1. Spotlight Harm From Alarm Fatigue

2. This presentation is based on the December 2015 AHRQ WebM&M Spotlight Case –See the full article at https://psnet.ahrq.gov/webmmhttps://psnet.ahrq.gov/webmm –CME credit is available Commentary by: Michele M. Pelter, RN, PhD, and Barbara J. Drew, RN, PhD, University of California, San Francisco –Editor, AHRQ WebM&M: Robert Wachter, MD –Spotlight Editor: Bradley A. Sharpe, MD –Managing Editor: Erin Hartman, MS 2 Source and Credits

3. Objectives At the conclusion of this educational activity, participants should be able to: Define alarm fatigue and describe potential errors that can occur due to alarm fatigue Identify federal and national agencies focusing on the issue of alarm fatigue List strategies that nurses and physicians can employ to address alarm fatigue 3

4. Case: Harm From Alarm Fatigue A 54-year-old man with hypertension, diabetes, and end-stage renal disease on hemodialysis was admitted to the hospital with chest pain. His initial electrocardiogram (ECG) showed no evidence of significant ischemia but cardiac biomarkers (troponin T) were slightly positive. He was admitted to the observation unit, placed on a telemetry monitor, and treated as having a NSTEMI (non-ST segment elevation myocardial infarction). 4

5. Case: Harm From Alarm Fatigue (2) Overnight, the patient's telemetry monitor was constantly alarming with warnings of "low voltage" and "asystole." The bedside nurse initially responded to these alarms, checking on him several times and each time finding him to be well. The resident physician responsible for the patient overnight was also paged about the alarms. He came and checked the patient and the alarms and was not concerned. Both clinicians felt the alarms were misreading the telemetry tracings. 5

6. Background: This Case The scenario described is common: skilled and well-intentioned providers diligently respond to repeated false alarms However, excessive false alarms can lead to unintended harm 6

7. Background: Telemetry Monitoring Hospitalized patients often monitored using telemetry A standard electrocardiogram (ECG) acquires data from 12 different leads Telemetry monitoring is a 5-electrode configuration –Acquires 6 limb leads (I, II, III, aVR, aVL, aVF) and 1 chest lead (V) –Telemetry display usually only shows 2 leads (often leads II and V) A computer algorithm then continuously analyzes a limited number of leads (usually 1–2) The algorithm monitors for arrhythmias or other significant changes 7

8. Misreading Asystole Telemetry devices often misidentify heart rhythms as asystole –Most common cause is failure to detect low-voltage QRS complexes In this case, telemetry monitor was "misreading" the patient's heart rhythm –True asystole would have been clinically apparent The nurse appropriately checked on the patient and contacted the physician However, the correct response should have been to search for another lead with a larger QRS complex 8

9. Low-Voltage QRS Complex In a recent study, low-voltage QRS complexes were a major cause of false cardiac monitor alarms In that study, one patient contributed 5725 arrhythmia alarms due to a low-voltage QRS complex 9

10. Case: Harm From Alarm Fatigue (3) The nurse and resident decided to silence all of the telemetry alarms (this observation unit did not have constant or centralized monitoring of telemetry tracings). The patient was not checked for approximately 4 hours. When the bedside nurse went to perform morning vital signs, the patient was found unresponsive and cold with no pulse. A code blue was called but the patient had been dead for at least a few hours. The cause of death was unclear, but the providers felt the patient likely had a fatal arrhythmia related to his NSTEMI. 10

11. This Case Silencing all telemetry alarms in this patient was an error that contributed to his death This patient was at risk for an arrhythmia due to his acute myocardial infarction Presumably an arrhythmia would have triggered an appropriate alarm had the alarms been functioning This adverse event reveals a clear hazard associated with hospital alarms 11

12. Alarms in the Hospital In general, there are three types of clinical alarms in the hospital 1)Arrhythmia alarms: detect a change in cardiac rhythm 2)Parameter violation alarms: detect when a vital sign (e.g., heart rate, blood pressure, etc.) exceeds the alarm limit settings 3)Technical alarms: indicate poor signal quality (e.g., low battery in a telemetry device) 12

13. Arrhythmia Alarms Monitor manufacturers never want to miss an important arrhythmia Thus, alarms are set to "err on the safe side" This results in a nearly 100% sensitivity but a poor specificity for detecting an arrhythmia –That is, the devices rarely miss true arrhythmias but at the cost of triggering for many tracings that are not true arrhythmias 13

14. Arrhythmia Alarms (2) In an analysis of 77 intensive care unit (ICU) beds over a 31-day period, there were 381,560 audible alarms (all kinds) This is an average of 187 audible alarms per ICU bed each day Of the 12,671 arrhythmia alarms, 88.8% were false alarms and not true arrhythmias 14

15. A Fatal Case of Alarm Fatigue Patient safety concerns surrounding excessive alarm burden garnered attention in 2010 after a highly publicized death at a well-known academic medical center In that case, there were repeated low heart rate alarms before the patient's cardiac arrest No one working that day recalled hearing the alarms In the investigation, the Centers for Medicare and Medicaid Services (CMS) reported that alarm fatigue contributed to the patient's death 15

16. Alarm Fatigue Alarm fatigue occurs when clinicians are desensitized by numerous alarms –Many alarms are false or clinically irrelevant Alarm fatigue is not surprising given the frequency of alarms –Nearly 190 audible alarms each day for each patient in the ICU –If only 10% are true alarms, then the nurse is responding to 170 false audible alarms each day, or more than 7 per hour 16

17. National Focus on Alarm Fatigue Federal agencies and national organizations have disseminated alerts about alarm fatigue Warnings have been issued about deaths due to silencing alarms on patient monitoring devices Alarm fatigue was listed as the number one hazard of health technology in 2015 (4 th year in a row) The Joint Commission established alarm safety as a National Patient Safety Goal in 2014 17

18. Dangers of Excessive Alarms The biggest harm from alert fatigue is that a patient develops a life-threatening problem that is missed because of excessive false alarms Many factors result in excessive cardiac monitor alarms including: –Alarm settings not tailored for the individual patient –Presence of certain patient conditions like low ECG voltage, pacemaker, or a bundle branch block –Deficiencies in the computer algorithm 18

19. Device Settings to Combat Alarm Fatigue Hospital alarm default settings can be reviewed to determine if some alarms that don't require intervention can be changed to inaudible text message alerts Devices can be modified to maximize accuracy in identifying true clinical concerns –For example, in a patient with persistent atrial fibrillation triggering repeated alarms, the monitor could generate a prompt, "Do you want to continue to hear an atrial fibrillation alarm?" 19

20. Device Settings to Combat Alarm Fatigue (2) Creating algorithms that analyze all available ECG leads, rather than just a few, could minimize number of false alarms Algorithms that integrate parameters (e.g., link heart rate and blood pressure) check to see if there was a physiologic response with the alarm –For instance, an algorithm-defined asystole event not associated with a simultaneous drop in blood pressure would be re-defined as false and would not trigger alarm 20

21. Individual Strategies to Reduce Alarm Fatigue Individual nurses and providers can take steps at the bedside to improve the usefulness of alarms Nurses can tailor alarms to an individual patient –Default settings may not make sense for every patient 21

22. Role of Institutions in Reducing Alarm Fatigue To address alarm management, committees should be formed and include representatives from all levels of the organization All staff who interact with monitoring devices should receive education and training on how to use monitoring equipment 22

23. Take-Home Points Alarms should never be completely silenced; clinical staff should instead problem-solve why an alarm condition is occurring and work to resolve it Cardiac monitor devices have a high sensitivity for detecting arrhythmias and vital sign changes but a low specificity –Therefore, they generate many false positive alarms Clinicians should learn to tailor alarm thresholds to individual patients to avoid excessive alarms and alarm fatigue Alarm safety is a National Patient Safety Goal, highlighting the importance of developing institutional policies and standards to improve awareness and design interventions to reduce the burden on clinicians, while ensuring patient safety 23