Written by Dr. Dinesh Rai, MD
As the number of medical devices and technologies in healthcare settings has increased, so has the number of alarms sounding in hospitals. These alarms are intended to notify staff of a patient’s condition and have benefited countless patients and providers. However, they have become a new source of risk. Alarm fatigue occurs when a medical professional becomes desensitized to the constant sound of alarms and begins to ignore them. Patients are surrounded by continuous beeping and chirping. Noise from alarms makes it challenging to focus on work, communicate with colleagues, and remain calm, leading to burnout and fatigue. Alarm fatigue can cause delays in care for patients and lead to injury.
Studies have shown that the number of alarms has gone from six in 1983 to forty in 2011. (1) This increase in alarms has been linked to an increase in alarm fatigue. One area of the hospital is a common culprit of over-alarming, the intensive care unit (ICU). According to the WHO, the average ambient sound levels in a hospital should not exceed 35 dB. ICU noise levels average between 44-77 dB (a 10-point increase in dB is equivalent to a doubling of noise levels). A significant contributor to this is the constant alerting from alarms. (2) The average number of alarms per patient daily is between 150-400. An ICU nurse attends to these alerts, most of which do not lead to any clinical intervention. Up to 35% of an ICU nurse’s shift addresses these largely unnecessary alarms. (3) The problem of excessive alarming is ever increasing and the burden on ICU staff is growing.
The Boston Globe cites two deaths that directly resulted from alarm fatigue. One was a 77-year-old woman on a monitor that was generating alarms about a failing battery. These alarms were ignored, and the patient unfortunately suffered cardiac arrest after the monitor failed. Another case was a patient who suffered a head injury leading to intracranial hemorrhage. The patient was reportedly often restless and agitated, leading to false alerting of low oxygen saturation. The patient was medicated with a sedative to calm him down. However, the medication was administered all at once instead of in small aliquots. An hour later, his alarm again alerted his oxygen saturation dropping and his heart rate increasing. Another alarm was triggered when the patient stopped breathing and CPR was administered. The patient suffered an anoxic brain injury and was withdrawn from life support several days later. (4) Cases like these frequently happen and are often not reported as a direct result of alarm fatigue. These deaths could have been avoided with practical solutions to over alarming.
In addition to causing alarm fatigue among staff, over-alarming can lead to anxiety and stress among patients. Patients are often attached to various machines that constantly beep and chime. For some patients, this can exacerbate an already stressful and overwhelming experience. They may worry about why alarms are being ignored, experience poor quality sleep, and start ignoring their own alarms.
In 2013, the Joint Commission released a sentinel event alert on the issue. The Commission states alarms are creating similar sounds and default settings set too tightly and not changed increase the risks of false negatives. An estimated 85%-99% of alarms do not require clinical intervention. (5) Between Jan 2009 and Jun 2012, 98 significant events related to alarms were recorded in the Joint Commission’s Sentinel Event database, 80 of which resulted in death and 13 in permanent injury. Of note, 21 events resulted from improper alarm settings. The FDA also reports 556 alarm-related deaths between Jan 2005 and Jun 2010. (6)
Hope is not lost, however. There are efforts to reduce alarm fatigue. Adjusting the layout of a ward to improve sightlines to alarm monitors, ensuring adhesive connections to alarms are replaced daily, and improving the specificity of where the alert is presented can all reduce levels of alarm fatigue. Instead of alerts projected throughout a unit, sending alarms to pagers, cell phones, or other personal devices would also reduce alarms. If the leads fall off a patient, alert a tech; if a patient enters an arrhythmia, alert a nurse, etc. Smart alarms offer longer delays in alarms for more minor excursions from thresholds or alerts based on a conglomerate of multiple vital signs and other inputs. (7) The Joint Commission offers several recommendations to mitigate alarm-related adverse events. One suggestion involves setting specific default settings (ICU, Emergency Room, Floor) and clinical condition-specific default alarm thresholds. They further go to suggest setting patient-specific thresholds once defaults have been established. (6)
Over-alarming is a severe problem in healthcare across the country. Not only can it cause alarm fatigue among medical staff, but it can also lead to anxiety and stress among patients. To combat this problem, hospitals should form cross-disciplinary teams that take ownership of alarm-related issues, develop procedures to assess equipment failures and malfunctions, produce educational materials for staff, and construct policies to input appropriate alarm thresholds continuously. Alarms have provided considerable benefits to society and the healthcare space. Lives have been saved by alerting providers of life-threatening conditions promptly. However, a balance must be reached where alarms are high quality (sensitive and specific).
Sources:
- Padmakumar AD, Bhasin V, Wenham TN, Bodenham AR. Evaluation of Noise Levels in Intensive Care Units in Two Large Teaching Hospitals – A Prospective Observational Study. Journal of the Intensive Care Society. 2013;14(3):205-210. doi:10.1177/175114371301400306.
- Cho, O. M., Kim, H., Lee, Y. W., & Cho, I. (2016). Clinical Alarms in Intensive Care Units: Perceived Obstacles of Alarm Management and Alarm Fatigue in Nurses. Healthcare Informatics Research, 22(1), 46-53.
- Keller JP Jr. Clinical alarm hazards: a top ten health technology safety concern. J Electrocardiol. 2012 Nov-Dec;45(6):588-91. doi: 10.1016/j.jelectrocard.2012.08.050. Epub 2012 Sep 27. PMID: 23022300.
- Kowalczyk, Liz. “Alarm Fatigue’ a Factor in 2D Hospital Death.” BostonGlobe.com, The Boston Globe, 21 Sept. 2011.
- Association for the Advancement of Medical Instrumentation. “AAMI. Priority issues from the medical device alarms summit” [Internet]. 2011 [cited 2012 Oct 12]; 1-48.”
- “Sentinel Event Alert 50 Medical Device Alarm Safety in Hospitals.” The Joint Commission.
- Hravnak, Marilyn, et al. “A Call to Alarms: Current State and Future Directions in the Battle against Alarm Fatigue.” Journal of Electrocardiology, vol. 51, no. 6, 2018.