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, our featured article is “Medical Alarms: Critical, Yet Challenging” by Kendall J. Burdick, Nathan Taber, Kimberly Albanowski, Christopher P. Bonafide, and Joseph J. Schlesinger from the June 2023 APSF Newsletter.
We have talked about alarm fatigue on the podcast before on Episode #13, and we hope that you will check it out soon.
Here are some important definitions:
- Alarm fatigue:
- When a clinician becomes desensitized to alarms from excessive, on-actionable, or invalid alarms leading to delayed or no response to the alarms.
- May lead to missed alarms and medical errors which may result in death, increased clinical workload and burnout, and interference with patient recovery.
- Interventions to help decrease alarm fatigue include the following:
- Consistent equipment
- Delaying alarm activation
- Reducing alarm volume
- Actionable alarms:
- Alarms that require action and intervention by the clinical care team.
- Intervening is necessary to help prevent an adverse event and keep patients safe.
- Non-actionable alarms:
- Alarms that require no action by the clinical care team.
- Invalid alarms:
- Alarms due to device artifact or error.
Here are citations to the studies that we talked about on the show today.
- Schlesinger JJ, Baum Miller SH, Nash K, et al. Acoustic features of auditory medical alarms—an experimental study of alarm volume. J Acoust Soc Am. 2018;143:3688. PMID: 29960450
- Burdick KJ, Gupta M, Sangari A, Schlesinger JJ. Improved patient monitoring with a novel multisensory smartwatch application. J Med Syst. 2022;46:83. PMID: 36261739
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© 2023, 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. It is almost time for the next APSF Newsletter release in October, but we still have time to review another June 2023 Newsletter article. I will give you a hint for which one we are reviewing today.
Before we dive into the episode today, we’d like to recognize Masimo, a major corporate supporter of APSF. Masimo has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Masimo – we wouldn’t be able to do all that we do without you!”
Well, I think I probably gave it away with that big hint. Today, our featured article is “Medical Alarms: Critical, Yet Challenging” by Kendall Burdick and colleagues. To follow along with us head over to APSF.org and click on the Newsletter heading. First one down is the current issue. Then, scroll down until you get to our featured article today. You can also click on the Newsletter archives and select June 2023 and scroll down until you get to our featured article.
And now, [Alarm Sounds], let’s get into the article. The authors highlight the challenge that anesthesia professionals must face to keep patients safe during anesthesia care in the distracting environment of the operating rooms. Medical alarms are necessary to help alert clinicians to vital sign changes in order for clinicians to respond, they must also filter out other distractions such as equipment delays, personal conversations, and paper/electronic device use. The alarms must be accurate and clinically actionable in order to keep patients safe.
We have talked about alarm fatigue on the podcast before on Episode #13, and we hope that you will check it out. Alarm fatigue occurs when a clinician becomes desensitized to alarms from excessive, on-actionable, or invalid alarms leading to delayed or no response to the alarms. Alarm fatigue is a threat to anesthesia patient safety leading to missed alarms and medical errors which may result in death, increased clinical workload and burnout, and interference with patient recovery. Interventions to help decrease alarm fatigue include the following:
- Consistent equipment
- Delaying alarm activation
- Reducing alarm volume
It’s time for some important definitions. Alarms that require action and intervention by the clinical care team are actionable alarms. Intervening after an actionable alarm is necessary to help prevent an adverse event and keep patients safe. Non-actionable alarms are alarms that require no action by the clinical care team. Did you know that up to 85% of clinical alarms fall under this category? Invalid alarms are alarms due to device artifact or error, for example, when the ECG reports ventricular tachycardia in response to patient movement or a loose ECG lead. Invalid alarms are quite frequent as well and may range from 85-99% of all clinical alarms. Desensitization and dissatisfaction among clinicians may increase with increased frequency of nonactionable or invalid alarms. Medical alarm research and innovation are critical to decreasing alarm fatigue and desensitization.
Medical alarms are necessary during anesthesia care with recommendations from the APSF as well as the American Society of Anesthesiologists and other organizations. The APSF recommends the use of medical alarms to improve anesthesia patient safety and decrease adverse events during the perioperative period. The ASA has made workplace safety a priority, so stay tuned for an “Alarm Position Statement” later this year from the ASA. In addition, The Joint Commission has named alarm fatigue as a Top 10 safety priority every year for the past decade and the ECRI named missed alarms and alarm overload as a Top 10 Health Technology Hazard from 2012-2020. The Association for the Advancement of Medical Instrumentation held a Medical Device Alarms summit in 2011 and has provided webinars and research grants to support further research and innovation.
Let’s talk about changes that may improve the accuracy of medical alarms. First, you may consider individualizing alarm parameters by modifying the alarm threshold to reflect an individual patient’s physiologic status compared to an unmodified default clinical alarm setting. These adjustments have been shown to decrease the rates of nonactionable alarms and perceived workload. Here are some examples of adjustments:
- Alarm threshold tightening
- Adding delay periods between detection and alarm
- Disabling nonactionable alarms
- Adjusting volume based on priority.
Another tool to help create safe and effective personalized alarm setting includes evidence-based software. The authors provide the example of Ruppel and colleagues who evaluated alarm parameter customization software in an ICU with a program called Intellivue Alarm Advisor. This program is FDA-approved and designed to provide additional support for nurses about the types and frequencies of their patient’ alarms. Results from their study were significantly reduced number of alarms by 16% and duration of alarms by 13%. The takeaway is that alarm parameter customization may help to improve alarm accuracy and decrease the workload for clinicians who are responsible for responding to these critical alarms. Further research in this area is necessary to evaluate alarm setting customization, technology, and education for clinicians going forward.
Another modification to medical alarms is changing the sounds to make them more learnable, communicative, and tolerable. Clear and communicative alarms are necessary for anesthesia professionals who may be performing procedures that require visual attention in a setting with often concurrent alarms. For a little history of the alarm sounds, we need to travel back in time in 2006 when the International electrotechnical commission of IEC created the international standard for medical alarms 60601-1-8. Alarms that followed this standard all used the same melodic structure and were difficult to learn and tell apart from concurrent alarms. This led to a group of researchers creating auditory icons that could be used as an alternative to standard auditory alarms. Auditory icons mimic or represent the monitored parameter. The authors provide the example of the standard monotone beeping of the heart rate monitor with an auditory icon that sounds like the “lub-dub” of a heartbeat. I will include a link in the show notes so that you can take a listen to some of these IEC icons as well. The auditory icons had the advantage of being easier to learn and were more localizable than traditional alarms. Data from clinical simulations that tested the two different alarm types found that participants were able to discriminate between simultaneous alarms and identify alarm type better when auditory icons were used compared to traditional alarms. This led to the IEC updating the alarm standard in 2020 to include auditory icons as a supported medical auditory alarm. Auditory icons are important components for alarm systems notifications.
Let’s check out Table 1 in the article which is a comparison between traditional alarms and novel alarms. The first category is auditory icon. For traditional tonal alarms, this is a simple, melodic structure. For novel alarms using auditory icons, the sound mimics the physiologic structure. The next category is Amplitude Envelope. For traditional alarms, a flat envelope is used with quick onset and offset of the alarm while a decaying envelope is used for novel alarms with quick onset and gradual offset similar to the noise of clinking wine glasses. The final category is multisensory alarm. Traditional alarms only use the tonal alarm. Novel alarms may incorporate a visual display with vibration and auditory alarms.
Have you ever been annoyed by just the sound of a medical alarm? This contributes to alarm fatigue as well. Novel alarms that use the decaying envelope with a quick onset and gradual offset are less annoying and this change does not interfere with learning or performance and preserves the alarm’s melodic and rhythmic structure. Another modification that may be beneficial is decreasing the alarm volume. The clinical environment volume in hospitals is above the World Health Organization’s recommendations frequently. Decreasing alarm volume may preserve the accuracy of alarm identification while reducing overall environment volume. If we look at the literature, a study evaluated alarms delivered at a volume 11 dB below background noise compared to the typical 4 dB above background noise. Participant performance was similar between the two alarm volumes. I will include the citation in the show notes.
Technology may play an important role in alarm volume as well. Have you heard of the Dynamic Alarm System for Hospitals or DASH? This system has been developed and patented to regulate alarm volume based on surrounding noise levels and may help to improve the overall auditory environment by decreasing unnecessarily loud alarms. When you think of medical alarms, you may think of auditory alarms with partial visual notification on a monitor. The future of medical alarms will likely include multisensory alarms that provide alerts using sound, light, and vibration so that these alarms are easy to be noticed in a busy operating room or intensive care unit environment. Multisensory alarms may help to improve patient safety and outcomes by allowing clinicians to respond quickly when the patient’s condition changes and take appropriate action. Newer technology may include wearable notification systems such as an ankle band or smart watch. Check out the study by Burdick and colleagues that studies ICU patient monitoring using a new Apple Watch application. I will include the citation in the show notes as well. The goal for this study was to develop a wearable multisensory alarm system with auditory icons and pre-alarming to provide continuous information and improve alarm relevance. The undergraduate participants in this feasibility study using the novel smartwatch application showed better accuracy, faster reaction times, and decreased mental workload. Stay tuned for the results of follow-up studies with clinical end-users to confirm the workflow and performance benefit. This is an exciting development for medical alarms going forward with the innovation of multisensory alarms which may help to decrease the auditory burden, prevent alarm fatigue, and increase quality of care and patient safety.
And that alarm means that we made it to the end of the article. The authors remind us that anesthesia professionals have a critical role for monitoring patients, recognizing physiologic changes that require intervention, and taking the appropriate steps to keep patients safe during anesthesia care. We are trained to respond quickly to medical emergencies that may come up during a procedure and we need safe and effective medical alarms to do so. Alarm design and optimization are necessary to enable the constant vigilance for safe anesthesia care. The authors leave us with the following call to action:
“Currently, the demanding workplace environment challenges staff with suboptimal alarm technology, contributing to alarm fatigue and burnout. By focusing on patient and provider safety, clinical workflow, and alarm technology, researchers, and policy makers can transform the medical alarm realm into one that is evidence-based and personnel-focused.”
If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.
For more information about advances in medical alarm technology, we hope that you will check out the 2023 APSF Stoelting Conference recap, on “Emerging Medical Technologies – A Patient Safety Perspective on Wearables, Big Data and Remote Care.” Head over to the APSF YouTube Channel to see the conference recap and learn more about the impact of emerging medical technologies in the modern landscape of healthcare today.
Until next time, stay vigilant so that no one shall be harmed by anesthesia care.
© 2023, The Anesthesia Patient Safety Foundation