Episode #13 Alarm Fatigue and Patient Safety

September 29, 2020

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Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel. This podcast will be an exciting journey towards improved anesthesia patient safety.

Today, we are going to review a featured article from the June 2019 Newsletter, “Alarm fatigue and patient safety” by Keith Ruskin and James Bliss. This topic was requests by several of our twitter followers as well. Thank you for the great suggestion!! You can find the article here: https://www.apsf.org/article/alarm-fatigue-and-patient-safety/

Bliss and Gilson’s taxonomy of signaling terms:

  • Signal refers to all stimuli that occurs for an emergency notification in general
  • Alarm refers to a transient sensory signal (auditory or visual) that indicates ongoing danger that requires immediate corrective action
  • Alert refers to a transient sensory signal (auditory or visual) that indicates an adverse event may occur in the future

Xiao and Seagull’s taxonomy of alarms:

  • False alarms occur when no danger exists, often because sensor thresholds are set too conservatively.
  • Nuisance alarms may indicate a problem in a specific context, but they have been activated in a different context (e.g., an arterial catheter low pressure alarm that activates when a blood pressure cuff is inflated).
  • Inopportune alarms occur at the wrong time, perhaps as alerts that signal a condition far in the future.

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© 2020, The Anesthesia Patient Safety Foundation

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Alli Bechtel and I am your host. Thank you for joining us for another show.

(Insert alarm noises)

Today, on the show we are going to have a very important discussion so I need you all to pay attention like someone’s life depends on it…wait, what’s that…it’s hard to pay attention with all these alarms…are those important alarms? Are they false alarms?

(Alarms off)

Okay, that’s better, where were we? Today, we are going to talk about a very important topic and our patient’s lives are at stake because we are talking about alarm fatigue and patient safety.

Before we dive into today’s episode, we’d like to recognize Medtronic, a major corporate supporter of APSF. Medtronic has generously provided unrestricted support as well as research and educational grants to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Medtronic – we wouldn’t be able to do all that we do without you!”

And now, if you are near your computer, we hope that you will check out APSF.org and click on the Newsletter heading, the 4th one down is the Newsletter archives and then you can click on the June 2019 issue. Alarm fatigue and patient safety by Keith Ruskin and James Bliss is the first featured article so let’s check it out. This topic was requested by several of our twitter followers as well. Thank you for the great suggestion!!

We have come a long way from paper charting and manual blood pressure measurements in the operating room. Electronic medical devices provide monitoring, charting, and life support and have improved patient safety throughout the hospital. Each of these devices may have different audible and visual alerts and alarms whenever there is a change from the normal physiological parameters as an early warning for clinicians so that action can be taken to before a patient is harmed. Another type of alarm is a device function alarm that is intended to alert healthcare providers about device malfunction or failure. These alarms are absolutely essential for life support devices such as ventilators and cardiopulmonary bypass machines. In the clinical setting and especially in areas of high acuity such as the operating room and the intensive care unit, there is a high frequency of alarms. Studies have been done in this area. In one study, almost 9,000 alarms occurred during 25 consecutive procedures and 359 alarms during each procedure which ended up being about 1.2 alarms each minute of the procedure. One explanation for the high frequency of alarms is that equipment manufacturers set alarm defaults to a high sensitivity to prevent missing true events, but as a result many alarms have a low specificity and low positive predictive value and are often silenced or ignored. In addition, there are alarms for so many parameters that the result is often a loud and potentially distracting clinical care area which may compromise patient safety.

Alarm fatigue is defined as an increase in a health care provider’s response time or a decrease in his or her response rate to an alarm as a result of experiencing excessive alarms. This is not unique to medicine and may occur in other professions as well, such as transportation. When there is such a high frequency of alarms (false and real), the professionals may ignore or actively silence the alarms in order to continue their work. Alarm fatigue has led to medical accidents and patient harm and the Joint Commission made clinical alarm management a National Patient Safety Goal. Alarm fatigue also falls into 2 of APSF’s Perioperative Patient Safety Priorities related to preventing, detecting and mitigating clinical deterioration in the perioperative period and distractions in procedural areas.

Let’s look a little closer at the research into excessive alarms. Bliss and Gilson created an early taxonomy of signaling terms taking into consideration the time between he signal and the associated situation. Signal refers to all stimuli that function as a general emergency notification. More specifically, alarm is defined as a transient sensory signal that may be auditory or visual in the face of a specific danger that requires an immediate action to correct it. An alert refers to a signal for an adverse event that may occur in the future. The purpose of the alert is to give the operator more time to react in order to prevent a problem from occurring while by the time the alarm sounds, the patient is in danger and needs corrective action immediately.

There is a current standard for medical alarms, IEC 60601 1-8 that addresses basic safety and performance requirements with alarm categories that are prioritized by degree of urgency and consistency of alarm signals. This standard does not report on high sensitivity of alarm setting and the resultant low specificity. The goal for a medical alarm is to give the health care professional ample time to act to prevent an adverse outcome. Let’s look at a couple more definitions. Clinical alarms refer to a signal that the patient needs immediate attention and technical alarms refer to a signal that the biomedical equipment needs attention. For example, if the EKG displays ventricular fibrillation, this will lead to a clinical alarm but if the EKG is inadvertently disconnected this may lead to a technical alarm. The authors reports on another taxonomy of alarms by Xiao (Shee-owe) and Seagull for medical professionals monitoring clinical situations. I will include this table in the show notes as well. False alarms occur when there is no danger and are often the result of low sensor thresholds. Nuisance alarms occur when there may be a problem in a specific context, but the alarm is activated for a different reason that does not indicate patient danger. Inopportune alarms occur at the wrong time such as for a condition that may occur far in the future. These alarms must be distinguished quickly from actionable alarms that occur when there is a physiological change in the patient’s condition that requires immediate action by the anesthesia professional whether it is increased monitoring for a mild deviation or mediation administration or initiating CPR for a life-threatening problem. Other alarms may occur that are nonactionable alarms in the setting of a monitoring artifact from skin prepping or electrocautery or a true deviation during a clinically insignificant abnormality such as holding ventilation at the surgeon’s request and the hearing the ventilator apnea alarm.

With all that talk about different alarms and opportunities for false alarms, it is no wonder that alarm fatigue may occur and we are going to review this important topic now. Remember, alarm fatigue occurs when there is failure to respond to an alarm and this may lead to patient harm and it has led to patient harm. The US FDA reported more than 500 alarm-related patient deaths over a 5 year time period. This is an important area for improved patient safety and research has shown that improved alarm and alert design can lead to improved patient safety. It is a complicated area since we need alarms that are attention-grabbing to alert the provider that an abnormal event has occurred, but when there are many nonactionable attention-grabbing alarms, this leads to the cry-wolf effect.

[Insert wolf howl]

The cry-wolf effect is when health care providers become desensitized to frequent false alarms and this is more likely to occur during periods of high workload when providers mistrust or ignore subsequent alarms from the same or similar devices.

Alarms are often loud, right? They have to be to grab your attention, but loud and intrusive auditory alarms may lead to increased stress levels for the health care providers especially at night and may affect patients leading to poor sleep in the hospital and increased ICU delirium. Ruskin defined the term alarm flood to refer to the large number of alarms which may be in different patient care areas.

The scope of the problem of alarm fatigue is immense and the solution will also be complex. The authors write that “The overarching goals for a comprehensive solution to alarm fatigue should be to clearly and accurately indicate potential hazards while minimizing false or nuisance alarms.” There are several areas for potential solutions including organizational aspects of the patient care area and layout, workflow and processes, and safety culture. There are things that we can do right now to help minimize the negative consequences from alarm fatigue with technical and engineering solutions, workload considerations, and practical changes to the way we use technology and ultimately these changes will lead to new initiatives in training, clinical workflow, and organizational policies. One simple solution is consistent signals across all equipment in the health care environment. In addition, it is important to minimize distractions due to noise, lighting, competing task demands, distrust, and inattentional blindness or deafness. New medical equipment should be designed to decrease the clinician’s workload so that they can respond to alarms and alerts in a timely fashion.

Another solution that the authors propose involves changes to the alarm processing algorithms of our physiologic monitors to minimize the number of nonactionable alarms. For example, delaying alarm activation for short and clinically-irrelevant time periods due to minor violations can improve alarm reliability. This delayed alarm activation has been shown to decrease false alarms by 74% and values returned to within normal limits without clinician action before alarm activation. Improving alarm design may also be a good area for machine learning to simultaneously look at multiple parameters and minimize false alarms and improve alarm accuracy. There is definitely room for improved medical equipment monitoring design to increase the positive predictive value of clinical alarms leading to decreased false alarms and mitigating alarm fatigue.

What if we look at the sound of the alarm itself? Historically, it was thought that alarms needed to be loud if operators were going to notice them and respond in a timely manner. A recent study on alarm volume by Schlesinger and colleagues reported that physicians were able to distinguish alarms that were below the ambient noise level. The benefit of decreased alarm volume for non-life-threatening alarms is to lower the overall noise in the clinical environment.

Is there anything that we can do in anesthesia patient care areas right now with regards to alarm fatigue? It is important to use appropriate alarm limits for each patient rather than just the default clinical settings and disable non-essential alarms. This can decrease the perceived workload and help to improve alarm accuracy, operators’ experience, and overall satisfaction. Some specific examples include using pediatric profiles for peds cases or using the paced mode for ECG in a patient with a pacemaker. Another solution to decrease false alarms from artifact is to replace disposable sensors when they need to be repositioned such as pulse oximeters or electrodes. Finally, it is important to use the appropriate monitors for each patient to avoid over-monitoring and the resultant increased number of alarms.

Alarm fatigue is an important consideration for patient safety during anesthesia care. Going forward, we can take some simple steps in the OR to minimize false and nonactionable alarms. In addition, this promises to be an exciting area for innovation with medical equipment manufacturers developing alarm processing algorithms to improve alarm accuracy and minimize alarm fatigue.

That’s all the time we have for today!! Thank you so much for joining us today on this journey towards improved patient safety. If you have any questions or comments from today’s show, please email us at [email protected].

Visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today. Plus, you can find us on twitter @APSForg. Follow along with us for additional patient safety information tweets!! If you are enjoying listening to this podcast, please rate us and leave us a review!! We are so excited to continue to grow our Anesthesia Patient Safety Foundation Family!

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2020, The Anesthesia Patient Safety Foundation