By CS Copeland, PhD
Picture yourself as a nurse in a busy contemporary hospital. Is the scene you imagine a quiet one? If so, you probably haven’t been in a hospital in a while. Quiet is the opposite of the status quo in most busy modern medical centers.
Prominent among the noise sources is a cacophony of beeping and chiming from clinical alarm systems. This constant alarm noise can lead to fatigue among healthcare workers, lost sleep and poor healing by patients. Besides being irritating, though, the noise from constant clinical alarms presents a more immediate danger: The human response to noise like this is to desensitize to it, and that can be very bad for patient safety.
The Nuisance of Noise
It was a 2005 study of the sound levels in Johns Hopkins—a busy but typical American hospital—that shined a spotlight on the ever-growing noise levels in modern hospitals. The researchers found a shocking level of noise throughout the hospital: 50-60 dB on average throughout the day, compared with the WHO recommended background noise level of 35 dB during the day and 30 dB at night. Since the typical level of speech between two people is 45-50 dB, this meant that workers routinely needed to shout to be heard above the noise. The noise level was not only high enough to interfere with patients’ ability to sleep and clinicians’ ability to communicate, but was also extremely irritating to both patients and visitors. Constant noise of this level contributes to fatigue and burnout. Furthermore, the vast majority of the alarms resulted in no action — they did not signal critical situations, so the noise they added was not only annoying but also unnecessary and unhelpful.
The Dangers of Alarm Fatigue
A half-decade after the initial noise study at Johns Hopkins, Maria Cvach, RN, director of policy management and integration at Johns Hopkins, began “sounding the alarm on alarms” by publishing on the phenomenon of alarm fatigue in hospitals. The sheer number of clinical alarms sounding in a typical day was staggering: at the time, clinical staff were exposed to as many as 700 physiological monitoring alarms per patient per day. Hearing hundreds of alarms throughout the day, week after week, inevitably leads to desensitization, resulting in ignoring alarms or, in some cases, turning alarms off because they are constantly beeping. Naming monitor alarm fatigue “the #1 medical device hazard in 2012,” Cvach detailed how desensitization results from a high false-alarm rate and lack of alarm standardization, coupled with the sheer number of medical devices in use.
The Boy Who Cried Wolf
The most serious outcome of this is that, because almost all (72-99%) clinical alarms are false, the alarm noise can have a “boy who cried wolf” effect that can acutely compromise patient safety. The danger can even be deadly. Nursing researchers Sendelbach and Funk tell the tragic story of a patient who, in the midst of a cacophony of alarm sounds, lost his life despite multiple alarm warnings. The patient’s telemetry battery needed replacing, but the alarm indicating this was drowned out by surrounding noise. When the battery finally died, the patient went into cardiac arrest. This, too, went unnoticed, until the patient was found, too late for resuscitation. Sadly, this was not an isolated incident — in a 4-year period leading up to 2011, the FDA received reports of over 500 deaths related to alarm systems on monitoring devices.
The Joint Commission Adopts Clinical Alarms as a National Patient Safety Goal
To prevent tragedies like the one described above, the Joint Commission, a non-profit that certifies and accredits US healthcare organizations, adopted “reducing the harm associated with clinical alarm systems” as one of its National Patient Safety Goals. To accomplish this patient safety goal, four “elements of performance” are recommended: establishing alarm system safety as a hospital priority, identifying the most important alarm signals to manage, establishing policies and procedures for managing the alarms identified as truly important, and educating staff and licensed independent practitioners about the purpose and proper operation of alarm systems for which they are responsible.
Alarm System Safety as Hospital
Critical to reducing the harm associated with clinical alarm systems is the establishment by hospital leaders of alarm system safety as a hospital priority. If hospital leaders do not prioritize alarm system safety, even the most committed individuals will be unable to solve the problem. As with all patient safety systems, a thoughtfully designed program is key — effective adoption of patient safety practices requires all hospital staff members to work together as a committed healthcare team, and this requires direction from leadership.
Identify the Most Important Alarm Signals to Manage
Since the vast majority of alarms result in no action, it can safely be said that most alarms should be turned off. At the same time, important alarms should never be turned off (or ignored). Hence, the Joint Commission considers identification of the most important alarm signals to manage as the second recommendation towards accomplishing this patient safety goal. They recommend that identification of these alarm signals should be based on:
Input from the medical staff and clinical departments
Risk to patients if the alarm signal is not attended to or if it malfunctions
Whether specific alarm signals are needed or unnecessarily contribute to alarm noise and alarm fatigue
Potential for patient harm based on internal incident history
Published best practices and guidelines
Establish Policies and Procedures for Managing Important Alarms
Third, the Joint Commission recommends that policies and procedures be established for managing the alarms identified as important, as detailed above. These policies and procedures should address the following questions:
What are the clinically appropriate settings for alarm signals?
When can alarm signals be disabled?
When can alarm parameters be changed?
Who in the organization has the authority to set alarm parameters?
Who in the organization has the authority to change alarm parameters?
Who in the organization has the authority to set alarm parameters to “off”?
What will the procedure be for monitoring and responding to alarm signals?
What will the procedure be for checking individual alarm signals for accurate settings, proper operation, and detectability?
Education on the Purpose and Proper Operation of Alarm Systems
The fourth recommendation is education of staff and licensed independent practitioners on the purpose and proper operation of alarm systems for which they are responsible. Importantly, education encompasses not only presentation of information, but also feedback in real time. As with other patient safety goals, such as the prevention of hospital-associated infections and improving the safety of using medications, this goal requires not only support from leadership and changes in policies and procedures, but also feedback from fellow healthcare professionals and technological feedback systems to ensure that procedures are being carried out as recommended.
The education recommendation is key in countering a litigation-conscious culture that encourages the ostensible caution that clinical alarm systems offer. Healthcare professionals need to be educated on both the “how” and the “why” of policies that decrease the number of clinical alarms. Armed with this knowledge, healthcare professionals can be confident that reducing clinical alarms in a thoughtful way will not only make the hospital environment more comfortable, but will actually improve patient safety as well.
Dr. CS Copeland holds a BA in neuropsychology from the University of California at San Diego and a PhD in molecular and cellular biology from Tulane University, specializing in parasitology and virology, with postdoctoral research in molecular entomology and computational genomics.