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Wednesday, July 30, 2014

Alarms and alarm fatigue.

You should expect to hear a lot about alarm fatigue, and methods of resolving it, in the coming years.  This was made into one of the top priorities of the Joint Commission for 2014.

A good article can be found in an editor's note in the June, 2013, edition of RT: For Decision Makers in Respiratory Care called "Joint Commission Goal: Cause for Alarm."

Another good article is by Erich Faust at Advance for Respiratory and Sleep Disorders, "Preventing Alarm Fatigue."

Faust defined fatigue this way:
Alarm fatigue occurs when clinicians become overwhelmed by the high number of patient alarms and fail to respond to potentially critical patient alarms. The issue is recognized by many clinical organizations as a significant hazard to patient safety and care. In fact, the ECRI Institute has published the "Top 10 Health Technology Hazards" list annually since 2011 and "alarm hazards" has been on the list since its inception, topping the list in 2012 and 2013.
Faust also described how the movement was born. He said:
In 2013, The Joint Commission released a Sentinel Event Alert on "Medical device alarm safety in hospitals." The Joint Commission recognizes this issue as a "frequent and persistent problem" with 98 alarm-related events reported between January 2009 and June 2012 - 80 resulting in death and 13 in permanent loss of function. They also cite alarm fatigue as "the most common contributing factor" to alarm-related events.

As a result, The Joint Commission has made a number of recommendations to address the issue, including the implementation of The Joint Commission National Patient Safety Goal, in two phases. Phase I requires hospitals to establish alarms as an organization priority and identify the most important alarms to manage based on their own internal situations. In Phase II, hospitals will be expected to develop and implement specific components of policies and procedures.
With these recommendations in mind, there is a clinical need to develop more intelligent alarm management strategies to reduce clinically-insignificant alarms while identifying alarm conditions that require intervention. Device manufacturers are taking significant steps to develop smarter alarm management systems and remote patient monitoring systems that have the potential to reduce clinically insignificant alarms while alerting caregivers to clinically-significant events.
Furthermore, he said "nuisance" alarms are a constant cause of alarm apathy, especially considering "85-99 percent of alarms do not require an intervention." The negative effect of this is the medical clinician becoming deconditioned to to alarms.

Potential remedies noted are:
  • Proper education as to where to set the alarm limits
  • The addition of "smart alarms" to existing medical technology
  • Educating staff as to importance of responding to all alarms.
  • Creating alarms with a soft, or pleasant cadence 
  • Remote patient monitoring
I actually attended a conference a few years back where the keynote speaker gave a presentation about alarm fatigue and efforts made to combat it.  He displayed a pulse oximeter that had an alarm that was smart, or a smart alarm.  It was designed so it would not go off every time the patient's pulse ox reading was, say, 88%.  It would only go off if the SpO2 was consistently low.  This way the patient doesn't get awakened every time he gets into a deep sleep and his sat dips ever so slightly, and the staff doesn't get annoyed or deconditioned to the alarm.

While at the present time such devices are expensive, I would imagine they will be the wave of the future.  There might even be an effort to add this technology into ventilators and other medical equipment that is already in use.  Smart ventilator alarms would only alarm when a patient consistently has a minute ventilation out of range, or a consistent leak is sensed. This would allow for the patient to get better rest, and would come a long way toward reducing therapist apathy toward alarms.   

Another neat thing about these smart alarms is that, instead of being an annoying screech, they would provide a soft, pleasant sound. This would make sure that the appropriate people are notified that something needs attention, but the cadence would be soothing to the patient.  

Remote patient monitoring is already being done to some extent at hospitals. "Remote monitoring systems help busy clinicians manage the constant stream of alarms from bedside devices by allowing them to observe patient data from a central location or on the care floor using a pager/smart phone," said Faust.

While this technology is currently used with telemetry systems that monitor heart rhythm strips, it might eventually include similar alarms for IVs, ventilators, and other important equipment.

The advantage of remote monitoring is, said Faust, that "By providing remote visibility to alarms and information from bedside devices, clinical caregivers are better able to prioritize their responses to better manage the needs of patients."

So expect to hear more about this in the not so distant future.
Further reading: 

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