Hospitals across the country continually deal with alarm fatigue, an issue borne out of well-meaning but ultimately misguided attempts to monitor patient safety, and the results of simply having too many alerts can, in the worst-case, be deadly or near deadly.
At a minimum, the issue can significantly impact work flow at busy hospitals, prompting nurses to tune out one too many alerts.
At Lucile Packard Children’s Hospital, part of Stanford Healthcare, a pilot project is underway to curb the fatigue by re-defining guidelines on vital signs that trigger alarms. It’s an issue for all hospitals, but with chidlren’s hospitals in particular given the level of complexity for their patients, according to Dr. Veena Goel, a fellow in clinical informatics and pediatric hospital medicine fellow at Lucile Packard.
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“The issue of alarm fatigue is very real for our patients and their providers,” she said. “We did an audit of our med-surge floor and found that 2,000 alarms go off any given day. This is just med-surge.” So across an entire hospital, the number is significantly higher.
The issue is big enough for the Joint Commission to weigh in for accreditation, calling it a “frequent and persistent problem.” Last year, hospitals started to be required to establish alarms as a priority. Starting in 2016, hospitals are expected to implement specific procedures addressing the matter.
“It is estimated that between 85 and 99 percent of alarm signals do not require clinical intervention, such as when alarm conditions are set too tight,” the commission said in an alert to accredited hospitals. “Default settings are not adjusted for the individual patient or for the patient population; ECG electrodes have dried out; or sensors are mis-positioned. As a result, clinicians become desensitized or immune to the sounds, and are overwhelmed by information – in short, they suffer from ‘alarm fatigue.’”
Part of the problem, Dr. Goel said, is that every hospital operates according to its own metrics – there is no industry standard, and what triggers an alarm for adult patients at, say, a trauma center, is vastly different from that of an eight-year old with a chronic or rare condition, or even a healthy eight-year old.
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Lucile Packard, in response, looked at about 100,000 measures across a 7,000 patient sample size over a year, just on its med-surge floor, to best determine what signs should actually trigger an alarm. Particularly with issues like heart rate and respiratory rate, the differences are often vast, and the hospital, like many, was going off of signs not tailored to the patients.
“We stratified it all by age,” Dr. Goel said. “Our vital signs were very different from the ranges we used. If we use these new numbers that caused alarms, 50 percent of all of our kids would alarm. When we created these new data-driven signs, we could drop that number in half – that was enough evidence to say we should change our reference rates.”
“What we’ve done here is custom tailor it for the children we care for and the numbers are recorded off of them in real time,” she added.
In its alert to some 3,300 accredited hospitals, the Joint Commission cites the seemingly arbitrary measures that prompt alarms. It also notes that it’s “Sentinel Event database” includes reports of 98 “alarm-related events” between 2009 and 2012, with 80 such events resulting in death, 13 in a permanent lost function and five in unexpected additional care or extended stay.
That means a lot of additional cost in the healthcare systems, in addition to the obvious issues of patient safety.
Similar efforts at Children’s Hospital of Philadelphia and Cincinnati Children’s Hospital have been undertaken to cut down on the issue, and Dr. Goel said Lucile Packard hopes to help bring wider attention to the matter upon finishing its pilot, perhaps even helping to craft best practices for children’s facilities.
Dr. Goel said Lucile Packard would like to expand its pilot to other departments across the hospital, and that it hopes it can help establish at least a baseline on a broader level. But every hospital is different and will need to have some level of customization, the Joint Commission said.
Fundamentally, Dr. Goel said the effort is about using the best data to address a vexing problem in healthcare.
“We actually have a really unique system set up through information services,” she said. “Every bedside in the hospital downloads its data, including alarm data, on a minute-by-minute basis, into a data warehouse. We learned recently that we have over seven years of minute-by-minute bedside alarm information on ever data. It’s given us a really unique way to study alarms and make them more meaningful for our patients.”