Why Alarm Fatigue in Nursing is a Real and Present Danger
- The frequency of false alarms and what events can trigger a false alarm.
- How alarm fatigue affects the efficiency of nurses and the safety of patients.
- How patient satisfaction is impacted by alarm fatigue, including overwhelming noise and long periods of waiting for care.
Alarm fatigue in Nursing is a term familiar to anyone in healthcare. But many people don’t understand why alarm fatigue is a real and present danger. It’s like this. We know that alarms and alerts are designed to help healthcare professionals, especially nurses and patient care techs, stay attuned to patient health. But we lose sight of the alarms’ unrelenting noise, causing desensitization to individual alarms, alerts, and notifications.
And this can be dangerous.
According to Kathleen Gaines BSN, R.N., B.A., CBC, writing for nurse.org, “Alarm fatigue is one of the most troubling and highly researched issues in nursing.” Gaines explains that, over the last decade, research has found the following staggering statistics related to alarm fatigue and false alarms:
- The Food and Drug Administration reported more than 560 alarm-related deaths in the United States between 2005 and 2008.
- Between January 2009 and June 2012, hospitals in the United States reported 80 deaths and 13 severe injuries.
- One study showed that more than 85 percent of all alarms in a particular unit were false.
- A hospital reported an average of one million alarms going off in a single week.
- A children’s hospital reported 5,300 alarms in a day – 95% of them false.
- A hospital reported at least 350 alarms per patient per day in the intensive care unit.
Alarm, alert, and notification overload is listed as number six in The Top Ten Health Technology Hazards for 2020, published by ECRI. According to the executive brief, notification overload focuses on the cumulative cognitive load of all the notifications that clinicians experience and how it affects their work. ECRI suggests that healthcare should consider the global notification burden as a factor affecting work, along with time pressures and competing administrative or clinical tasks.
Finally, the brief states that while improving clinical alarm system safety is a Joint Commission National Patient Safety Goal, universal solutions have yet to be identified to provide a systematic and coordinated approach to alarm management.
Alarm fatigue is a real and present danger. We see it daily.
Oh, wait. It’s a false alarm.
“Medical alarms are meant to alert medical staff when a patient’s condition requires immediate attention,” writes Jordan Rosenfeld for Patient Safety and Quality Healthcare (PSQH). “Unfortunately, there are so many false alarms — they’re false as much as 72% to 99% percent of the time.” A study published in 2016 by Healthcare Informatics Research cited medical staff that encountered 771 patient alarms per day.
As an example, hospitals often use telemetry to measure and transmit information about patient conditions. Electrocardiogram (ECG) monitors, Blood pressure monitors, respiratory rate monitors, SpO2 (oxygenation), and dialysis machines are examples of telemetry equipment that issue alarms and alerts. False alarms can happen for a wide variety of reasons, including:
- Highly sensitive monitors
- Inadequate leads or wires
- Leads detaching from the patient
- Alarm settings not tailored for the individual patient
- Leaving hospital default settings in place
- Deficiencies in programming algorithms
Bedside monitors can and do generate false alarms also. And to the high number of false alarms, just add to the general noise nurses deal with daily. For nurses, it’s hard enough to pay attention to the high level of noise coming at you throughout your shift, but false alarms make it even harder to know when you are dealing with a critical situation. Let’s dig a little deeper.
Why is alarm fatigue dangerous?
I wrote about the types of alarms and alerts, and notifications hospitals use to monitor patients in the first post in this series. The combination of notification, multiplied by the multiple patients assigned to a nurse in a twelve-hour shift, can desensitize a nurse. This desensitization can cause issues in the following three areas:
- Patient safety events
- Nurse burnout
- Patient dissatisfaction
Patient Safety Events
Clinicians are exposed to a cacophony of noise throughout their shifts. As I have mentioned, this extended noise exposure can cause nurses and others to become desensitized to the sounds of alarms. They also may find it challenging to differentiate between urgent and less urgent warnings.
“As a result, nurses may miss necessary alarms, which interrupts care, contributes to job-related burnout, and compromises patient safety,” states Jordan Rosenfeld, writing for Patient Safety & Quality Healthcare (PSQH.)
Rosenfeld states that the FDA reported 566 alarm-related deaths in 2005-2008, and 80 deaths and 13 severe alarm-related injuries between January 2009 and June 2012. According to Rosenfeld, the problem had become so significant that back in 2008 the ECRI Institute started including false alarms on its list of Top 10 Health Technology Hazards.
The Joint Commission, the nation’s hospital accrediting body, attributed 80 deaths and 13 serious injuries to alarm-related failures in a recent four-year period, and in 2013 required hospitals to commit to preventing alarm fatigue, as reported by The Star Tribune. Hospitals accredited by The Joint Commission (and the majority are) must comply with this National Patient Safety Goal related to alarms, which was a big deal when it came out in 2014 and needed to be enforced beginning in 2016. Today, in 2020, alarm, alert, and notification overload ranks sixth in hazard status.
The problem is that we monitor patients to watch the trending of their clinical data, especially for physiologic monitors. So if a nurse happens to miss this patient’s heart rate slowly going up over time, and she is just ignoring and silencing the alarms or ignoring them on her devices, she may miss essential patterns.
For example, she may not see that the pulse ox is trending down. It might dip down to the lower eighties and then pop back up and dip down again. The nurse may not be aware because she is getting inundated with so many alerts that they become meaningless to her, and she may miss an early warning that something is going on with this patient. Because she’s gotten multiple signals for each of her patients, she’s struggling to absorb all of it and to cognitively differentiate between the noises and the ones that are vital indicators of real problems.
Here is an example of the kind of thing I am describing. Federal investigators concluded that “alarm fatigue” experienced by nurses working among constantly beeping monitors contributed to the death of a heart patient at Massachusetts General Hospital in January 2010. “Patient safety officials across the country have said the heart patient’s death at Mass. General shines a spotlight on a national problem with heart sensors and other ubiquitous patient monitoring devices,” according to the account published on boston.com. “Numerous deaths have been reported because of alarm fatigue, as beeps are ignored or go unheard, or because monitors are accidentally turned off or purposely disabled by staff who find the noise aggravating.”
We know that nurses are a vital part of healthcare. What some may not realize is that nurses comprise the largest segment of healthcare. According to the World Health Statistics Report, there are approximately 29 million nurses and midwives globally, with 3.9 million of those individuals in the United States. The World Health Organization has estimated that close to one million additional nurses would be needed by 2020.
And this was before the onset of the COVID-19 Pandemic.
Nurses are burning out. According to Thomas Reith, in his peer-reviewed article, “Burnout in United States Healthcare Professionals: A Narrative Review,” burnout is a combination of exhaustion, cynicism, and perceived inefficacy resulting from long-term job stress. “The consequences of burnout are not limited to the personal well-being of healthcare workers,” he states. “Many studies have demonstrated that provider burnout is detrimental to patient care.”
In 2019, privately-held healthcare research and consulting firm PRC published a study focusing on the implications of nurse burnout. According to the research, “Trends and Implications with Nursing Engagement,” 15.6% of all nurses reported feelings of burnout, with the percentage rising to 41% of “unengaged” nurses. The PRC study defined unengaged nurses as nurses who:
- May not be part of a team with their colleagues,
- Have diminished morale,
- Feel emotionally checked out from their work (which also ultimately affects their patient care)
“What’s really interesting as well, is that 50% of nurses who reported feeling burned out also reported that they had no plans to leave their organization—pointing to the importance of supporting and meeting nurses where they are at in the workforce,” writes Chaunie Brusie, for nurse.org.
Alarm fatigue has been documented as adding to nurse burnout. Nurses try to manage the high levels of noise and distraction while providing high-quality patient care to as many as eight patients during twelve-hour or longer shifts. Nurses struggling with alarm and alert fatigue can slide into burnout and decreased engagement, and then run the risk of missing important notifications on their patient’s conditions.
“Patient satisfaction is an important and commonly used indicator for measuring the quality in health care,” states Bhanu Prakash in an article published in the Journal of Cutaneous and Aesthetic Surgery. And of course, he’s right. For the hospital, patient satisfaction can affect clinical outcomes, patient retention, and medical malpractice claims. As Prakash points out, patient satisfaction affects the timely, efficient, and patient-centered delivery of quality health care. It reflects on the patient’s perception of the care he or she has received and may even impact healing.
Noise is often a top complaint for hospitals. Patients express that they are left stranded, having to endure the noise while nurses and aides attend to other patients or other responsibilities. “Tens of thousands of alarms shriek, beep and buzz every day in every U.S. hospital,” writes Melissa Bailey for Kaiser Health News. “All sound urgent, but few require immediate attention or get it. Intended to keep patients safe alerting nurses to potential problems, they also create a riot of disturbances for patients trying to heal and get some rest.”
Patients struggle with alarm fatigue too, which impacts patient satisfaction—or lack thereof. The constant alerting and the overwhelming noise surrounding them prevents them from resting and sleeping. They often wait for long periods until a nurse or an aide comes to turn off a beeping monitor or blaring alarm.
“Some studies have found during a day at the hospital, noise levels are 72 decibels, which is the same as running a vacuum cleaner,” writes Morgan Haefner for Becker’s Hospital Review. A study published by Johns Hopkins study counted the number of alarms that went off over 12 days, and it amounted to an average of 350 alarms per patient each day. For one type of breathing monitor, 90 percent of the warnings were false positives.
Hospitals across the country are actively searching for methods of reducing the noise levels–for clinicians and patients. That means finding ways to lessen the number of alarms, alerts, and notifications while at the same time finding ways to lower the volume on the remaining alarms. It’s a work in progress.
In my third post, I describe how organizations are developing solutions to reduce the number and volume of the alarms, alerts, and notifications generated in-hospital patient monitoring.
Thank you for reading,