Hospital's simple interventions help reduce alarm fatigue

On an August day in 2012, the staff on 7 North, one of Boston Medical Center's medical-surgical floors, waited anxiously, watching the clock. As noon approached, they held their breath and listened. And then, abruptly, the incessant cacophony of beeps that had become commonplace on the unit stopped.

“It was dead silent,” said Patricia Covelle, BMC's director of critical-care nursing.

That day marked the go-live of a new and deceptively simple set of interventions designed to reduce the onslaught of alarms coming from cardiac monitoring devices on the hospital's medical-surgical units.

Experts say the din caused by hospitals' increased use of monitoring devices can desensitize nurses to alarms and raise the likelihood that a true safety event will go unnoticed. Also, noisy environments add to patients' anxiety and make rest and healing difficult.

Safety advocates are increasingly concerned about the damage done by what some call alarm fatigue. In April 2013, the Joint Commission, the nation's largest hospital accreditation organization, issued a sentinel event alert warning of the dangers of alarm desensitization and urging hospitals to beef up alarm management protocols and alarm-setting guidelines.

Just two months later, the Joint Commission raised the stakes even higher when it announced a newly drafted National Patient Safety Goal on clinical alarm safety. As of January, hospitals are required to demonstrate that they have made alarms an organizational priority and identify the types of alarms they plan to target. By 2016, hospitals will need to develop and implement specific protocols aimed at curbing unnecessary alarms.

The issue has rocketed to the top of hospital quality and safety officials' checklists. A recent survey by the Physician-Patient Alliance for Health & Safety, a patient advocacy group that receives financial backing from device and hospital instrumentation companies, found a high degree of concern about alarm fatigue among hospital officials. “They worry it's interfering with patient safety and workflow,” executive director Michael Wong said.

BMC was early in recognizing the extent of the problem. Its multidisciplinary task force began looking at the issue of alarm safety in 2008, focusing mainly on the need to standardize devices' default settings across units.

The task force's most recent initiative built on that early work and included a painstaking review of alarm data, input from frontline users and an evaluation of the autonomy nurses had over device settings.

The task force conducted focus groups with nurses, physicians and residents. “We asked them why they thought we had so many unanswered alarms, what the obstacles are and what is very likely the cause of the problem,” Covelle said.

The review of alarm data, which involved BMC's cardiac telemetry monitoring vendor, revealed that 67% of the alarms came from violations in heart rate default settings. They reset high and low parameters from 120 and 50, to 130 and 45—clinically acceptable changes, they said.

They also changed heart rate alarms to “crisis” level instead of “warning” so they could not automatically reset. “Those alarms were going off constantly, sometimes when patients simply got up out of bed or went to sleep,” said Deborah Whalen, BMC's clinical service manager of cardiology. “Staff were used to warning alarms resetting so if they went off, they often waited to see if they went away.”

Finally, the task force developed a process that gave nurses the authority to raise or drop the default heart-rate parameters, depending on the condition of the patient. For a change to be made, two registered nurses had to review the patient's alarm history and medical record and agree that a different lower or higher rate was appropriate, said James Piepenbrink, BMC's director of clinical engineering.

BMC's RNs are required to score at least 90% on an examination assessing heart-rate knowledge, Whalen said.

“Two nurses could agree, for instance, to drop the lower limit by five,” Piepenbrink said. “They would submit that order to house staff to put it in the (electronic health record) and officially log it as a change. What that did is put the opportunity to better manage the patient in the end user's hands.”

After putting the task force's changes in place, the number of audible cardiac alarms on 7 North plummeted 89%, from nearly 90,000 to roughly 10,000 over the course of a six-week pilot. The hospital also saw a modest jump in patient-satisfaction scores. BMC has since implemented the program in its nine remaining medical-surgical floors, resulting in a 60% drop in audible alarms across the hospital.

Other hospitals are approaching alarm safety in a number of ways. Some are using a central place, or “war room,” where technicians review all monitor alarms. Other hospitals put monitor watchers on each unit or they route alarms through clinicians' pagers or cellphones to cut down on noise, Piepenbrink said.

Those tactics were not viable options for BMC because the safety net hospital lacked the resources to layer on more technology, he said. More importantly, the task force wanted to find a way to make sure that alarms were relevant and provided useful clinical information.

“If you route alarms through a smartphone or a pager, you don't address the fundamental issue that you have a broken process,” Piepenbrink said.

BMC's initiative drew praise from James Keller, vice president of health technology evaluation and safety for ECRI Institute. The Plymouth Meeting, Pa.-based not-for-profit safety group has included alarm fatigue on its annual list of top 10 technology hazards since the list's inception in 2007.

Next on the agenda for BMC's task force are two more projects. One will look at setting appropriate alarm parameters for tachycardia, or a sustained heart rate above the normal range, which accounts for 33,000 alarms a week hospital-wide, Whalen said. The second will work to fine-tune alarms for pulse oximetry, which the task force says accounts for another 200,000 alarms.

“Before the rollout of the pilot, there were 1 million alarms a week across the hospital,” she said. “Now it's down to 400,000 a week. These projects will hopefully put us under 200,000 a week this year.”

Follow Maureen McKinney on Twitter: @MHMMcKinney