With estimates that as many as 85-99% of alarms do not require clinical intervention, alarm fatigue is continually cited as one of the greatest healthcare challenges, both in the ICU and post-surgical care.
By Greg Thompson
Adding new medical technology to the clinical arena usually means better patient care, but too often it also means one more alarm added to an already daunting barrage of auditory warnings. For RTs dealing with increasingly sensitive equipment, the alarms add up to considerable frustration.
“Monitor fatigue is real,” declares Karen LaRoché, RRT-ACCS, clinical specialist, MultiCare Health Systems, Puyallup, Washington, “and it’s super dangerous.”
Dave Crotwell, MHL, RRT, RRT-NPS, FAARC, has seen the potential for danger firsthand. As director of Respiratory Care Services at Seattle Children’s Hospital, he has sought out the latest technology in an effort to boost outcomes. The conundrum is that each new innovation adds to the cacophony.
“As we add new devices, and attach them to patients, we’re layering alarms on top of one another,” Crotwell said. “Staff members hear so many alarms, and they respond. In many cases, the alarms are not reflective of what’s going on with patients, or they are nuisance alarms based on sensitivity or settings associated with the device. RTs develop a conditioned response and continually find that patients are fine; but then there’s that one time, or few times, in which patients really need an issue addressed, and that gets us in trouble. That one time that you don’t address something is when you have a bad outcome.”
Worse yet, simultaneous alarms emanating from different rooms can make RTs feel as if they must be in two places at the same time, which only piles on stress. “They naturally get frustrated and fatigued when responding to so many alarms that are not real, because either the settings or alarm protocols are not appropriate,” Crotwell said. “The signal-to-noise ratio is too high.”
The number of false alarms depends on the specific monitor, and where the monitor attaches to patients. Crotwell uses the example of cardiorespiratory monitors that use sticky impedance electrodes affixed to patients’ chests. “These generate artefact when the patient is moving around,” he said. “In some cases, the stickers will come off and attach themselves to the bed sheet.
“If you’re talking about pulse oximetry probes on the finger, or sometimes on the earlobe, those are sensitive because they are looking for pulsatile flow, and then using infrared light to measure saturation of oxygen in the blood,” Crotwell continues. “It’s dependent on perfusion. So if a patient has cold extremities, they have poor cardiac output, and it’s difficult to get an accurate measurement. It drops out, doesn’t read it, and generates an alarm. There are circumstances that occur that create artefact in all types of non-invasive monitoring.”
“We often deal with patients at end of life, and they are on oxygen with continuous monitoring,” added Brian L. Tiep, MD, director of Pulmonary Rehabilitation, City of Hope, Duarte, California. “The monitor goes off when the patient moves, falls asleep, or the probe falls off the finger. Most of the time the information, whether or not correct, is unhelpful and often is a total annoyance…Just because it is easy to monitor oxygen saturation does not mean that good decisions are based on the information, and sometimes it is detrimental to quality of life.”
Improving quality of life, not to mention job satisfaction, depends on reducing alarm fatigue—often easier said than done. Kenneth Miller, RRT, has experienced the layering of alarms during his 46-year career, and he believes the key to avoiding alarm fatigue starts with a customized approach.
“Alarms should be set specifically depending on an individual patient’s condition and clinical situation,” said Miller, educational coordinator and wellness champion at Lehigh Valley Health Network, Allentown, Pa. “For example, if I have a patient who is critically ill, and on a paralytic drip, I would keep alarms very tight, because the margin of error is pretty minimal and risk to the patient is very high.”
For patients weaning off the ventilator, or with inconsistent or chaotic breathing patterns, alarms would be modified yet again. “When clinical situations change, you change the alarms accordingly,” Miller said. “If you don’t do that, you put patients at risk in one area, and clinicians at risk of alarm fatigue.”
Fine tuning alarm settings to reduce fatigue depends on knowing the devices well through education and hard-won experience. In Crotwell’s department at Seattle Children’s, that means determining the strengths and weaknesses of various monitors to accurately develop alarm protocols for specific devices.
One way to reduce nuisance alarms is to address “appropriate alarm delay” for specific patients. To those who want “no delay” and want to know about every alarm, Crotwell is confident that experience will eventually impart a different philosophy.
“Once you hear every alarm, you will soon say, ‘There’s too many’ and you’ll learn the importance of setting an alarm delay that’s appropriate for the patient, the unit, or the area of the hospital in which you are monitoring,” said the 48-year-old Crotwell. “And an alarm delay that’s appropriate in one unit may not be appropriate for another. If you’re using an alarm delay in the cardiac ICU, you may want your alarm delay setting to be different than if you were monitoring a patient on the medical floor.”
According to Crotwell, Seattle Children’s developed a multidisciplinary team of medical professionals who examined, unit by unit, all of the monitoring systems in the hospital and assessed where certain parameters should be set. In some cases, parameters could be standardized across all areas of the hospital. In other areas, alarm settings were highly dependent on the type of patient and the accuracy of the particular device.
Pamela Held, respiratory operations manager at the Hospital for Special Care, Bristol, Conn, has heard alarms that seem to be “non-stop” for the entire shift. Fortunately, technology has improved the problem by allowing clinicians to prioritize alarms.
“Evolution of Bernoulli [acquired by Capsule Technologies in 2019] has paved the way to improve alarm fatigue,” Held said. “In the old days, everyone on a ventilator/pulse oximeter was connected to a nurse call system. There was no way to differentiate between nuisance alarms and priority alarms. With the implementation of Capsule, overall alarm volume has significantly decreased, because you are able to identify only your critical alarms that require immediate response.”
As director of Product Management – Hospital Respiratory Care, Philips, Kevin O’Donnell tries to address the “very real” issue of alarm fatigue by ensuring alarms are clinically relevant and actionable. Specifically, Philips patient monitoring alarm management tools keep track of how quickly and efficiently care teams respond to each patient alarm, and suggest possible modifications to enhance patient care.
“Our ventilator alarm settings have been evolving in ways that make appropriate alarms easier for clinicians to set,” O’Donnell explained. “The ability to visualize alarm settings in the context of both ventilator settings and monitored parameters helps clinicians make informed choices, and in some cases to batch ventilator settings with associated alarms, and also to receive support from the onboard Help feature. Our alarm management clinical consulting services combine analytics, environmental and process assessments, and technology to help improve alarm performance.”
Karen LaRoché has seen the benefits of improved technology, but she hopes for greater efficiency and consistency across the various manufacturer platforms. “A lot of manufacturers have too many things that we alarm, so it’s redundant,” she lamented. “Just because you can monitor doesn’t necessarily mean you should if you already have a parameter that’s going to basically function in that same way. With ventilators, it’s anywhere from six simple things that you monitor to 26 depending on the manufacturer.
“It would be awesome if we had a Food and Drug Administration [FDA] regulation on what should be monitored as a regular gold standard for mechanical ventilators,” LaRoché continued. “That would help institutions create policies and procedures that were a little more universal and simple, but more effective for supporting patients and staff.”
Crotwell agrees that uniformity/consistency would be helpful, particularly in the area of proprietary nomenclature. Different language and different terms, he reasons, can often lead to different alarm settings and less efficient monitoring. “I may go to another institution that uses Philips monitoring, like we do, and the terminology and parameters will be uniform,” he explained. “But if I’m going to a hospital on the East Coast that is using GE monitors or Dräger monitors, their terminology may be totally different. In some cases, you will have the same setting with a different name depending on the brand—which can make it difficult.”
Crotwell agrees with LaRoché that an FDA role in standardization would be welcome, because right now “it’s confusing for clinical staff to have three different mechanical ventilators, but use three different terms for the same mode of ventilation—and have different settings associated with those…With mechanical ventilators, we don’t tend to take old modes of ventilation away. They just layer new modes on top of it, with new nomenclature on top of the old.”
As manufacturers update, upgrade, and create new alarms from scratch, Crotwell hopes that more end users can be involved in the process. While acknowledging the brilliance of biomedical engineers, Crotwell laments that devices are “pushed out to end users, and we have to design our workflows around the design of the device.”
“We really need to flip the script when it comes to design of these devices and involve end user input at the beginning of device development,” he said. “In the end, we will get a device that is designed the way we need it to work, as opposed to a design based solely off of engineering ideas and thresholds.”
Yet another solution to the problem of alarm fatigue comes from the less is more mindset. After all, if outcomes are not improved by monitoring, why do it? Crotwell sees a perfect example in infants with bronchiolitis [viral upper respiratory infections]. “We know that pulse oximetry monitoring in bronchiolitis patients can increase hospital length of stay,” he said, “but the monitoring does not change patients’ outcomes.”
This problem of over utilization of some monitoring devices speaks to the need to apply “the right monitor to the right patient at the right time and for the right length of time,” and then to stop monitoring at a point that is safe so patients can be discharged.
“Everyone to a certain degree may have a desaturation event when sleeping, but it doesn’t mean we need to be in the hospital,” Crotwell said. “That happens with babies with bronchiolitis. If that keeps you from discharging this patient, and this patient is well enough to go home, then you’re increasing cost of care by increasing length of stay. You’re increasing strain on the family. You’re increasing alarm fatigue for RTs. The solution is to implement protocols about when to stop monitoring.”
Greg Thompson is a contributing writer to RT. For more information, contact [email protected].