Cheng Zhang

Clinical Engineer, VA Boston Healthcare System

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How to effectively reduce alarm fatigue in hospitals?

Our increasingly complex medical technology is forcing our clinicians to stay on top of an overwhelming number of parameters and physiological alarms. Over the past few years, the number of incidents involving alarm fatigue has escalated, leading to media frenzy (http://articles.boston.com/2011-09-21/lifestyle/30185391_1_alarm-fatigue-nurses-patient). Several patients were severely injured and some even died due to medical alarm exhaustion.

Proposed solutions:
1. Integrate alarms to reduce the number of alarms
2. Decreasing physiological threshold (doctors are very conservative about this)
3. Monitoring how long it takes the clinicians to respond to each alarm
4. Offer more training to clinicians about the alarm functionality
5. Deliver alarms to responsible clinician via beeper, cell phone.

Any inputs or suggestions are welcome!

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    Oct 21 2011: Cheng

    Thank you for bringing this to TED..I have never heard that term "alarm fatigue" but I have seen the devastating effect of non-response on patiens in hospitals and nursing homes.

    . It is something that most people won't connect with as an issue unless they have been at the bed side of someone dearly beloved who needs help, pushed the button and got no response.

    Iimagine that you have no dementia..that you are you in every way except you can't get out of your wheel chair on your own .Iimagine that you are painting a water color in your room at the nursing home listening to your favorite opera and realize you have to go to the bathroom. You ring. no one comes. you ring again, no one comes. You wheel yourself out to the nurses station and try to get someone's attention."I'll be right back" someone promises and then it's too late. Your bowels have emptied and you are now sitting in the corridor at the nurses station in soiled pants.The next niurses says "Well there's no hurry now..go back to your room and wait..I'll be there as soon as possible" I arrived about 15 minutes after that and found my elegant friend, a retired english professor who taught at Bowdin College still sitting by the nurses station tears streaming down his face and he told me what had happened. It was a long time before.help came. I went to the nurses several times before help came. (in memory of Richmond)

    I slept at night at this same nursing home on the floor next to a friend with a broken neck because of "alarml fatigue" we were worried that our beautiful wilfull Clara would simply try to get up on her own if no one came..that she would fall and die. Over that first week sleeping next to Clara on the floor the corridor at night was full of the cries and tears of bed ridden patients needing help their room alram lights on..not a nurse in sight. ( in memory of Clara

    "Alarm fatigue" isn't about alarms and technology..it's about deeper care issues.
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    Oct 16 2011: There is a lot of literature in the Computer science literature under the heading of 'Human Factors" to help you with this. Why not contact a university prof in the field of Human Factors for assistance and direction?
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    Nov 2 2011: There is a whole field of study that might be relevant for you: vigilance. Currently, the leading expert is Professor Raja Parasuraman.

    Vigilance decrement is what happens to sustained attention over time (and you might want to search on "vigilance decrement" and "sustained attention" as phrases specifically). Alarm fatigue sounds distinctly like and instance of Troxler's fading. For a cool explanation with visual, see: http://en.wikipedia.org/wiki/Troxler%27s_fading

    Anyway, what can be done? Breaks. Changing the tone. Working on the accompanying compassion fatigue that is undoubtedly a component of the problem. First responders who actually determine the severity of the situation and who can handle the lesser issues or escalate it to the next tier if need be.
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      Nov 3 2011: Thaks for coming here to speak to this issue Gisela.

      I think you are pointing to some very important elements of the problem and its possible solutions.

      One of the things I noticed about changes in the hospital critical care environment, well established 10 years ago,, is that the job of nursing has been been broken up into many many small discrete jobs ..people wheeling trollies room to room doing highly specialized tasks.

      That kind of care and the use of machines to replace phsyical presence all serve to desensitize the system to the humanity part of being ill and helpless.

      The kind of training you are pointing tomight very well hell help make sure that each and every task performed in the process of care includes compassion and humanity.
  • Oct 31 2011: Hi Cheng,

    I've spent my career implementing alarm and diagnostic systems for the telecom industry. The missing piece is integration. We have many monitors for the patient, all of which are important, none of which speak for the patient as a whole. This is a common pattern in alarm system maturation. The better result would be a "wrapper" or manager that interfaces with all of the systems and can make intelligent decistions about what conditions need immediate help, what need to be noted, and what can wait for later.

    In telecom, there are standards organizations that define how systems work together, It's a very slow process but absolutely necessary if variousmanufacturer's systems are to work together. I don't know if those kind of standards exist in the medical equipment field.

    Believe me, saying that there are too many alarms and maybe we shouldn't monitor "xyz" is not the answer. Adding staff is only a stopgap that will cause problems of it's own.

    And BTW: For all of you looking for the "Next Big Thing", here's a chance to build something, make the world a better place, and make a pile of money all at the same time. Don't think that the medical equipment manufacturers aren't trying to do exactly this.

    Thanks,
    Doug Bell
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      Oct 31 2011: Douglas,

      great to have your voice here and so nice that TED Admin has seen this issue as worthy of being featured. (thanks admin)

      I'm interested, from the patient advocacy side of this issue, have you been directly involved in meeting in your company ( or with your client company's) using this term"alarm fatigue". How has the issue been discussed and presented in these meetings.?

      Also, may I ask, have you actually spent any time ina hospital setting observing how alarms confuse or overwhelm staff? Whether they are working properly? Set properly?

      what kind of training and oversight do your clients companies have in hospitals to insure that monitoring equipment is properly used and claibrated?

      why do you say with such conviction it is not about inadequate staffing?

      And just at a personal level, if you are willing to answer, I wonder if you or someone you love has been in intesive care and depemdent on these monitors?

      I would be most appreciative of your views and information on these things, as a patient advocate at the total other end of the system. (Anne the other patient focused commenter here is actually writing a book about medical care from the patient point of view and like me has "been there"..I am sure she would be grateful for your furthe comments as well.

      Thanks Doug
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    Oct 21 2011: I haven't your experience, Lindsay, but my observations suggest that nursing staff may downplay alarms when they relate to patient needs that are not life threatening. That would suggest two things. One is a need to distinguish between alarms from equipment monitoring vital signs, and the other is the need for more priority to go to patient request type alarms.

    When I got home from hospital I needed to deal with developing, but not open, pressure sores, and I was offered some sort of barrier spray to protect from 'urine, faeces and other body fluids'. To me that said a great deal about the treatment of immobile patients, implying that they are allowed to remain in a condition where that sort of protection is needed.

    Not entirely tongue in cheek, but if your suggestion about technicians spending time with patients is followed, perhaps those technicians should have their access to water and to toilet facilities as limited as is the patient's. That would be a telling lesson as to priorities!
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      Oct 22 2011: Anne,

      Thank you for sharing that Anne. You must have gone through quite an ordeal to have pressure sores emerging. And yes, the instructions for your barrier spray are very telling about prevailing standards of care for immobile and helpless people.

      I think Cheng's question was framed with respect to life monitors in intensive or critical care situations but I made reference also to the non-response to ordinary calls for help in nursing homes .because it points to the same "standard of care" issues I have seen in intensive care units and because both, as you point out from your own experience, are about people totally unable to do basic essential things for themselves, both are about dignity and humanity..
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    Oct 21 2011: Integration of audible alarms sounds like a good idea - the primary function should be to highlight that the patient needs urgent attention. But this needs to be supplemented by something non-audible showing the nature of the attention needed.

    However, as others have said, there is a big problem with audible alarms in that nearby patients are disturbed. The same is true of beepers and cellphone ringtones. Having recently spent time in hospital I know just how badly recovery is affected by never getting a night's sleep because of this. So the need is for any audible alarm (or flashing light) to be at a nurses' station, and for there to be sufficient, and sufficiently trained' staff to respond to the level of alarms in any particualr type of ward.

    As with a lot of problems in the healthcare sector today, the solution lies with people issues much more than with technology.

    There is an added danger when technology is offered as a solution - it is often seen as a means of reducing costs through reducing staffing requirements, so however effective the technology seems in isolation, in a real world context it can make the problem worse.
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      Oct 21 2011: Wonderfully spoken Anne.

      Your voice as a patient is important to this discussion.

      I agree completely that technology alone is not enough for crisis response in the intensive care units of hopsitals and in critical care settings where monitors and alarms are about the frailty, weakness and vulnerability of the patient being monitored.

      Peeling apples in my kitchen just now,( a pie for a freind who has traveled from London to remote rural Maine today on a care crisis with her parents), it ocurred to me I would ask all the technicians and consultants and hospital engineering people who are trying to to respond to care staff burn out ( failing to respond to alarms) should volunteer to spend several hours for several nights in a row with one patient in intensive care..not as a technical observer but as companion and advocate for that person

      .Obviously if people are dying because hospital staff didn't respond to alarms..we need to solve that problem.

      The problem itself would be viewed and framed differently I think if the people engineering solutions and designing crsiis response technology had a deep immersion in the patient side of things in intensive care.

      I googled "alarm fatigue" and read many articles. In one I saw a stat that 85% of alarms are false alarms. That didn't jibe at all with my many hours with many people over more than a decade in intensive care, end of life and other seetings where alarms are deemed medically necesssary for the patients safety and well being. I don't recall any false alarms.

      I traveled from NYC to Maine for 3 day weekends when my father was in intensive care for more than a month at a very highly regarded Portland Maine Hospital..a teaching hospital.and spent all my time into the night there. It is common for several in intensive care to get into trouble all at once. There have to be enough live bodies present to respond.

      Intensive care candy stripers maybe? Volunteers to sit with one patient.?
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    Nov 14 2011: Make alarms that are sensitive and precise. So that they are novel enough to insight a response. If heart monitors set of code blues all the time then the mortality rate would be great but the reason that alarm is sensitive is because its governed by a reliable moderator. If IV tubing was less prone to getting kinks, if pulse ox had a consistant way of staying on and deliver constant data, if O2 delivery was comfortable, these alarms wouldn't happen. the human element isn't the primary reason. the lack of human is. the lack of pt interaction in general is causing this fatigue. our pt's are numbers on a computer and their bodies are about as important and the interactive mannequin we had in school. until we change the back to pt first and first touch then we won't solve the urgency in health care
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    Nov 2 2011: A few comments so far have mentioned about integration. That's one of the key issues in my opinion. We need to make sure that technologies that produce alarms should NOT be designed without considering other alarm sources.
    Moreover, customization can help reduce fatigue. So clinicians and patients that benefit technologies should be able to adjust alarms.
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    Nov 1 2011: Lindsay: My own families experiences with our Houston hospitals (both inpatient and outpatient) have included laprascopic double hernia surgery, radiation implant, one ER visit (lung infection), followup radiation therapy, full hysterectomy, and emergency surgery on a severely infected leg (5 inpatient vancomycin drips over 2/1/2 days).

    In all instances, the staff was efficient, courteous, helpful, and friendly. Then again, Houston, Texas, is a city that has a lot of the nation's best hospitals and this part of the country tends to be more 'friendly' than other places in which I've lived.

    I'm sorry to hear that so many folks have had such lousy experiences.... Houston has had a number of hospitals over the years which provided sub-standard care -- but here everyone is constantly 'talking' about their 'hospital experiences' and most of the ones with 'reputations' have gone out of business over the years..... Word gets around!
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      Nov 1 2011: Thomas..thanks for this post.

      .Yes, I agree "word gets around" and also that the patients voice is in the system..when the patients voice and experience is well represented things work a lot better.

      You are truly blessed to have such hospitals.

      One day I hope that s true everywhere.

      It is certainly not true in my region. It is more than than three hours to a good hospital.
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    Oct 31 2011: Here is an interesting article by two nurses involved in an experiment to address the alarm fatigue problem..appears it was addressed with remarkable success ( a 43% reducton in alarams) just through staff training in how to use the monitors properly..a lo tec intervention

    .http://ajcc.aacnjournals.org/content/19/1/28.abstract

    technology only works well when it is used well and desigbed well to full a need.
  • Oct 31 2011: Hi Lindsay,

    The term Alarm Fatigue is new to me. The problem is not, however I am not currently involved in this with any company or client.

    The issue isunderrepresented in meetings. Most often the people who are concerned are the ones who are directly effected. In my case it's the people running a Network Operations Center. In the hospital setting I would expect that the nursing staff is most aware of the issue, but you'd have to check with them to see if I'm right.

    It's almost a universal experience that whomever is asking for a monitoring system to be established ALWAYS wants to be notified (or to pull the proverbial fire alarm) for each and every hiccup. This phase usually lasts a few weeks or months and invariably results in alarms being ignored. If you build a few of theise systems you learn that an event is not always an alarm. A good monitoring system can be programmed to provide levels of urgency, everything from "so noted" to "get someone in here now!" You would also like to see some intelligence in the monitor so that combinations or repeated events which may not normally be important can be seen as urgent because they came in together or at a rapid rate. And, you'd like to see all of the event reported in one place, instead of each machine being it's own universe.

    I feel it is not a staffing issue because:
    1) You can't monitor the systems as well as the machines can. Really.
    2) You don't want to waste a valuable person for a chore that the machine does better.

    This is not to mean that staff isn't important. Just the opposite, they have more important things to do other than watch a group of ECG / BP / SpO2 monitors.

    Yes I have recently spent time with a relative in intensive care due to an automotive accident. (They should have a full recovery.) There was plenty of time to look at the equipment and how it fit into the "ICU" system.

    Best wishes,
    Doug
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      Nov 1 2011: Hi Douglas,

      Thanks for this post.

      A lot of wisdom there. In fact on the same page with you, I think. When technology has the right tasks, people know how to use it, and it is well deigned with end users in mind ( in this case niursing staff)..it serves life, serves, cmmunity and serves patients.

      I was very heartened by the nurses article on an expereiment in her hospital that rediced alrms by 43% just from retraining of personnel.

      Glad your relative will make a full recovery.
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    Oct 25 2011: This should be a routine *hospital management* issue. If hospital management is unaware of this problem, they are at fault. If management is aware of the problem and are not addressing it, management is also at fault.

    If a doctor, PA, nurse or whatever feels the management of a hospital is not doing the job, it's time to find an institution where management IS doing its job. In this respect, a physician is just like any other person. Sometimes it's just time to say, "Good bye! I have decided to move on...."
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      Oct 31 2011: Hi Thomas..patients are moving on.

      .to the next life..as a result of what s being called "alarm fatigue"..i.e. hospital personnel fail to respond to a critical alarm and someone dies as a result.

      I agree with your point that nurses and doctors do perhaps have the choice to "move on" if they feel they are in hospitals compromising patient safety but I gather from the many background articles avaialble on this sbject hat it is widespread..ubiquitous..everywhere..As a patient advocate I am trying to understand why it is everywhere.Have you heard about incidents of patients ding because alarms were;t answered in your community? Has it hapened to anyone close to you?
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    Oct 24 2011: That point about overuse of monitors is interesting. It does tend to confirm that technology is depersonalising and deprioritising patient care, doesn't it.

    Re writing about my experience, a book is part written, hoping to have it available on Kindle this year.
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    Oct 23 2011: Lindsay, I think you just encapsulated the problem in four words - 'transients in the system'! That phrase really brings out the problem of patients being treated as subservient to the system instead of the purpose for its existence.
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      Oct 24 2011: Yes..very hard to get a patient voice represented in the health care system or properly centered in its deliberations on policy. People who need monitors, especially, come in crisis, totally unprepared ( who could prepare?) for all that is about to happen to them and their loved ones, families totally lost in their grief and confusion.

      Our local cancer support center has a patient navigator system..past patients becoming treatment copansions and resources for current patients. Perhaps that could and should be used more widely.

      I think you are amazing that you are willing to bring your experience as a patient here to shed light on this issue and of course it is unusual to have a public ocasion where that is possible..(thank you , TED Conversations community)

      I spent some time reading what hospitals and the manufacturers of monitoring equipment have had to say about "alarm fatigue".. ( that term alone offends me as it seems to excuse un answered alarms that result in patient deaths).

      The hospital where the widely publicized event occurred is focusing on reducing the number of patients on monitors..iei attributing"alarm fatigue" to over use of monitors. Other hopsitals are doing the same..with the same focus. That suggests to me the possibility that hospitals have tried to use monitoring to cut back staff or to operate on the premise that with more monitors adequate care coverage can come with fewer staff.

      On the technology side from what I have read the issue of false alarms is mostly a matter of improper set up and calibration by users. I don't know anything about that part..who sets up monitors in hospitals and what there ongoing relationship is with care providers overseeing monitored patients

      .Ever thought of writing a letter to the editor or "op ed" piece for your local paper or even for the Boston Globe where this issue is most visible ( hasn't been mentioned here). And one to one you can be a patient navigator to friends loved ones and neighbors.
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    Oct 22 2011: The problem with a technical solution is it can't be divorced from wider care issues. Cheng's third point partly acknowledges that, but it won't help if wards are understaffed. And it won't do anything for the situation where, for example, nursing staff are used to a situation where a patient regularly gets distressed when tthey wake up with a need for the loo and it pushes their BP and heart rate up.

    On the surface it might be possible to address this by recording reason and response for every alarm, but if the nursing staff are overly busy or disinclined to offer basic care, then the responses can become formulaic or even be falsified.

    The trouble with a technical solution is that it doesn't address the underlying issues and distracts attention from them. And as the technology is implemented and the care problems start to show, layers of process are added to deal with the symptoms of the underlying problem when the effort should go in to eliminating the root cause.

    So I think it is very valid that this part of the thread is covering care issues. I don't want to detract from Cheng's original question because I can see some value in a more effective way of presenting alarm information to clinicians, but once that technology is in place long enough for it to be viewed as commonplace, it is inevitable that the care issues will resurface.
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      Oct 23 2011: I agree completely, Anne, that technology that will solve problems in hospitals and bring imporant new tools and solutions must be driven by issues of patient care.

      I think the only way for technicians who might have useful technological systems to bring to bare on improved patient moniotring and improved patient monitor response by nurses is to actually observe what happens in an intensive care unit..maybe they could do that via web cams with permission f the patient and patient family.

      What they would see from the patients view, from the patients families view would be very different, I think, from what hospital administrators and staff are saying is the problem.

      Patient voice and experience is absent from the care evaluations and decisions because patients are tarnsients in the system. Those especially who get on the intensive care roller coaster are so glad to be off, and with any luck take their loved one home, and usually so everwhlemed with after care issues that they are not likely to address issues that happened to them (like failing to respond to an alarm..or in my father's case mis installing a feeding tube..something we discovered and had corrected). So only one side of the story is ever fully told.

      The alarm fatigue" issue is an important one..the most vulnerable, the sickest are dying because hospital staff fail to respond to alarms.. It just seems absurd to me that anyone would accept the premise that its because there are too many alarms going off and care staff are densensitized...that switching from auible to visual alarms would save patients or reduce stress.
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    Oct 17 2011: Chen Zhang,
    I wonder if you have the ability to send a link to this question to hospital personnel around your area, or all over.

    This looks like a very important issue, yet very specific to hospitals. I think they would be the ones providing the most useful answers... we are just, well patients or potential patients...

    I truly think the TED community would benefit from their participation!
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      Oct 17 2011: Actually, there is a group of clinical engineers (representatives from several different hospitals) working on solutions including organizations like AAMI and HTF. But what I'm really looking for are simple approaches we can take like designing a more sound absorbent room, or feeding patients with white noise to drown out the alarm.

      Ultimately, I'm posting this on TED to get a wider perspective (e.g. human factors as Debra suggested).

      Thanks!
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        Oct 21 2011: I'm confused now..are you thinking of sound absorbent rooms and white noise for patients to insukate them from the rest of the noise of alarms ad cries? I think that is a great idea..part of the dehumaizing, demorlaizing, spirit eroding experience of having to be in a hospital or nursing home, especially at night, are these noises of cries, screams,and alarms.

        But it will only help the very very few who are in private rooms..most have at least one room mate and the only relief from the cries of a rom mate is a fast response from care staff..The longer the alarm gos unanswered the greater the distress..the louder the cries.

        Again, the interventions for "alarm fatigue" are not technology..it's adequate staff, adequate training, cultivating compassion as the culture of all hospitals and nursing homes.