Walking into a hospital often means subjecting oneself to auditory overload. Beeps from the left and chirps from the right don't only prevent patients from getting the rest they need, these annoying alarms deliver providers the clinical equivalent of junk mail when they should only send top priority information.
"There are so many different devices that produce alarms," says Marjorie Funk, RN, PhD, a professor at the Yale University School of Nursing in New Haven, Conn. "Alarms go off not only when a patient is in trouble, but also if a device's batteries are running low."
Clinical alarm management is complex frequently because there are simply too many alarms. Most are not clinically significant and caregivers are often left to guess if an alarm means a patient is in trouble or if a SpO2 sensor simply fell off his or her finger.
Making a Determination With Data
At Johns Hopkins Hospital in Baltimore, Maria Cvach, RN, MS, and her co-workers scoured reams of unorganized data captured by clinical information systems to determine that a vast majority of alarms sounded at the 1,051-bed facility were categorized as low priority rather than medium or high priority alarms.
In the surgical intensive care unit alone, an average of 317 alarms were sounding per patient per day, of which 245 were advisory alarms. Cvach, assistant director of nursing, estimated that 80 to 90 percent were false or clinically insignificant. Designed for sensitivity rather than patient specificity, these alarms were sounding too frequently and often alerting nurses to minor equipment errors and inactionable events.
Cvach went with numbers in hand to the clinical leaders on each unit to discuss adjusting the patient monitor default settings to reduce clinically insignificant and false alarm signals. In the surgical intensive care unit, this meant adjusting the alarm thresholds for SpO2 and arterial lines, which caused approximately 70 percent of total alarms on the floor, and changing from audible to visual alarms for inactionable events, such as certain arrhythmias.
After the intervention, the average number of alarms sounding per bed per day in the unit decreased from 317 to 212. "I've observed that it seems to be working, and it does seem to be calmer," Cvach says. "Noise competes for people's attention, but if you can give clinicians true and actionable alarms, they are more likely to respond."
Teaming up with IT
"One of the problems with a past monitoring system was that nurses would get false alarms for every little crimped cable or moving finger," says Steve Miller, CIO of Oklahoma Heart Hospital, a two-hospital and 60-clinic system headquartered in Oklahoma City. "They couldn't tell the difference between a life-threatening alarm and a nuisance alarm."
When clinicians and the biomedical engineering team at Oklahoma Heart Hospital came to the IT department with this problem, Miller shopped around for an appropriate tool. The facility now uses an unobtrusive, user-friendly interoperability engine that reads patient monitor data and transmits that information wirelessly to nurses' mobile devices.
Like Johns Hopkins, Oklahoma Heart Hospital customized parameters so only the most crucial alarms would reach nurses. The interoperability engine reads every data field in a patient monitor, interprets the data according to the parameters and transmits notifications of critical events along with graphical wave data and room to nurses. Using the system, the hospital has eliminated the need for a central monitoring room and reduced false alarms by setting time delays for certain events. For instance, an alarm caused by an SpO2 sensor will not reach a nurse until it has sounded for 30 seconds, which eliminates alarms caused by crimped cables or moving patients.
"We implemented this technology due to nurse alarm atrophy," Miller says. "Nurses reported that, on our previous system, up to 80 percent of alarms were nuisances and not critical," Miller says. The initiative has garnered strong support from the chief nursing officer and nursing leadership who monitor response to alerts transmitted through the alarm management system.
There are also multiple redundancies installed in the system to ensure alarms receive attention. If a nurse does not respond to a notification by pressing the acknowledge button on his or her device, it is escalated to another nurse after a set amount of time. Additionally, test messages are sent to the mobile devices