised that there should be clear processes in place for when a clinician needs to set alarm parameters outside the standard. If this occurs at Seattle Children’s Hospital, RTs can consult a physician to adjust the settings outside of the normal protocol limits, and document the reasoning in the patient’s chart.

Consult Your Alarm Data

Hospitals can’t fix a nuisance alarm problem if they don’t know what the problem is, so one of the first steps clinical leaders need to take is to get ahold of their alarm data, said Cvach. “If you don’t have the data on what is alarming, you can’t fix it properly.”

Most institutions, through their clinical engineering department will have what they call alarm reports through their central monitoring system. That is a great resource for clinicians to see how often alarms are actually going off, said Tom Malinowski, MSc, RRT, FAARC, director of Pulmonary Diagnostics and Respiratory Therapy Services at the University of Virginia Medical Center in Charlottesville.

Consult with the Medical Device Manufacturer

Crotwell also suggests RT managers look into working with their pulse oximetry vendor to adjust settings. “As most people who work in healthcare know, pulse oximetry is one of the most common alarms in the hospitals, and is frequently inaccurate,” he said. For this reason, Seattle Children’s set delays on their pulse oximetry units across the entire hospital. Clinical leaders consulted with the pulse oximetry manufacturer to avoid false alarms and capture real desaturations.

After implementing these changes, the positive results were clear. “We actually looked at the frequency of total alarms coming from our cardiorespiratory monitors in a specific unit, over a 24-hour period, and what we saw was a significant decrease in the total number of alarms, and no increase in serious safety events or patient decompensations associated with that,” said Crotwell.

Adjusting Alarms Can Improve Patient Comfort

False alarms can disturb patients, especially during the night, when oxygen levels may fall lower than usual. A patient may be continuously woken up throughout the night by the devices at their bedside.

“We certainly know the risks of delirium from patients who cannot get a decent, consistent, night’s worth of sleep or blocks of sleep that are conducive to recovery. So I think it is a very real issue,” said Malinowski. This can also lead to anxiety in both the patients, their visiting family members, or caregivers, who may find the alarms to be a source of stress, he added.

The standard patient satisfaction survey at Seattle Children’s Hospital did previously see frequent complaints about alarms, specifically there were concerns about the pulse oximeter alarm sounding all night, without medical staff coming to turn it off in a timely fashion. Since implementing the pulse oximetry delays, Seattle Children’s Hospital has seen a decrease in patient complaints, said Crotwell. Even adjusting the pulse oximeter limit just a few percentage points can make all the difference for certain patients, Malinowski added.

Build a Multidisciplinary Team

For other RT department leaders looking to create an alarm limit protocol, Crotwell suggests that it is essential to have a multidisciplinary team to collaborate with and correspond with medical device manufacturers.

“It may not make sense to have a standard across an entire institution for an alarm delay, but it may make sense to have a standardized practice around setting those alarms, even if it is just unit specific, and to ensure that people are adhering to that standard for setting alarms,” said Crotwell.

Evaluate the Manufacturer’s Default Alarm Settings

Ventilators have tiered alarms, including high, medium and low-priority, but there are issues with a lack of uniformity among manufacturers’ default settings. “There is no requirement that says certain alarms have to be high, medium and low, it is really up to the manufacturer to determine this,” said Cvach.

In a paper published in the peer-reviewed journal Anesthesia & Analgesia and coauthored by Cvach, researchers were able to collect data from three ICUs and determined that ventilator manufacturers Hamilton Medical and Medtronic prioritized alarms differently.1

“If you just stick the device on the unit, the way that manufacturer sent it out of the box, you’re going to get possibly a lot of unnecessary alarms, that really are not value-added and actually cause more harm than good because they distract you from real patient conditions,” said Cvach.

Divide Your Unit Into Alarm Zones

At Johns Hopkins, as an alarm management technique the hospital has divided each unit into smaller zones, so alarms will only sound within their zone. “If you have a 40-bed unit, you are not going to hear alarms for the entire unit, you will only hear them for the zone that you are standing in,” said Cvach. “That can really help to get rid of alarm fatigue.” RT


Lisa Spear is associate editor of RT. For more information, contact editor@RTmagazine.com.


Reference

  1. Maria M. Cvach, Jacqueline E. Stokes, Sajid H. Manzoor, Patrick O. Brooks, Timothy S. Burger, Allan Gottschalk, M. (2018) Ventilator Alarms in Intensive Care Units: Frequency, Duration, Priority, and Relationship to Ventilator Parameters. Anesth Analg.