Monday, April 25, 2011

Alarms! Sounding the Alarm on Alarms, Finally

“Patient alarms often unheard, unheeded” states a recent headline in the Boston Globe. Now the Joint Commission and the FDA are going to target “alarm fatigue” as a patient safety priority. Apparently it is not a very high priority as the article describing the effort states that the two organizations will be meeting “over the next few months” to “pinpoint a strategy.”

My question is, where has everyone been? This issue has been apparent for years to anyone who has ever worked in an intensive care unit. Walk into any ICU and within 30 seconds, you will hear an alarm sound its annoying bleat and see the staff going about their business without a second thought.

As far back as the early 1990s, studies documented the issues. There are too many alarms. In 1994, researchers from Ohio published a study in which they played some 33 different common alarm tones for 100 ICU staff members. Only 50% of them were able to identify the source of each alarm. The authors concluded that there were too many alarms for even experienced staff to identify and proposed that alarms should be used for only critical problems.

Another 1994 study from a pediatric ICU observed alarm activity over a week’s time. They noted that of 2,176 alarm soundings, 68% were false, 26.5% were induced by staff dealing with patients and only 5.5% were actually significant.

An interesting study performed on college students in 1995 showed that people respond to alarms on the basis of their expectations. In other words, if an alarm is known to usually be false, the individual is less likely to respond to it. Obviously, if 95% of alarms in an ICU are false, the staff will be conditioned to ignore them.

There have been many other papers on the subject documenting the above as well as the stress on the staff that the constant level of noise produces.

In 2011, the problem is even worse as more and more devices have related alarms. For example, the push to prevent patient falls has prompted the invention of the bed alarm. Some of these alarms are so sensitive that the mere touching of the bed by staff triggers the alarm.

The solution to the problem of alarm fatigue is not simple. Every new device seems to come with its own random noise and sound level. A concerted effort by device manufacturers, regulatory agencies and hospitals is needed. My suggestion is to 1) scrap all current alarms and develop standardized tones for a select few important events and 2) improve the sensitivity of triggers to reduce the false alarm rate. Good luck.


Mike said...

I think a different technique for reporting alarms is in order. If there could be a large screen of some kind, similar to an airline gate status board, that's visible in the hallway to passersby and particularly in view of the desk person -- incoming alarms of any kind could be displayed in large print and what type of alarm, and perhaps flashing if critical. A soft tone could indicate that a new alarm has been triggered, prompting the desk person to glance up at the board and page/direct staff as needed. The biggest problem with this might be getting each device to relay the needed information to the receiver, since I'm sure most devices are from varying manufacturers and lack a universal reporting standard..

Farm said...

Unfortunately, auditory fatigue, or auditory desensitization, occurs in many working environments where auditory perceptual needs go unmet. Poor auditory environments challenge our ability to understand a situation, make appropriate decisions, and respond in a timely manner. Fortunately these challenges can and should be addressed through appropriate auditory system design. Check out some of the solutions suggested & feel free to comment.

Skeptical Scalpel said...

Thanks to Mike and Farm for the thoughtful comments. Farm, you make some good points in your blog. Now, if only someone would listen [pun intended].

anarchic teapot said...

Not just auditory fatigue, you also get too many lights (so one more coming on or flashing can pass unnoticed). It's a well-known and well-documented phenomenon, and has been for years. Same with the "crying wolf" problem (oversensitive or unnecessary alarms).

I find it scary that such a situation should have been allowed to grow up in the first place.

Felix said...

...alarms are present and frequent in the mission critical business of electricity and gas. In mechanical systems the voltage range is a plus/minus % variation in which equipment continues to operate within the range. Outside the range it may operate but equipment is stressed over time. Lights blink and alarms go off. However, the chief engineer is always present looking at his systems. Think Scotty in Star Trek. Same with hospitals. Thanks goodness.

At the macro level, an outage an outage; things are on or off. That's when disaster may strike. Hopefully backup systems are in place to ride through the event.

However, when humans operate the high voltage, there is no mercy in mission critical high voltage systems. Training and industry standards are key. If not, the human may perish. Attention to detail is important. Work is done in teams. Safety is #1. Same with hospitals.

My point is I agree with the Doctor. We need to rely on human observation, the analog not the digital The machine is just a tool. A series of terrible coughs is better than a series of beeps in understanding my sickness.

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