In April 2013, the Joint Commission (TJC) issued Sentinel Event Alert No. 50: Medical Device Alarm Safety in Hospitals in response to reports of a significant number of adverse events, nearly all of which were deaths and cases involving permanent loss of function. Alarms from patient monitors are usually associated with critically ill and immediate postoperative patients; however, alarms are also routine for care of women during labor, birth, and recovery. Alarms can be activated as part of electronic fetal monitoring (EFM), including various fetal heart rate (FHR) patterns, and as part of automatic blood pressure (BP), pulse, and oxygen saturation (SpO2) monitoring. Virtually all of these processes involve generally healthy young women and are triggered by maternal or fetal movement and loss of signal of clinical parameters that are actually within normal limits when detected. It is estimated that between 85% and 99% of alarms do not require clinical intervention (TJC).
With this high rate of false alarms, it is easy to see how busy clinicians can, over time, learn to ignore alarms or not respond in a timely manner. Other common responses are to mute alarm volume, set clinical parameters so wide that alarms will not be triggered, or turn alarms off entirely (TJC, 2013). In most cases, especially in the perinatal setting, there are no adverse effects of these actions. But what about situations when the alarm is triggered by a clinical situation actually requiring prompt intervention? This is a real patient safety issue. No doubt that many nurses can recall an event where a near miss or adverse outcome occurred after an alarm was triggered, but ignored, or did not receive a timely response. For example, coincidence alerts indicating that the signal being recorded as FHR is likely maternal heart rate, a loss of fetal signal associated with uterine rupture, hypotension and tachycardia during the immediate recovery period related to postpartum hemorrhage, and low oxygen saturation preceding respiratory arrest.
As use of technology has increased, so have medical device alarms. Overuse of technology can have negative unintended consequences. This problem will only continue to escalate unless there are concerted efforts to develop practical solutions. Recommendations from TJC (2013) involve developing policies, education for clinicians, appropriate use of technology, and leadership accountability. A number of these recommendations were also offered by the Association of Critical-Care Nurses (AACN, 2013) in their Practice Alert: Alarm Management. Two of their recommendations most applicable to the perinatal setting are customizing alarm settings based on the individual needs of the patient and monitoring only those with clinical indications for monitoring (AACN, 2013).
Consider how different our practice would be if low-risk women were not monitored via EFM during labor? What if low-risk women's vital signs were assessed approximately every 4 hours during early labor and the frequency gradually increased in active labor, as per long-standing recommendations in the Guidelines for Perinatal Care (American Academy of Pediatrics & American College of Obstetricians and Gynecologists, 2012). There would be no need for continuous automatic blood pressure and oxygen saturation monitoring devices to low-risk women in labor and no false alarms would be generated. Neither TJC (2013) nor AACN (2013) mention appropriate nurse staffing as a solution, however, with a nurse at the bedside of a laboring woman, an alarm, if triggered, would have a prompt response. If the woman was high risk and being monitored via EFM, loss of FHR signal due to maternal or fetal movement or FHR patterns that may indicate potential problems would be identified by the bedside nurse before an alarm was generated. These practical strategies may be helpful in addressing this serious problem.
Strategies to Potentially Reduce Risk of Alarm Fatigue in the Perinatal Setting
* Monitor only those with clinical indications for monitoring
* Customize alarm parameters based on the individual clinical situation
* Provide appropriate nurse staffing resources
References