By Lola Butcher
Proactive hospital leaders are working to reduce the number of meaningless monitor alarms that fatigue clinicians and threaten patient safety. An added benefit: A quieter atmosphere may improve HCAHPS patient satisfaction scores-and value-based purchasing payments.
Providers are addressing alarm management with the following strategies:
- Seek C-suite-level support to improve alarm-related patient safety
- Identify the patient care areas that are most at risk for alarm-related safety events
- Quantify the number and type of alarms in that clinical area
- Appoint an interdisciplinary team and supply that team with the data and support it needs to improve alarm safety
- Achieve quick reductions in alarms by appropriately setting device parameters and following manufacturers' recommendations
- Identify additional improvement approaches (for example, sending alarms to nurses' pagers)
What does too much information sound like?
Try 942 high-priority monitor alarms per day on a 15-bed unit. That is what The Johns Hopkins Hospital found when it sought to understand its alarm environment. "I call it a cacophony of sound because you have horns and beeps and buzzes and all kinds of noise," says Maria Cvach, MS, RN, assistant director of nursing of clinical standards at Johns Hopkins.
Johns Hopkins is by no means alone. During a 24-hour period at Boston Medical Center (BMC), patients and staff in a single unit heard 2,489 cardiac arrhythmia alarms. The vast majority-some 1,600-were clinically insignificant; 743 were "warning" alerts of a potential problem, and 70 were "crisis" alarms that called for immediate attention.
"It causes alarm fatigue," says Jim Piepenbrink, director of clinical engineering at BMC. "People get desensitized to alarms and they may overlook a crisis tone."
All that noise is not just annoying; it can be deadly. Alarm fatigue-along with malfunctioning or disconnected alarms and other alarm safety issues-contributed to more than 500 patient deaths between 2005 and 2008, according to a report by the Association for the Advancement of Medical Instrumentation.
Eliminating unnecessary noise is also important to patients' recovery and may influence hospital revenues. Through its value-based purchasing initiative, Medicare is evaluating each facility's scores on the HCAHPS patient satisfaction survey, which includes this question: "During this hospital stay, how often was the area around your room quiet at night?"
Addressing the problem of alarm safety is both simple and complex. Relatively easy, low-cost fixes can significantly reduce noise. However, to truly understand, manage, and address alarm safety issues, healthcare leaders need to adopt a C-suite-endorsed, systematic approach that enlists a great amount of time and effort from a wide group of stakeholders.
Topping the Hazard List
Ironically, problematic alarms are often attached to medical devices that are critical to saving patients' lives, such as telemetry monitors, ventilators, infusion pumps, and dialysis units. Hospital alarms associated with these devices top ECRI's report, Top 10 Health Technology Hazards for 2012.
While many hospitals are proactively working on alarm safety to prevent problems, many others are not doing anything about the cacophony, hoping they do not experience an adverse event. "There are many, many hospitals that are taking a reactive approach," says Kathryn Pelczarski, director of applied solutions at the ECRI Institute.
In its report, ECRI identified several specific alarm issues that endanger patients. In addition to becoming desensitized to the noise, nurses and other staff members sometimes adjust alarm limits outside the appropriate range-or turn the volume too low-to reduce noise stress on patients and family members. In addition, staff may not recognize urgent alarms or be able to tell which device is issuing an alarm because so many alarms are occurring in close proximity to each other. There is also the issue of whether alarms accurately notify the appropriate staff person via pager or wireless phone.
Access related sidebar: What Causes Alarm-Related Adverse Incidents?
The full scope of the problem is not yet known because hospitals do not currently report alarm data to any outside agency. But that eventually may change: The Food and Drug Administration and The Joint Commission announced last year that they are jointly working on a strategy to address alarm fatigue. This spring, The Joint Commission also conducted a survey of healthcare facilities to collect information about clinical alarm management, with the goal of identifying best approaches for addressing the issue. According to the survey introduction, "accreditation requirements" is one option under consideration.
Addressing Alarms Systematically
Unlike many patient safety issues, the concept of "best practices" for alarm safety is not well-developed, although there are some common strategies that all hospitals can adapt as they determine the best way to improve alarm management in their organizations, says Pelczarski. "You really need to take an introspective look at the culture, infrastructure, practices, and technologies within your own organization-and within each patient care area-because making alarm management safer is really a very complex issue, she says.
Setting device parameters. Johns Hopkins began addressing alarm safety in 2006 through a quality improvement project on a medical progressive care unit. By conducting small tests of several interventions, the project team reduced the number of monitor alarms by 43 percent-and identified ways to make changes in other units throughout the hospital.
"The lessons we learned are that you need an infrastructure within your institution, support from administration, and an interdisciplinary approach," says Cvach.
The hospital's Alarm and Monitor Subcommittee-which includes physicians, nurses, respiratory therapy staff, clinical engineers, IT staff, and human factors engineers-is a standing committee that reports to the Critical Care Committee. The group wrote a cardiac and physiologic monitor policy, which is updated regularly, and works to standardize the operation of alarms and monitors throughout the hospital. For example, cardiac monitor software has been standardized throughout the hospital and acceptable secondary alarm notification systems have been defined.
Beyond that, Cvach worked with two physician leaders-the vice president of medical affairs and the chair of the Critical Care Committee-to create an Alarm Management Committee that examined the default parameters for alarms on every monitored unit in the hospital.
Manufacturers of devices and monitors often provide dozens or even hundreds of parameters that can be set to determine when an alarm sounds. "Unit managers are supposed to figure out the parameters if they don't want to use the manufacturer's defaults. The problem is that most people don't have enough information to make an informed decision about what parameters to choose," says Cvach.
The physician-led Alarm Management Committee revised these parameters so that nurses would only be alerted to actionable alarms. "In other words, when you hear an alarm, you're going to do something about it," she says. "You're not going to ignore it. That's what our focus was."
The same committee also developed criteria for which patients should have continuous versus intermittent physiological monitoring, and it is currently working on recommendations for when those monitors should be discontinued.
Despite the work to standardize alarm management, Johns Hopkins leaders recognize that alarm safety cannot be accomplished by forcing a one-size-fits-all approach. That's why the hospital's Alarm Management Committee provides a list of options. For example, when the hospital opened a new patient care building, unit nursing leaders were given three notification choices, using an alarm escalation scheme:
- Hire staff to watch unit-based monitors
- Have monitors page bedside nurses when their patients' alarms go off
- Send alarms to a pager worn by a designated person, such as a charge nurse, who then notifies the appropriate bedside nurses about their patients' alarms
- Plus, strategically place waveform screens in the unit hallway to display ECG rhythms and critical alarm activity
Given the choices, various units are using different strategies. For example, on the new 40-bed pediatric ICU, unit leaders chose to have designated nurses receive secondary alarm pages. "Nurses are going to receive primary alarm notifications from the bedside monitors. However, if an alarm is not addressed in a set timeframe, designated nurses will receive zone alarms through a pager," says Cvach.
Meanwhile, the nurse leaders on the cardiac progressive care unit chose a unit-based monitor watch approach because of the high-risk patients being treated for cardiac abnormalities. Trained technicians will observe patient monitors 24 hours a day and inform nurses via wireless phone of arrhythmias or technical issues requiring attention.
Focusing on arrhythmia patients. At Boston Medical Center (BMC), Piepenbrink's clinical engineering staff first spotted the variance in alarm defaults when it started assembling a database of all the hospital's medical devices and their default settings. A task force of physicians and nurses was recruited to identify where the variance presented a patient safety issue, and arrhythmia alarms topped the list.
"The group ran with that, and we identified the best strategy for ensuring that all arrhythmia devices are standardized," says Piepenbrink. "We changed the alarm defaults to make them uniform and, in concert with that, we provided staff education on why we were making the change."
In addition to reducing noise, BMC is working to ensure that bedside nurses know when telemetry patients need help. Typically, at BMC, alarm notifications are sent to the central nursing station. But nurses are often away from the station, taking care of patients. So they may not know that a particular patient's alarm went off. To curtail that problem, flat panel displays that show and sound alarm activity are being installed in locations throughout each telemetry unit.
"Staff will be able to hear alarms better but also, instead of walking all the way to the central station, they will be able to go to substations to have a look and see what the alarm is about," says Piepenbrink.
The flat panel displays are expected to improve the care of monitored patients at a nominal expense. "The caution I have for those who tackle the alarm issue is this: Be careful about what you throw at this in terms of capital investments," says Piepenbrink. "There are a lot of solutions out there for alert management and distribution, but if the process of alarm management is broken, additional technology will magnify the problems."
Although patient safety is its first goal, BMC leaders also are focused on patient satisfaction. Piepenbrink's holy grail is to methodically and safely eliminate clinically insignificant alarms so that patients can rest during hospital stays. "We know that this is not going to happen overnight," he says. "It is a gradual thing, and the reason is that we don't necessarily know what is a good alarm versus a bad alarm because every patient is a little different."
BMC's task force is now systematically reviewing monitors throughout the hospital to look for alarm settings that can be safely changed. The hospital is comparing alarm data from its monitor manufacturers with its own patient data to analyze false positive alarms and identify opportunities for improvement.
Starting with Simple Fixes
Meanwhile, Johns Hopkins discovered one easy way to reduce meaningless alarms: Change the ECG lead electrodes attached to patients every day. While many monitor manufacturers recommend a daily electrode change, it is not generally practiced. When Johns Hopkins tried it on one unit and saw the number of daily alarms drop by 48 percent, Cvach was incredulous.
"We didn't believe it, so we decided to repeat it on a different unit with different staff," she says. "This time, we saw almost a 50 percent reduction in alarms-just by changing electrodes."
Cvach says the effect may stem from several factors, including better skin prep, fresh electrodes that deliver high-quality tracings, or better skin-electrode contact. "Regardless, the benefit of changing electrodes daily in reducing nuisance alarms outweighs the pennies it costs to replace electrodes," she says. Thus, Johns Hopkins is rewriting its policy to require daily electrode changes for all adult patients.
Another simple fix: Asking clinicians to think about whether a patient needs a monitor. At BMC, the computerized order entry system is embedded with decision support regarding the appropriate use of telemetry. "This helps ensure that patients are using telemetry for an appropriate period of time instead of just keeping them on for no apparent reason other than convenience," says Piepenbrink.
Those examples show that alarm safety can be improved in some ways without major expense. In some cases, hospitals may need to hire people specifically to monitor alarms or invest in an alarm integration system that directs all or a subset of alarms to a clinician's wireless device, but those high-cost solutions are not always the right choice.
"A lot of the simple strategies for improving alarm management are really process issues," says ECRI's Pelczarski. "There are many things you can do to improve alarm management that are not cost intensive."
Lola Butcher is a freelance writer and editor based in Missouri.
Interviewed for this article (in order of appearance): Maria Cvach, MS, RN, is assistant director of nursing, clinical standards, The Johns Hopkins Hospital, Baltimore (email@example.com). Jim Piepenbrink is director of clinical engineering, Boston Medical Center, Boston (Jim.Piepenbrink@bmc.org). Kathryn Pelczarski is director, applied solutions, ECRI Institute, Plymouth Meeting, Pa. (firstname.lastname@example.org).
Publication Date: Friday, May 25, 2012