Obstacles and Solutions for Healthcare Professionals (HP)’s understanding and response to monitor alarms:
A literature Review
Abstract: The alarm systems employed in the intensive care unit (ICU) are vital for patient care and safety. They give readings for heart rate, oximetry and the cut-offs for the alarms are set by the individual or the manufacturer. There have been adverse events associated with alarms systems and recently, it has become a serious health hazard. The purpose of this paper is to review the literature for healthcare professionals’ (HP) understanding and response to monitor alarms in the hospital and any solutions proposed.
The alarm systems give readings of many physiological variables including heart rate, respiratory rate, oximetry and the cut-offs for the alarms are set by the individual or the manufacturer(2). These alarms can also be silenced. The machine employed in NICU in CUMH contains a Stop and Pause function(2). The Pause function silences all alarm parameters for 2 minutes, whereas the stop function silences only one particular alarm parameter for 1 minute. There is also a setting known as ‘Extreme alarm’, which alerts the HP when the particular physiological variable has gotten worse (eg oxygen saturation has been gotten less than 80% for neonates in CUMH). The reason for such functions (ie stop and pause) is that an alarm may not be deemed serious by the HP and the HP may decide to ‘wait and see’ if this is just an isolated incident. Also, alarms may not be as serious and the HP may deem it to be a ‘false positive (FP)’. This is because the alarms are just one input of information for the HP and he/she takes into account other inputs, such as clinical context(3). Also, the patient population itself in the ICU is to be considered. For example, it is common for neonates to have episodes of tachycardia and as such, isolated incidents would not cause the HP to be worried about patient. Rather, the alarms become worrisome if the variables are not coming back to normal limits (i.e. assessing if the alarms are continuing to sound as opposed to being an isolated incident)(2).
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The alarms are aimed to have a high specificity so that a true event is not missed. However, this can be burdensome. In a day in the ICU, this could translate to 187 alarms/bed, of which majority are false positive alarms(4). Another study found that for a cardiac surgery, roughly 1 alarm would go off every minute and approximately 80% of the alarms had no practical benefit (i.e. no clinical action could be taken)(5).
Alarm systems can lead to adverse events and in 2010, alarm hazards was amongst the top 10 technology health hazards and in 2012, it had surpassed the others to become the leading technology health hazard(6, 7). The potential consequences of adverse events can be fatal as one of the databases for the FDA had reported that in a span of 3 years, from 2005 to 2008, there were 566 deaths related to monitor device alarms(8). In Ireland (NICU in CUMH), a neonate could have been hypoxic after a prolonged period due to misunderstanding of alarms, highlighting the global scale of such a problem(2).
This literature review was aimed to see if there are any papers dealing with HP’s understanding and response to monitor alarms in critical care setting and ways in which it is affected. Response and understanding in this paper refers to whether the staff: (i) responded/became aware of the alarm and (ii) carried out the correct response based on the alarm that sounded. These specifically are:
- Factors affect their response and understanding
- Effects of in-adequate response and understanding
- Solution(s) proposed to improve response and understanding
- Difference in understanding after stratification: between doctors and nurses, between specialties of ICU (e.g. CCU vs NICU)
The conclusions drawn from the review will give insight into audits carried out in CUH regarding monitor alarms and solutions to ‘close the audit loop’. It will also allow for comparison of HP’s understanding in CUH to others hospitals.
Papers that dealt with the following:
- HP’s understanding/interaction with monitor alarms
- Alarms employed in Hospital (as opposed to ambulatory care)
The following databases were searched: PubMed, Cochrane Collaboration. Preference was given to most recent articles as well as review articles. Abstracts were reviewed and if they met inclusion criteria, they were read. Filters applied: ‘English’, ‘Full Text available’, ‘Human’
Search terms entered included: ‘Monitor Alarms’, ‘Monitor alarms + Understanding’, ‘Monitor Alarms + Fatigue’, ‘Alarms’.
Cochrane database yielded no articles with any of the search terms, except ‘alarms’( which yielded articles, but they had no relevance to topic).
Alarm fatigue and its effect on HP’s understanding
Alarms, by their nature, are in place to alert the staff that the patient needs attending to and have limits set in place such that a true event is not missed. As a result, they have a tendency to stuffer from a high false positive rate (FP) and thus, poor positive predictive value (PPV)(9). Clinically insignificant and/or FP alarms range from 80-99%(9, 10). Another study done showed the PPV to be as low as 27%(11). This contributes to staff not being aware of the alarms (desensitization), mistrust in the alarms and not responding to them(3, 9). As stated earlier, 566 alarm related deaths were reported to FDA from 2005 to 2008(8).
Alarms can be induced by patient motion, which further contributes to false alarms(12). These cases can be avoided by staff silencing the alarms for a set period of time prior to moving the patient(11).
Due to the high FP rate of alarms, the more reliable the alarm is (i.e. how well it predicts true alarm), the higher the response will be from staff(9). Also, the factors that determine response can be divided into: intrinsic to the alarm itself and extrinsic.
Internal factors are whether alarm continues to sound or it ceases to sound soon (i.e. alarm duration). Also, the more ‘rare’ or unlikely for an alarm to go off, the more it would warrant a response. The limits set by the staff for the alarm may not be appropriate for the given patient resulting in having too many alarms that are not actionable(5).
Extrinsic factors to an alarm are: work load, task complexity, patient condition. The higher the workload or task complexity, HP’s have a lower tendency to react to it. The opposite is true for the more severe the patient’s condition is(3, 9).
Solutions proposed to improve response and understanding:
To reduce the high FP rate, and ultimately, improve alarm response, different solutions have been proposed in the literature. Since alarms often self-correct, by adding a delay time to the alarms before they sound can reduce the number of alarms themselves(11). ‘Smart Alarms’ can be introduced that have algorithms in place that will alert only if it is a true alarm(9). These systems take trends into account as opposed to raw data itself. Increasing the ‘volume’ of alarms higher than environment was recommended (as opposed to having a fixed dB level for an alarm sound)(13). This is supported by the fact that sound may not be heard due to: room doors closed, events such as noise produced by machines that clean the floors(14). It is further supported by the fact that most hospitals have exceeded the noise levels recommended by WHO, and as such, the volume of the alarm should be customized to the environment to ensure it is heard(15). However, other literature favours different modalities of alarms (i.e. visual or vibrating), since the noise contributes to symptoms in staff such as fatigue and concentration problems(16). Standardization of alarm sounds would decrease the number of alarm sounds the HP’s have to ‘learn’(17). Another solution proposed has been to have a central notification centre as opposed to a staff monitoring patient(s)when their alarms go off, which was reported to be advantageous.
Alarm limits should be changed to levels by HP’s taking into account: if the alarm goes off, it will require some sort of clinical action, and the patient’s specific condition(s)(9). This is in contrast to when HP’s do not change limits and keep to default levels set by manufacturer, which are set to different values depending on the country (18). Customizing limits will decrease the alarm load and increase sensitivity to alarms by healthcare staff(18).
Ongoing training should be provided to the staff with an aim to have the training environment as closely simulating the real clinical environment as possible(9). Training in the form of showing staff how to troubleshoot alarms should also be implemented. Alarms that have built in ‘intelligent system’ to assist in troubleshooting have shown to be beneficial. In a simulated environment, intelligent alarms helped the anaesthetists solve various breathing circuit faults 62% faster (45 sec to 17 sec)(19).
Pros and Cons of Literature:
There is evidence in the literature on the potential adverse events of alarms and reasons for such events and the severity of this problem. Solutions to improve understanding were also given.
There was no study found that dealt with whether staff understood how to operate the alarms properly and to what extent did this problem exist. Information related to the severity of the problem only indicated a problem in understanding and response. However, there was no mention of whether any of the deaths were due to the HP’s not knowing what buttons to press once the alarm came on (eg did they silence the alarm for too long without knowing). This could be a potential barrier in improving understanding since solutions such as ongoing teaching can not be customized effectively.
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The review of the literature has only taken data from nurses or doctors, but not both. Therefore, comparisons in understanding between doctors and nurses could not be made. Majority of data and studies was done on nurses. However, this is expected since nurses would’ve interacted with the alarms more frequently than doctors since they are more frequently at the bedside of the patient and are the first to react to any alarms of the patient.
Also, no studies have been found to compare understanding between HP’s of different specialties. It would be expected that any critical unit, regardless of specialty, would’ve had the same obstacles to monitor alarm understanding since the reasons for alarm fatigue are the same across the specialties. However, knowing of such studies would yield information about which alarm(s) specifically do the staff understand better or worse? Also, there is a possibility that the understanding diminishes when certain machine alarms are simultaneously on (e.g. ventilator machine as well as monitor alarm). As a result, training could be tailored to each specialty and emphasis placed on areas where their understanding is not sufficient.
The literature review suggests that the level of monitor alarm understanding and response is not sufficient. Also, this problem of monitor alarm response and understanding is serious and not to be taken lightly. In terms of barriers in response and understanding, they include: too many alarms as well as types, low PPV of alarms, inappropriate limits. Also, no studies have been found that stratify this understanding based on staff (ie doctors or nurses) or specialty (e.g. CCU vs NICU). Moreover, the reasons identified for barriers in understanding of alarms did not appear to be different between doctors and nurses. No studies have been found that assess, specifically, whether the HP knew difference in operating the alarm system itself (ie did they press correct button to silence an alarm). The studies looked at whether they reacted to the alarms and if they did, did they carry out the correct response.
Solutions proposed include: incorporating delays, having smart alarms, using different modalities for alarms as well as having continuous teaching.
HP’s use alarms as one of the inputs in their decision making process. While alarms are there to alert of any physiological variable crossing a limit (in order to not miss a true event), this leads to the PPV being compromised and as such, the confidence and response to such an alarm decreases. Thus, moving forward, it is essential that strategies are aimed to increase the PPV of alarms, decrease the number of alarms themselves, and incorporate continuous teaching to ensure that the input alarms give holds more weight for the HP in the decision making process.
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5.Schmid F, Goepfert MS, Kuhnt D, Eichhorn V, Diedrichs S, Reichenspurner H, et al. The wolf is crying in the operating room: patient monitor and anesthesia workstation alarming patterns during cardiac surgery. Anesthesia and analgesia. 2011 Jan;112(1):78-83. PubMed PMID: 20966440. Epub 2010/10/23. eng.
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10.Lawless ST. Crying wolf: false alarms in a pediatric intensive care unit. Critical care medicine. 1994 Jun;22(6):981-5. PubMed PMID: 8205831. Epub 1994/06/01. eng.
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12.Chambrin MC, Ravaux P, Calvelo-Aros D, Jaborska A, Chopin C, Boniface B. Multicentric study of monitoring alarms in the adult intensive care unit (ICU): a descriptive analysis. Intensive care medicine. 1999 Dec;25(12):1360-6. PubMed PMID: 10660842. Epub 2000/02/08. eng.
13.Minoru H, Eiji S, Mototake T, Kenichi K, Hirosuke K, Satoshi W. Characteristics of Auditory Alarms for Medical Equipment and Future Issues. Journal of Clinical Engineering. 2005;30(4):208-.
14.Sobieraj J, Ortega C, West I, Voepel L, Battle S, Robinson D. Audibility of patient clinical alarms to hospital nursing personnel. Military medicine. 2006 Apr;171(4):306-10. PubMed PMID: 16673744. Epub 2006/05/06. eng.
15.McLaren E, Maxwell-Armstrong C. Noise pollution on an acute surgical ward. Annals of the Royal College of Surgeons of England. 2008 Mar;90(2):136-9. PubMed PMID: 18325214. Pubmed Central PMCID: Pmc2443309. Epub 2008/03/08. eng.
16.Ryherd EE, Waye KP, Ljungkvist L. Characterizing noise and perceived work environment in a neurological intensive care unit. The Journal of the Acoustical Society of America. 2008 Feb;123(2):747-56. PubMed PMID: 18247879. Epub 2008/02/06. eng.
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18.Block FE, Jr., Nuutinen L, Ballast B. Optimization of alarms: a study on alarm limits, alarm sounds, and false alarms, intended to reduce annoyance. Journal of clinical monitoring and computing. 1999 Feb;15(2):75-83. PubMed PMID: 12578080. Epub 2003/02/13. eng.
19.Westenskow DR, Orr JA, Simon FH, Bender HJ, Frankenberger H. Intelligent alarms reduce anesthesiologist’s response time to critical faults. Anesthesiology. 1992 Dec;77(6):1074-9. PubMed PMID: 1466459. Epub 1992/12/01. eng.
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