- The difference between alarms and alerts, common nurse calls and alerts, and how an excess number of alarms and alerts can cause “alarm fatigue.”
- Why it is critical to ensure the right people are receiving the right alerts and alarms.
- What changes healthcare organizations are making in order to reduce alarms and alerts sent to clinicians.
The Dangers of Alarm Fatigue Concern Nurses
In healthcare, we talk about the dangers of “alarm fatigue” and its consequences. Such as the threat to patients when an alarm is overlooked, the hospital’s cost, and the toll that unrelenting alarms and alerts exact on clinicians. It’s all real.
Not unlike “the boy who cried wolf,” as Nadine Salmon, of rn.com writes. Salmon describes, “…the constant drone of beeps and buzzes, not to mention false alarms in between, [that] can leave today’s healthcare provider desensitized and in danger of missing the next alarm.”
She’s right. I’ve been there.
All clinicians struggle with alarm fatigue, but I will talk about this from a nurse’s perspective. I have worked with alarms and alerts as a nurse myself—within acute settings and as part of a team that comes in to provide solutions that reduce the number of alarms and alerts directed at clinicians.
What is alarm fatigue?
According to the American Association of Critical Care Nurses (AACN,) “…alarm fatigue is a sensory overload that occurs when clinicians are exposed to an excessive number of alarms, which can result in desensitization” to alarm sounds—as well as an increased rate of missed alarms. We call those clinical alarm hazards and what we’re describing is anything that can keep a nurse from responding to an alarm or taking appropriate action to an alarm in a timely fashion. “However,” according to the ECRI Alarm Safety Handbook, “the issue of alarm hazards extends well beyond alarm fatigue. Preventing alarm-related adverse events requires scrutinizing all aspects of how alarms are initiated, how they are communicated, and how staff responds.”
It’s important to note that we have two issues here. We have alarm fatigue, and we also have alert fatigue. It’s valuable to point out that in healthcare, there are differences between alarms and alerts. And while alarms can become alerts, not all alarms do become alerts. Nor should they. Let’s take a closer look at the difference between the two.
What is the difference between alarms and alerts?
Within the clinical space, an alarm is an actual notification coming out of the originating system, the bedside monitor, for example. The alert is what is received and where it is received and who is receiving it at the alarm’s endpoint. “Alarms are typically derived from medical devices and often communicate an immediate life-threatening patient condition. Think a v-fib or asystole alarm from a patient monitor,” writes Brian McAlpine for HISTalk.com.
“Alarms are always more time-sensitive and a delay of a few seconds may matter to the safety of the patient,” he continues. “Another key characteristic of alarms is that they are almost always intended for nurses or respiratory therapists (i.e., non-physicians).” Alarms are regulated by the FDA from the alarm management middleware and the medical device side. Physicians don’t respond to alarms, nurses do. Alarms can be converted into alerts, but alarms are really in the physiologic space. Physiologic alarms are an important modality in the care of critically ill patients. “Yet,” state Kathy Baker and James Rodger, writing for ScienceDirect.com, “the many electronic devices used in patient care and the combination of alarms can cause sensory overload in caregivers. This sensory overload can lead to monitor fatigue, and caregivers may miss critical alarms, which can be fatal for patients.”
There are different types of nurse calls and alerts.
Alerts, on the other hand, are what the alarm can be converted to at the endpoint of the system That could be a central monitor at a nurses desk, remote monitors dispersed across a nursing unit or mobilized to a device carried by a clinician. Physiologic monitors are one example of what sends an alert. The nurse call system is one of the other biggest, generator of alerts. Depending on how the health system has nurse calls set up, five or six different types of notifications come through the nurse call system and need to land somewhere to be addressed by a clinician. Let’s look at those more closely.
There can be just a regular call where the patient pushes a button and says, “I need help.” There can be ice and water calls. You may not have realized, but there’s a button that can be configured on the nurse call pillow speaker that says,” I need ice or water.” There’s an “I’m in the bathroom, and I need help getting back call.” And for those, you pull the little cord in the bathroom, and that’s a bathroom call. There’s “the bed is locked, and I’m trying to get out of bed.” And we call that one a bed exit,—that one is a big deal because you can have a fall and falls are tied to bad patient outcomes and longer lengths of stay.
Several nurse call calls generate alerts. And you also have to factor in things like the interoperability space between pumps sending notifications outbound from a pump. These notifications can happen with ventilators in the same kind of space as the bedside monitors. So a nurse or respiratory therapist may configure their patient ventilators to send alarms that are also audible and need to be addressed.
And then, we can’t forget, general alarms, like the EMR alerts. Nurses can get an alert about a patient who has met the criteria for something—whether good or bad—that particular patient has met criteria for discharge, or, oh no, the EMR may have used an algorithm to identify the patient is potentially septic and needs evaluation which can be mobilized to a mobile device. The nurse needs to activate some other team. But it’s essential to point out: Just because everything is an alarm, that doesn’t mean everything has to translate into an alert.
An example of alerts from monitoring devices.
An example of what I’m describing is the bedside monitor, which tracks a patient’s respiratory rate, blood pressure, pulse ox, and heart rate. Nurses must validate the orders within the EMR are reflected in the monitor at the beginning of every shift. If the order says to keep the patient’s heart rate between 60 and 90, then the parameters set within the bedside monitor have to be set to a high of 90 and a low of 60. If the patient’s heart rate goes above 90, there will be an alarm. If it goes below 60, there will be an alarm. But each of the indicators could have separate parameters set within the monitor.
A patient’s pulse ox typically alarms when it drops below 90% or if there is an artifact on the waveform, which can happen regularly throughout a shift. What becomes important is when that alarm becomes an alert with an audible outside alarm that goes to a nurse.
Let’s say the pulse ox sits at 85% for 30 seconds or longer, if it’s alarming for 30 seconds or longer, that can then turn into a meaningful alert to let somebody know the situation may have become problematic for the patient.
But, take a patient like this whose heart rate can be up and down. It will continuously alarm all day long. With multiple patients and multiple alerts, nurses tune out the noise because it’s just constant. Therein lies the danger. The constant noise and interruption make it challenging to stay attuned to the different alerts sounding off for each patient—no matter how vital they may. And how does a nurse or PCA know which alert is which?
Which people or roles receive alerts?
Alerts are typically directed at the nursing unit’s roles and can include nurses, unit clerks, and patient care techs (also called healthcare techs or care assistants.) And then you’ve got respiratory therapists and other ancillary team members who also can receive various types of alerts. But from the alarm perspective, if the alarm becomes an alert, those always go to the nurse. And if the nurse doesn’t respond, the alert should escalate to another nurse or a buddy nurse or charge nurse. All the physiologic monitors go to the nurses. Therefore, nurses should receive only the most important interruptions from devices.
Routing the right calls or alerts to the right person or role.
The nurse call system is where you can get smart about routing the right calls or alerts to the right person, preserving the nurses focused time. You can route calls to the unit clerk. You can route calls to the care assistant, or you can route calls to the nurse. You can also route calls to the whole unit. Based on the severity of the nurse call alert that comes out, you can decide who to send it to. For example, if it’s just a regular call, it can go to the unit clerk, and they can answer, asking, “can I help you?” And then the unit clerk decides, is this a PCA thing? Or is this a nurse thing?
If the patient is asking for pain meds, it’s got to go to the nurse. If they’re asking for another blanket, it goes to the PCA. If it’s a bed exit at that bed, as it goes to everybody on the unit, someone must make sure that patient is not getting out of bed because of the risk of a fall. Routing the calls or alerts to the right people or roles can help reduce the number of alerts that interrupt the nurses and the staff.
Organizations are making changes.
The Joint Commission’s continued work on the issue of alarm fatigue, there are no universal solutions in place to manage these challenges as yet. However, there are success stories as individual hospitals across the country tackle the problem. Like the cloud-based Halo Health clinical collaboration platform, technological solutions are helping reduce the numbers of alerts and alarms sent to clinicians.
I work closely with healthcare organizations to identify the range of alarms and alerts their nurses are receiving. In many cases, within the Halo application, we can configure specific tones for specific types of calls and alerts. Over time, the nurses can recognize what kind of notification they are receiving by the tone they are hearing. And that’s just one small example.
Nursing associations have also released recommendations to combat alarm fatigue, according to Kathleen Gaines. The American Association of Critical Care Nurses released a Practice Alert in May 2018 that outlined evidence-based recommendations to help reduce alarm fatigue and false critical alarms. The recommendations for Nurse Leaders included:
- Organize an interprofessional alarm management team.
- Develop policies/procedures for monitoring only those patients with clinical indications for monitoring.
- Develop unit-specific default parameters and alarm management policies.
- Provide ongoing education on monitoring systems and alarm management for unit staff.
Bedside clinicians were encouraged to:
- Provide proper skin preparation for and placement of ECG electrodes.
- Use proper oxygen saturation probes and placement.
- Check alarm settings at the beginning of each shift.
- Customize alarm parameter settings for individual patients in accordance with unit or hospital policy.
This is the first in a series of three posts that delve into the realities of alarm and alert fatigue. In my next post, I go into further detail about the problems alarm fatigue is causing in medical settings across the United States. Combatting the reality of alarm fatigue is ongoing with the direction given by organizations like The Joint Commission, ECRI, and healthcare associations such as the AACN. Individual hospitals are making changes and experiencing success on a case by case basis.
But it isn’t where it needs to be, and everyday nurses battle the noise and confusion of the alarms and alerts and calls and notifications they receive.
Technological advances will continue to help. The Halo Health clinical collaboration platform is but one example of the technical help on the horizon. And the nurses like myself, who have worked in the acute settings and understand the challenges of alarm fatigue, will continue to speak out on the subject. We are very hopeful that positive change will continue to happen—one hospital at a time.
This is the first of three posts related to the topic of Alarm Fatigue and its impact on nurses in hospital settings. The second post delves further into the dangers of alarm fatigue. The third post addresses the changes that are being made to address the problems.