Alarm Fatigue: Response Time to Bedside Monitors

Alarm Fatigue: Response Time to Bedside Monitors

One thing I believe to be overlooked at in my practicum setting are the alarms. Alarms are put in place to keep our patients safe, however, when no one responds to the alarms going off they aren’t doing much good. In the practicum setting I find that call lights and alarms go off for a good amount of time before they are responded to. The floor gets busy and chaotic during the day between rounds, discharges, admissions and then caring for the patients you have. As a nurse if you are in a patient’s room giving medications you can’t just drop everything and run to every alarm. This is why we have aides on the floor to help assist with things like this throughout the day. However, when there are only one or two aides for the entire floor this doesn’t always work, they get busy and have a lot of patients that need assistance with a lot of things. I believe response time to alarms as well as call lights should be looked at more. If a patient uses the call light but no one comes they could try to get up on their own putting themselves at risk for falling, which could then lead to injury.

 For practicum I am at a community hospital. The hospital has 3 “spokes”, these spokes are for medical surgical patients. Each spoke contains about 20 beds, give or take a few. Each nurse is assigned up to 5 patients but no more than 5. Normally for each spoke we have 3-4 nurses and 1-2 CNA’s depending on the census. The doctors, nurse manager, social workers etc. travel throughout all 3 spokes for bedside rounds every morning with the patient and the patients nurse. This allows the patients to see their entire team while they are in the hospital. All the nurses on the spokes work 8 hour shifts with exception to the nurse manager who works 12-hour shifts.

 As a student nurse my role is to be accountable for delivering care to patients with respect, while learning and also being aware of my limitations. Ways in which I do this is every morning at practicum we get our patient list. This includes who our patients are along with a print out of their chart. After given our assignments, my preceptor and I decide which patients would be most beneficial for me to take. Once assigned patients, my role is to go through their chart on the computer before going to see them incase anything was missed during report. I also check to see when they have medications due throughout the day during this time. I perform head to toe assessments, with a major focus on their admitting symptoms. For example, if I have a patient who has abdominal pain I will shift my main focus on things like bowel sounds, how the patient’s appetite is, their last bowel movement, pain level, where the pain is, pain upon pressure etc. The responsibility for charting my assessments after seeing each patient also falls on me. I find it easier to chart when the information is fresh in your mind and not waiting till the end of the day after you have done a million tasks. This also helps me with time management and having all of my charting done long before the shift is over and ensures I am ready at the end of the day to give reports. I dispense medications to my patients with my preceptor and throughout the day I perform whatever tasks need to be done. At the end of our shift my preceptor and I report off to the oncoming nurses.

Within almost all work settings there is a formal and informal power structure.When you have a formal power structure this means someone was specifically assigned to be in charge, delegate tasks etc. An informal power structure on the other hand is when a group follows and listens to one individual because that individual is respected. They were not assigned a position of power, rather they gained it through their peers. At my practicum setting I would say that it is more of a formal power structure setting. The nurse managers at my practicum facility are great though. There is one in particular who I really enjoy working with. Even though she is a manager and has say over everyone else she does not show it. She is always asking what she can do and there is nothing that she won’t help you with. If the floor is busy she will cover lunch breaks and really just helps wherever she can. Having strong leaders who are supportive and helpful allows for a cohesive work environment.

Working collaboratively is always the goal to providing the best patient care and there is always room for improvement. While call lights and bed alarms are put in place to ensure patient safety they are not always responded to quickly. Alarms are used for a variety of reasons to alert staff to the changes in patients’ status. Patients are weak and sometimes confused or recently had surgery, whatever the reason they need assistance. When a patient pushes the call bell or sets the bed alarm off the response time needs to be quick. They may try to get up on their own and this is when they could fall and get seriously injured. However, when staff is busy with other patients, response time is inconsistent and untimely.

 Studies have determined that the lack of timely alarm responses expose patients to significant dangers. The problem is that alarms are easily triggered leading to many false alarms. Daniels (2014) professional nursing article explained that another problem is nurses sometime forget to reset alarms or disconnect alarms that are consistently going off (p. 66). This regular bombardment of alarms has led to a condition known as alarm fatigue. A condition in which nurses get so used to hearing the alarms that they disregard or become immune to the sounding alarms. A Johns Hopkin study recorded 563 alarms sounded per patient in one day in the ICU (Daniels, 2014). While most alarms are not life threatening about 1% are significant. The Joint Commission found that failure to respond quickly to alarms accounted for 80 deaths out of 98 alarm related incidents. Patients who fall are also at risk for things like serious bleeding, opening wounds, osteoporosis fractures and prolonging their hospital stay. In 2013, alarm fatigue was named the number one technology hazard (Daniels, 2014). Educating nurses on response time is an important step to increasing patient safety.

 In some hospital environments, like the ICU, false alarms pull nurses away from high-priority tasks creating more patient safety hazards. Allan (2018) reported, “that for the fifth year in a row, reduction of clinical alarm harm is a Joint Commission National Patient Safety Goal” (p. 26). It has been found that alarm fatigue is caused by your brain not being able to process all the sensory information. As a result, sounds that don’t trigger a change in patient status are tuned out. With so many alarms and different alarm sounds going off daily important alerts can be missed. A QI project looked to establish if there was nurse awareness and if education or training would improve alarm fatigue. Twenty-three nurses participated in a pre-intervention nurse awareness survey and 13 agreed to participate in a post intervention survey. While the project focused on ICU nurses and had a small sample size it was determined that many nurses didn’t feel comfortable customizing alarm setting or understood alarm fatigue. After 8 weeks of education sessions there were clinical improvement in nurse awareness and reduction in alarm fatigue. The nurses participated in making educational posters, reviewing alarm data, discussing articles on alarm fatigue and exploring alarm management strategies. Weekly one-one beside sessions also provided promising interventions to improve nurse awareness and compliance.

 In 2018, Oliveira, Machado, Santos and Almeida conducted a quantitative and observational research that looked at the response time of health professionals before sound alarm activation in an adult intensive care unit. Observations were conducted for 1 hour and data was collected during the morning shift over a seven-day period. In the 20 bed unit observers turned on a stopwatch and noted motive, the response time and the professional conduct.  All staff was observed and consisted of two nurses, ten technicians, two doctors, two physical therapists and a resident doctor on each shift. Any alarms that went off due to handling of patients were not included in the data. When alarms went off the observers turned on the stop watch and watched carefully for the conduct of health professional before the alarms, recorded response time and their analysis. The study found that out of 103 activations, 66.03% of the alarm sounded for more than 10 minutes and less than 26% were responded to in less than 5 minutes (Oliveira et al., 2018, p. 3037).  These findings clearly outline that patient safety is at risk. For example, a response time after ten minutes can cause irreversible damage for a patient in cardiopulmonary arrest. The research supports alarm fatigue and the desensitization caused by noise levels and continuous alarm soundings from machines like infusion pumps. The study’s limitations including collecting data from one location and having researchers present however, its findings are similar to many other studies. The results showed the delay in response time before the monitoring sounds alarm can cause important alarms to be underestimated and puts patients at risk.

Another study examined the response time in a pediatric intensive care unit and the general ward at a children’s hospital. The researchers looked to find if there was a connection between the exposure of nonactionable physiologic monitor alarms and response time. The PICU nurses usually had 2 patients while nurses in the medical ward had up to 4 patients. Using video recordings and time stamped data the nurses’ responses to alarms were recorded. The nurses were also asked to fill out a questionnaire to see if they felt like their performance differed because they knew they were being taped which 36 said yes. Over 210 hours, 20 sessions in the PICU and 20 sessions in the general ward were filmed. Tapping occurred Monday through Fridays from 9:00 AM to 6:00 PM. The median years of nursing experience was 4.8 years and the patients median age for the general ward was 6 months and 2.5 years old for the PICU. The filming collected 4674 alarms with a median range of 75 per session (Bonafide et al., 2015, p. 348). After review, 12.9% of the alarms in the PICU were actionable while 1.0% were actionable in the general ward. Then the researchers compared the response time when the nurses were not in the room in relation to the number of nonactionable alarms that had gone off in the 120 minutes prior. The study found that the nurses’ response time to alarms while they were out of the room increased as the number of nonactionable alarms increased, supporting the notion of alarm fatigue (Bonafide et al., 2015, p. 349). As high as 90% of alarms are found to be nonactionable. The limitations to the study included no initial measures, sample size, awareness of tapping and the time frame which the data was taken.

The research studies and professional articles support the idea of alarm fatigue and how being slowly desensitized can occur. There needs to be increased awareness, education and procedures put in place to support health professionals in order to increase patient safety. Staff development on alarm fatigue should be implemented because many staff members may not even be aware of the concept. Education and hands-on training for nurses on effective response time but also on the correct handling of equipment. Proposals like having nurses and support staff complete rounds on patients more often and having bedside handoffs in patients’ room. The biggest change should come from improving the environment by implementing alarm-reduction strategies. As part of admissions both patients and family members could be educated on the appropriate use of the call light and reviewed with shift changes. Shutting off bed alarms for patients that don’t require them and new technology that offer alarm systems that turn off automatically when a patient’s status is not changing. Education and changes in practices will need to occur to make improvements.

The first steps to improving patient safety by reducing alarm fatigue is to develop a quality improvement team (QI) to help carry out improvement strategies. This multidisciplinary team should consist of nurses, physicians, medical assistants, clinical engineers, patient risk management, health educators, clinical leaders/nurse managers and medical director. The first steps would be to review the current process, gather input from staff and identify challenges. This could be done by using on-line surveys and observations completed by patient risk managers, nursing managers and educators. Using this information an implementation of alarm-reduction strategies should focus on alarm setting being set to the specific patient. This means changing alarm defaults to match the patient’s medical condition to reduce false alarms. Some alarms that are considered non-actionable could use a flashing light verse an audible alarm. Staff should also be encouraged to regularly replace electrodes and use proper skin prep procedures to cut down false alarms. These changes will require education on how and why to customize the alarm settings. The team’s clinical engineers are the ones most familiar with how monitors work and can help with staff training. While health educators and clinical leaders/managers should focus on educating staff on what is alarm fatigue and protocols. A plan that lays out procedures for response and levels of responsibility. So, who is responsible to respond first to alarms and who would be backup.

Another area that can lead to reducing false alarms is better communication at handoffs. Communicating with medical assistants on some floors to help with call lights and alarms could be helpful. Hospitals that have nursing aides can be trained to respond to call lights and help with personal assistance, bathroom assistance and accidental pressings. In some cases, they simply will just make sure the patient stays seated and waits for the appropriate assistance. Patients will know that they have been acknowledged and help reduce their frustration level which may cause them to repeatedly press the call light. Nurses can educate patients and family members on the appropriate use of the call light. This should be reviewed with shift changes but regular check-ins need to be incorporated. Patients are more likely to ask for assistance during check-ins and rounds while caretakers are in the room.

Helping to carry out the changes things like proper signage in patient rooms to remind patients proper use of call lights. A nurses’ sign off sheet so everyone knows when the last alarm setting was done, checked, or replacement of electrodes. This should also include the default setting and if any changes had occurred. Research has shown that steps to reduce false alarms and reduce unnecessary alarms will increase patient safety. Nurses and medical staff will be more responsive to actionable alarms with effective response time.

References

• Allan, S. H. (2018, May 10). Nurse perception of alarm fatigue impacts compliance with alarm management. Retrieved April 27, 2019, from https://www.americannursetoday.com/nurse-  perception-alarm-fatigue/
• Bonafide, C. P., Lin, R., Zander, M., Graham, C. S., Paine, C. W., Rock, W., … Keren, R. (2015). Association between exposure to nonactionable physiologic monitor alarms and response time in a children’s hospital. Journal of hospital medicine, 10(6), 345–351. doi:10.1002/jhm.2331
• Daniels, K. (2014, September). Fighting bed alarm fatigue in orthopedic units: Nursing2019. Retrieved April 27, 2019, from https://journals.lww.com/nursing/fulltext/2014/09000/
• Formal vs. Informal Power: Two Paths to Social Success. (2019). Retrieved from http://www.peopleskillsdecoded.com/formal-vs-informal-power/
• Oliveira, Adriana Elisa Carcereri de, Machado, Adrielle Barbosa, Santos, Edson Duque dos, & Almeida, Érika Bicalho de. (2018). Alarm fatigue and the implications for patient safety. Revista Brasileira de Enfermagem, 71(6), 3035 3040. https://dx.doi.org/10.1590/0034-7167-2017-0481
• Porter-O’Grady, T., & Malloch, K. (2016). Leadership in nursing practice: Changing the landscape of health care. Burlington, MA: Jones & Bartlett Learning.