By Michael Velez
This is my call to action. Do your part to combat the safety risks alarm fatigue poses to our patients! Alarm fatigue is the sensory overload experienced when clinicians and health providers are exposed to an excessive number of alarms in the hospital, which can result in desensitization to alarms and consequently missed alarms. During my IM rotation, just at the start of my 3rd year of clerkships, I remember the constant sound of alarms and monitors beeping as I strolled the floors of the hospital. Though I may have still been acclimating to the new environment, it felt as though no one around me was responding to them. For the first few weeks, I remember being in a state of hyperawareness. Any time I heard an alarm go off (which felt like it was happening every 20 seconds!) I would look around and assess the scene as I tried to identify the source of the alarm, anxiously worried if I was responsible for responding to it. My heart rate would quickly rise, my palms would get cold and clammy, and sometimes I would even start to feel little beads of sweat build up at the top of my brow and forehead. It was as if each alarm sent my sympathetic nervous system into overdrive; fight or flight. In this context, it meant I had to fight the gut feeling telling me to run from my daunting clinical duties in the hospital and instead hold my ground to figure out how things worked around here. I’m sure to all the nurses and hospital staff around me, I looked like a deer in headlights, standing in the middle of the hallway, looking around like I was lost, except I happened to be in a white coat. Though I don’t think I’m particularly more sensitive to alarms than anyone else, I definitely felt as though I was the only person caught up in trying to figure out what each alarm signified, who was responsible for attending to them, and which required immediate attention. When I asked my residents and attendings how they manage to appear unphased by the constant cacophony of beeping that filled the hospital wards, they told me they’ve managed to tune it out. After a few weeks seeing patients and rounding the same floors day after day with my team, I finally started to better understand the ebb and flow of the hospital. Though it is mainly each patient’s nurses that is responsible for most alarms we hear, the reality is that they aren’t always around or available to respond because they are balancing their time managing their other patients. When that occurs, other team members, nurses and physicians alike, must often step up to address the blaring alarm as they walk by.
Another way to conceptualize this phenomenon is to look at the numbers. One UCSF study1 found that there were 187 audible alarms PER bed per day in the ICU, with a false-positive rate of over 88% for arrhythmia alarms. In other words, this means that not only is there an excessive number of alarms going off, but also that the large majority are FALSE alarms. The mere frequency of alarms for each patient is disturbing for both patients and providers alike. It makes getting rest nearly impossible, causes excess worry and anxiety, and is a constant distraction to guests and hospital staff. With so much to do, ignoring alarms almost becomes a necessity to be productive. Nevertheless, the issue of alarm fatigue has become so significant that the Joint Commission named it a National Patient Safety Goal. As the number of ways we monitor our patients continues to increase, it is more evident than ever that we need a better system for managing alarms to ensure we avoid missing real emergencies and prevent deaths from happening as a result.
As the intelligence of technological devices used in the hospital increases exponentially over time, devices have already become more reliable than humans. A significant opportunity exists to improve physiologic monitoring and reduce alarm fatigue and this should be a priority in hospitals across the nation. To start combatting this often-overlooked issue in healthcare, all active alarms in each patients’ room should be limited to only what is necessary based on the patient’s individual needs (i.e. those lacking cardiac conditions or significant risk factors for cardiac events shouldn’t be hooked up to telemetry monitors). Additionally, there should be a platform in place that stratifies alarms based on a hierarchy of importance. This may involve developing systems that help triage alarms by priority, like the emergency department (ED) does with the Emergency Severity Index (ESI), a five-level ED triage algorithm that provides clinically relevant stratification of patients into five groups from 1 to 5 on the basis of acuity and resource needs. There could also be extra nurses/hospital techs, in addition to charge nurses on each floor that solely focus on managing and triaging alarms in their unit. Lastly, a final redesign alternative could involve strategically creating unique sounds to replace standard alarms and monitor beeps. Implementing this solution could reduce both the confusion of junior hospital staff adapting to their new work environment and the alarm fatigue in more veteran nurses and physicians simultaneously, allowing the whole team to instantly distinguish alarms by type and urgency, in order to facilitate faster responses.
As my IM rotation came to an end, I found myself feeling guilty as I realized that I was beginning to tune out the alarms as well. Whether it’s the bystander phenomenon in full effect, and my subconscious had learned over time to tune out the alarms as a result of never being the person responsible for responding to them, or I’ve just become desensitized and more comfortable in the hospital setting as my rotations went on. I experienced alarm fatigue firsthand within just a few weeks. Moving forward, I plan to do my part in staying mindful of each patient’s needs, responding to alarms when appropriate and helping my colleagues do the same.
Sources:
https://www.ucsf.edu/news/2014/10/119601/hospital-logs-staggering-25-million-alarms-just-month
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0110274
https://www.vocera.com/au/industry-solution/manage-alarm-fatigue