By Maria Cvach, DNP, RN, CCRN, and Michael Wong, JD
Patient monitors represent the good and the bad consequences of modern medical technology. The good results come when medical device alarms alert caregivers to clinical deterioration of their patients, allowing them to intervene. The bad ones happen when alarms sound too often, or for a nonactionable issue, and caregivers become desensitized or immune to the audible alarm sounds altogether.
In its “Sentinel Event Alert” number 50, headlined “Medical Device Alarm Safety in Hospitals,” The Joint Commission explained this dichotomy as follows:
Many medical devices have alarm systems; among them are bedside physiologic monitors that include ECG (electrocardiogram) machines, pulse oximetry devices, and monitors of blood pressure and other parameters; bedside telemetry; central station monitors; infusion pumps; and ventilators. These alarm-equipped devices are essential to providing safe care to patients in many health care settings; clinicians depend on these devices for information they need to deliver appropriate care and to guide treatment decisions. However, these devices present a multitude of challenges and opportunities for health care organizations when their alarms create similar sounds, when their default settings are not changed, and when there is a failure to respond to their alarm signals.1
The ultimate solution to alarm fatigue will require a systems approach composed of both people and technology in order to evaluate human and technology error patterns.
A Wish List
At the annual conference of the Society for Technology in Anesthesia last January, we presented an Alarm Awareness Wish List of nine technological solutions to help manage alarm fatigue and to promote better alarm management. Some of these solutions exist today, while others are suggested patient safety solutions to this issue:
1) Single Assessment Indicator: Multiparameter alarms versus single parameter to improve alarm specificity and decrease the false alarm rate.
2) Standardized Alarm Sounds: Standardization of alarm sounds across similar devices (all vents sound the same, all monitors have the same sounds, etc).
3) Pause Before Alarming: Slight delays to eliminate nuisance alarms that auto-correct. For example, ST alarms delayed by 2 minutes prior to sending an alarm.
4) Electrode/Skin Interface: A simple way for staff to determine if electrode/skin interface is good.
5) Escalation of Alarm Levels: Escalation of alarm levels based on quantity and/or change in alarm pattern (for example, when a patient has a sudden increase in the number of PVCs, or the heart rate suddenly goes down from 90s to 60s).
6) “Smarter” IV Pumps: IV pumps that can be smart enough to know when a critical medication is infusing, and the alarm sound is different and more urgent.
7) Device Interoperability: Increased interoperability among multiple devices.
8) Alarm Integration: An ancillary notification system that integrates all alarms within the patient room to a single device (highly accurate; no more than three to four alerts per hour).
9) Multifunction Wireless Device: A wireless device that is reliable, lightweight, and equipped with multiple features (barcode reader, Wi-Fi, text messages, phone, good battery life, few dropped calls, easy alarm escalation, and alarm acknowledgement).
Below, we discuss in further detail three of these nine technological alarm awareness wishes.
Single Assessment Indicator
A patient may have various devices monitoring specific measures of their physiological condition, such as blood pressure, oxygenation, and heart rate. However, rather than each of these monitors audibly alarming independently when a single patient parameter momentarily breaches a threshold, the parameters could be integrated into one indicator. This could reduce the number of audible alarm sounds, thereby improving alarm specificity, reducing noise, and reducing alarm fatigue. In addition, slight delays that allow for momentary breaches in single-parameter alarm thresholds can further reduce the number of alarm sounds.
In the first-ever comprehensive national survey of hospitals on practices related to patient-controlled analgesia, 7 out of 10 hospitals (70.7%) have said that they would like “a single indicator that accurately incorporates key vital signs, such as heart rate, SpO2, respiratory rate, and ETCO2.”2
In a quality improvement study performed at The Johns Hopkins Hospital, changing electrodes daily resulted in a 46% reduction in audible alarm signals on two units.3 In a pilot study, “Building a Strategy to Support Medical Device Integration and Alarm Management,” Kaiser Permanente’s Melanie Quinton found a similar result, demonstrating that electrode replacement and improved electrode hygiene decreased audible alarm alerts by 22%.4 As a result of these studies, many hospitals now recommend daily electrode changes.
However, we wonder whether, rather than replacing electrodes daily, a visual cue (such as a color or a symbol) could be integrated into an electrode to indicate a good electrode-skin interface. Clinicians would know when an electrode is still conveying accurate information. The hospital could save money by not disposing of electrodes that are still functioning, and patients would benefit from fewer “leads-off” conditions, less noise from false alarms, and less inconvenience and pain from electrode changes.
“Smarter” IV Pumps
At the AAMI/FDA Infusion Device Summit on October 5-6, 2010, the Veterans Health Administration reported that a significant number of adverse events involving infusion pumps were related to patient-controlled analgesia pumps. As Bryanne Patail, biomedical engineer at the US Department of Veterans Affairs, National Center for Patient Safety, summarized the findings in an interview conducted at that summit5:
VHA has been conducting root cause analyses since 1999. In looking at infusion pumps, we found that more the 13 percent (129 in all) involved two types of infusion pumps. Of these 129 events, 60 related to general-purpose pumps and 69 to PCA pumps. In other words, more than 50 percent of these events involved PCA pumps — roughly a 50/50 split between general-purpose and PCA pumps. However, there are about 10 times as many general-purpose pumps in use across the VA system than PCA pumps. This suggests that incidents with PCA pumps are about 10 times more than with general-purpose pumps. That’s significant!
From an engineering perspective, having a “closed” system where the PCA pump automatically stops infusing when the patient is becoming oversedated is ideal. Patail explains why the VA’s integrated product team recommended that PCA pumps have an integrated end tidal CO2 monitor:
The strongest fix for PCA pumps is a forcing function, such as an integrated end tidal CO2 monitor that will pause the pump. So, healthcare providers should first look at these strong fixes. There they will see the most impact on reducing errors and improving patient safety.
We are still faced with the need for clinical buy-in and further development of those types of specific alarm-awareness risk factors before we can develop a clinical pathway that all institutions would endorse.
Moreover, we should focus patient safety work on intense patient engagement in safety checklists surrounding the use of continuous monitoring and their respective alarms that signal potential harm.
Who is up for this clinical challenge?
The answer should be all of us who care for patients on continuous electronic monitoring and who use such technology to intervene as soon as possible when a patient’s condition deteriorates.
It is time for major change in the management of clinical alarms. It is up to us to make this happen for patient quality and safety. 24×7
Maria Cvach, DNP, RN, CCRN, is assistant director of nursing, clinical standards, at The Johns Hopkins Hospital, Baltimore. Michael Wong, JD, is executive director of the Physician-Patient Alliance for Health & Safety. For more information, contact editorial director John Bethune at [email protected]
1. The Joint Commission. Sentinel event alert. Issue 50; April 8, 2013. Available at: http://www.jointcommission.org/assets/1/18/sea_50_alarms_4_5_13_final1.pdf. Accessed February 13, 2014.
2. Wong JD, Mabuyi A, Gonzalez B. First national survey of patient-controlled analgesia practices. Paper presented at: Society for Technology in Anesthesia (STA) Annual Meeting; January 16, 2014; Orlando, Fla.
3. Cvach MM, Biggs M, Rothwell KJ, Charles-Hudson C. Daily electrode change and effect on cardiac monitor alarms: An evidence-based practice approach. J Nurs Care Qual. 2013;28(3):265-271.
4. Quinton M. Building a strategy to support medical device integration and alarm management: A practical example. Paper presented at: AAMI Conference and Expo; June 1, 2013; Long Beach, Calif.
5. Wong M. Reducing errors with patient-controlled analgesia pumps: Q&a with Bryanne Patail of the National Center for Patient Safety. Physician-Patient Alliance for Health & Safety. February 9, 2010. Available at: http://ppahs.org/2012/02/09/reducing-errors-with-patient-controlled-analgesia-pumps-qa-with-bryanne-patail-of-the-national-center-for-patient-safety. Accessed February 13, 2014.