The Joint Commission's 2014 National Patient Safety Goal .06.01.01 to reduce harm associated with clinical alarm systems highlights the need to manage the number of alarm signals and their noise (bells, dings, buzzers, etc).1 However, in the clinical area, staff rely on audible and visual alerts to prompt them to immediate interpretation, clinical assessment, and sometimes lifesaving action. To this effect, the advancement of technology has provided medical device manufacturers with the ability to provide a great number of physiological data point sensors at a low cost. This has resulted in an increased number of alarms being delivered to the care provider who is then expected to quickly synthesize and interpret a growing volume of data points into useful clinical information. One of the many problems is that frequent false or false-positive results give rise to alarm fatigue, whereby the healthcare providers become desensitized to the noise associated with the alarm.2 An important factor depicted in the work of Bliss et al3 is if an alarm is accurate 90% of the time, individuals will respond to the alarm 90% of the time. Conversely, if the alarm is accurate 10% of the time, individuals will respond only 10% of the time. This demonstrates that workers will modify their response rate to the alarm system's reliability. Subsequently, it becomes a patient safety mandate for clinical alarms to be valid not only to improve the accurate response rate, but also to reduce alarm fatigue.

Alarm fatigue is a human response to machine interface. When alarms are heard incessantly, the individual can be overwhelmed. The World Health Organization's Guidelines for Community Noise defines noise as unwanted sound. It further describes the capacity of noise to induce annoyance. For example, the sound pressure level (dBA) of the indoor environment, when it equals 35 dBA, can account for moderate annoyance.4 In a 2005 Johns Hopkins study, the daytime hospital noise level for the year 1960 was determined to be 57 dBA and in 2005 it was 72 dBA.5 Konkani and Oakley6 in their literature review equated sound sources that may occur on a daily basis with sound pressure levels. A noisy vacuum cleaner at a 10-m distance is equivalent to 50 dBA and a noisy lawnmower at a 10-m distance is equivalent to 60 dBA. In addition to annoyance, the human response to sound at these levels can become one of fatigue and/or desensitization to the alarm(s) that are asking the healthcare provider to promptly intervene. When this occurs, staff may miss, ignore, or disable alarms.7

The Pennsylvania Patient Safety Authority (in 2011), an independent state agency, reported that over a 6-year period, 31 of 35 reported deaths related to physiologic monitoring were attributed to human error. Of the 35 events, 28 involved telemetry monitors. Human error involved in the 31 events included equipment not connected to either the patient or the equipment (n = 14), transport outside the unit for diagnostic testing (n = 6), inadequate response to alarms (n = 6), and alarms being silenced (n = 4).8 To counteract human error, the Food and Drug Administration strongly advocates the application of human factors engineering into the safe design of alarm systems. By incorporating human factors engineering into the design, the user interface may become more appropriate for clinical staff, leading to higher levels of correct and safe action.9

THE CALL TO ACTION

Alarm fatigue can be partially addressed through designing more ergonomic alarm sounds such as urgency sound cues, greater use of alarm prioritization, and customization to specific clinical situations.10 Other best practices that avert alarm fatigue by reducing the number of clinically inactionable alarms include daily skin preparation and electrode replacement, the setting of alarm parameters specific to the patient, monitoring only patients whose condition warrants monitoring, and continued alarm device education for staff.11 Alarm fatigue is a heightened patient safety concern, but with an understanding of human abilities and the application of safe design, alarm fatigue-related medical errors can be prevented.

Hospitals are designed to promote healing and provide an environment that is patient centered. Nurses in monitored units utilize clinical alarms to assist them in detecting changes in a patient's condition. With alarm fatigue, there is desensitization to alarms creating a potential safety issue for patients. Many hospitals rely on human cardiac monitor surveillance, even though there is no randomized research evidence to support this approach. An early study conducted by Funk and colleagues12 revealed there were no significant changes in mortality with dedicated human monitor surveillance, although their presence did positively affect the recognition of ventricular tachycardia but not bradycardias. An integrative review in 2011 suggested that there is much needed research around the technology for alarm notification and its effectiveness compared with human monitor surveillance. The research should focus around patient outcomes related to the interventions developed to reduce alarm fatigue.13 The review recognized that one approach does not fit all monitored units within a hospital and that there is a large human interface part that needs to be acknowleged.14 Initial and ongoing education on the monitoring technology along with an alarm management policy is essential to decrease alarm fatigue and for patient safety.13

A MULTIDISCIPLINARY APPROACH

Given the regulatory requirements around reducing alarm fatigue, patient safety concerns, and the effect of excessive noise on clinical personnel, it is essential that hospitals develop a high-level process for dealing with the issue of alarm fatigue.

First, there needs to be an acknowledgement of the issue from senior leadership in the organization with the result that it is seen as a priority and appropriate resources allocated. Second, a system approach involving a multidisciplinary team that is representative of senior leadership, clinical nurse specialists (CNSs), biomedical personnel, information technology specialists, physicians, and quality and risk management specialists is required to develop and implement a strategy that is effective and evidence based. The team is responsible for investigating the current alarm management status in monitored units throughout the organization and examining the technology that may need to be reconfigured as part of the overall alarm fatigue reduction strategy. At the same time, an organization can use its purchasing power, to engage the manufacturers of patient monitoring devices to develop smart alarms that use an algorithm approach involving looking at multiple parameters at the time of a change in one before determining criticality and sending an alert to the end user. This multipronged approach ensures that the monitoring technology being used in a system is examined first as it may be that outdated technology will need to be replaced prior to human interface. It also provides an opportunity for performance improvement and Lean Six Sigma methods to be paired providing an opportunity to consider reducing cost through reducing defects.14

The American Association of Critical Care Nurses has developed a tool kit to deal with reducing alarm fatigue that is comprehensive and includes the use of performance improvement methodology that can be used to involve front line nurses in the process.15 The CNS is well positioned to lead the unit team on reducing alarm fatigue and ensuring patient safety. The CNS has served as a committed leader, delivering cost-effective care with optimal patient outcomes since 1953, and currently there are 72 000 in the United States.16 Their influence and ability to interact both on the professional and personal level with frontline staff provide a platform to build on that can be leveraged to assist with engaging the registered nurse in performance improvement and thus their ownership of reducing alarm fatigue. A bundled approach including timely customizing of alarms based on the patient's underlying pathophysiology, diagnosis, and current treatment regimen that is logical and relatively easy to implement and adopt will ensure that the process is sustainable.

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