Hospital records over 2.5 million patient monitor alarms in one month
27 October 2014
A study of five intensive care units in the University of California, San Francisco (UCSF), Medical Center over 31 days recorded 2,558,760 unique alarms. Many were caused by a complex interplay of inappropriate user settings, patients’ conditions and computer algorithm deficiencies.
The alarms include a subset of 1,154,201 arrhythmia alarms, of which 88.8% were false positives caused by computer algorithm deficiencies. The data came from electrocardiogram (ECG) leads; pressure, blood oxygen saturation and respiration waveforms; and user settings and alarms, among other technology.
Following the study, researchers at UC San Francisco have comprehensively defined the detailed causes as well as potential solutions for the widespread issue of alarm fatigue in hospitals.
Their study is in the Oct 22 issue of PLOS ONE and is available online.
Alarm fatigue occurs when clinicians become desensitized to the constant noise of alarms and ignore them or turn them off. Among the numerous detrimental results are anxiety in hospital staff and patients, sleep deprivation among hospitalized patients, and missed life-threatening heart rhythm events.
The issue of alarm fatigue has become so significant that The Joint Commission, a national organization that accredits hospitals, named it a National Patient Safety Goal. This goal requires hospitals to establish alarm safety as a priority, identify the most important alarms and establish policies to manage alarms by January 2016.
“There have been news stories about patient deaths due to hospital staff silencing cardiac monitor alarms and alerts from federal agencies warning about alarm fatigue,” said senior author Barbara Drew, PhD, RN, David Mortara Distinguished Professor in Physiological Nursing in the School of Nursing at UCSF. “However, there have been little data published on the topic to inform clinicians about what to do about the problem. Our study is the first to shed light on cardiac monitor alarm frequency, accuracy, false alarm causes and strategies to solve this important clinical problem.”
Based on these findings and earlier studies, the researchers suggest that medical devices focus on using all available ECG leads to identify the non-disruptive leads and the leads with adequate QRS waveform amplitude. These devices also should provide prompts to aid in more appropriate tailoring of alarm settings to individual patients. And, atrial fibrillation alarms should be limited to new onset and termination of the arrhythmia, with delays for ST-segment and other parameter alarms able to be configured.
“Nurses and patients are barraged by a staggering number of monitor alarms that could be resolved by improved computer algorithms,” Drew said. “Our results shed light on the high prevalence of alarms that are mostly false and provide insights into the causes of so many false alarms, along with suggestions for device improvement.”
Drew and her colleagues anticipate their study will be cited by current working groups attempting to solve alarm fatigue, led by The Joint Commission, the Association for the Advancement of Medical Instrumentation (AAMI), the International Society for Computerized Electrocardiology (ISCE), the Emergency Care Research Institute (ERCI), the American Heart Association, and the U.S. Food & Drug Administration (FDA) Center for Radiological Devices & Health.
“Because computer devices are more reliable than humans, an opportunity exists to improve physiologic monitoring and reduce alarm fatigue,” the authors write.