Nixing A Nuisance: Alarm management Strategies
Walking into a hospital often means subjecting oneself to auditory overload. Beeps from the left and chirps from the right don't only prevent patients from getting the rest they need, these annoying alarms deliver providers the clinical equivalent of junk mail when they should only send top priority information.

"There are so many different devices that produce alarms," says Marjorie Funk, RN, PhD, a professor at the Yale University School of Nursing in New Haven, Conn. "Alarms go off not only when a patient is in trouble, but also if a device's batteries are running low."

Clinical alarm management is complex frequently because there are simply too many alarms. Most are not clinically significant and caregivers are often left to guess if an alarm means a patient is in trouble or if a SpO2 sensor simply fell off his or her finger.  

Making a Determination With Data

At Johns Hopkins Hospital in Baltimore, Maria Cvach, RN, MS, and her co-workers scoured reams of unorganized data captured by clinical information systems to determine that a vast majority of alarms sounded at the 1,051-bed facility were categorized as low priority rather than medium or high priority alarms.  

In the surgical intensive care unit alone, an average of 317 alarms were sounding per patient per day, of which 245 were advisory alarms. Cvach, assistant director of nursing, estimated that 80 to 90 percent were false or clinically insignificant. Designed for sensitivity rather than patient specificity, these alarms were sounding too frequently and often alerting nurses to minor equipment errors and inactionable events.

Cvach went with numbers in hand to the clinical leaders on each unit to discuss adjusting the patient monitor default settings to reduce clinically insignificant and false alarm signals. In the surgical intensive care unit, this meant adjusting the alarm thresholds for SpO2 and arterial lines, which caused approximately 70 percent of total alarms on the floor, and changing from audible to visual alarms for inactionable events, such as certain arrhythmias.

After the intervention, the average number of alarms sounding per bed per day in the unit decreased from 317 to 212. "I've observed that it seems to be working, and it does seem to be calmer," Cvach says. "Noise competes for people's attention, but if you can give clinicians true and actionable alarms, they are more likely to respond."  

Teaming up with IT

"One of the problems with a past monitoring system was that nurses would get false alarms for every little crimped cable or moving finger," says Steve Miller, CIO of Oklahoma Heart Hospital, a two-hospital and 60-clinic system headquartered in Oklahoma City. "They couldn't tell the difference between a life-threatening alarm and a nuisance alarm."

When clinicians and the biomedical engineering team at Oklahoma Heart Hospital came to the IT department with this problem, Miller shopped around for an appropriate tool. The facility now uses an unobtrusive, user-friendly interoperability engine that reads patient monitor data and transmits that information wirelessly to nurses' mobile devices.

Like Johns Hopkins, Oklahoma Heart Hospital customized parameters so only the most crucial alarms would reach nurses. The interoperability engine reads every data field in a patient monitor, interprets the data according to the parameters and transmits notifications of critical events along with graphical wave data and room to nurses. Using the system, the hospital has eliminated the need for a central monitoring room and reduced false alarms by setting time delays for certain events. For instance, an alarm caused by an SpO2 sensor will not reach a nurse until it has sounded for 30 seconds, which eliminates alarms caused by crimped cables or moving patients.

"We implemented this technology due to nurse alarm atrophy," Miller says. "Nurses reported that, on our previous system, up to 80 percent of alarms were nuisances and not critical," Miller says. The initiative has garnered strong support from the chief nursing officer and nursing leadership who monitor response to alerts transmitted through the alarm management system.

There are also multiple redundancies installed in the system to ensure alarms receive attention. If a nurse does not respond to a notification by pressing the acknowledge button on his or her device, it is escalated to another nurse after a set amount of time. Additionally, test messages are sent to the mobile devices twice a day to ensure they are properly receiving notifications.

While Miller doesn't have data linking the monitoring system to improved patient outcomes, he believes it improves care by letting nurses spend more time with their patients. "We think our high patient satisfaction scores and clinical outcomes are partly driven by giving the nurses the technology tools they need for providing better care."

Unique Solutions For Unique Needs

Christiana Care Health System in Wilmington, Del., embarked upon one alarm redesign in the late 1990s. Unlike Johns Hopkins, Christiana standardized alarms across all units, turning off many unnecessary alarms and setting the exact same defaults for all patients.

Clinicians at Johns Hopkins believed that default settings should reflect the specific requirements of a unit's patient population, but standardizing alarms at Christiana made sense because it allowed nurses to move between units and still know how all the alarms should be set, according to Maureen A. Seckel, RN, MSN, a clinical nurse specialist.

Turning off unnecessary alarms alone was enough to reduce the number of alarms at Christiana, according to Seckel, but a more recent initiative has tweaked the hospital's alarm management strategy even further. Monitor technicians watch clinical alarms from a post across the street from the main facility.

A central monitoring room receives alarms from all units except for those originating in intensive care. Alarm silence has been achieved. "There are no alarm sounds on nursing units anymore," says Anita K. Witzke, MSN, manager of flex monitoring at Christiana. "All the noise is on our end."

Technicians receiving alarms in the central monitoring room use standardized notification criteria to alert nurses to a significant change in cardiac rhythm or pulse oximetry reading. All problems requiring attention are communicated to nursing units via telephone, but potentially lethal problems are communicated over a reserved network. The "lethal" phone located on each unit demands an immediate response when it rings, which has not posed a problem. It rings so infrequently and sounds so different to  indicate a crisis, the "lethal" phone always gets attention. "When that phone goes off, there is none of that alarm anesthesia we saw in the past," Witzke says.

Christiana investigated mobile monitoring, Seckel says, but "we wanted to provide an alarm filter and none of the computer systems do that quite as well as a human being."

The three organizations incorporated different technologies because "there are no simple solutions and potentially successful solutions vary from one environment to another," Funk notes. "Even within the same hospital, different units have different issues with alarms and, therefore, different solutions would be appropriate."

Moving alarm management forward

Despite ongoing efforts and recent success, Johns Hopkins' clinical team can't address all the issues with clinical alarms on their own. When Cvach looked at the alarms occurring in the hospital's cardiac surgery intensive care unit, she notes that 86 percent were warnings coming from SpO2 sensors. That number barely budged after adjusting alarm settings, indicating deficiencies in the equipment, which Johns Hopkins has since brought up with its vendors.

Additionally, hospitals shouldn't use the technology just because it's there.

"Don't even put certain patients on monitors to begin with," Funk says. "That's almost a bigger problem. We have the capability to put everybody on a monitor, but for so many patients there's no reason for it."

The Roles of FDA and Joint Commission
Managing clinical alarms extends beyond healthcare settings. Providers have a lot of control over alarms in clinical workflow, but many are frustrated with medical device manufacturers’ alarm design. In the wake of negative media coverage and legislators calling for further regulation to prevent alarm fatigue, the FDA and The Joint Commission (TJC) have partnered to mitigate the problem.

Discussions between the two agencies have emphasized ensuring that manufacturers consider alarm fatigue as part of their risk management strategy, according to Erica V. Jefferson, acting deputy director for the FDA’s Office of Public Affairs. The regulatory agency and the accreditor encounter the same hurdles as clinicians, particularly with the sheer number of alarms.

Jefferson says one obstacle to alarm regulation is the need for devices to be reviewed individually while alarm problems arise from interactions among systems of devices with unique configurations and environments.  Another challenge is the vast array of devices in use. “It’s difficult to develop appropriate requirements that enhance consistency that are adequately applicable to the full spectrum of devices involved.”

One common alarm complaint is that they don’t emit standardized sounds. For instance, the alarm on IV pumps manufactured by company X sound different than those on company Y’s IV pumps. The FDA is currently investigating the most effective sound characteristics, according to Jefferson, but this is one area where TJC has no power to directly affect change.

“If we had the power and influence to standardize the sounds of alarms, we would make that happen,” says Ana Pujols McKee, MD, executive vice president at TJC. “We can only work through collaboration with organizations to encourage standardization.”

While stakeholders are trying to help, one common complaint of those who study alarm fatigue is that alarms are often set for conditions that don’t require treatment.
TJC has considered the overuse of patient monitors and its consequences, but there is little the accreditor or the regulator can do.