Wednesday, April 6, 2011

The background of alarm fatigue in hospitals

Alarm FatigueBackground of the problem of alarm fatigue

According to the Boston Globe, between 2005 and 2010, more than 200 hospital patients died nationally from an improper response to “patient monitors.” Patient monitors are those machines that keep track of heart function, respiratory rate and other vital signs. Typically, nurses are responsible for watching monitors.

“Alarm fatigue,” a phenomenon where nurses become desensitized to frequent monitor beeping and constant false alarms, may contribute to instances of nursing negligence. A study at Johns Hopkins Hospital in Baltimore revealed 942 critical alarms on one floor, in one day. “That’s one alarm every 91 seconds,” said New York hospital negligence lawyer Michael A. Bottar, Esq., of Bottar Leone, PLLC, a Syracuse based law firm representing patients injured due to hospital mistakes and errors.

“The alarms become background noise,” Bottar said. In one case, a patient who was wheeled into an intensive care unit and connected to a cardiac heart monitor. The leads slipped off and the machine sounded an alarm, but nursing staff did not respond. The patient stopped breathing and died without anyone noticing. At a different hospital, a patient’s heart monitor displayed a flat line for more than two hours because the battery was low. Even though they were checking on the patient, the nurses did not change the battery. The patient suffered a heart attack without anyone knowing, and died.

Nurses work in a loud, busy and often over-stimulating environment. As there are only so many nurses to care for the patient population, when machines are simultaneously emitting a “low-priority alarm (e.g., a low battery) and a “high-priority alarm” (e.g., a cardiac arrest), the high-priority alarms receive greater attention. The low-priority alarms get attention when there is time. But low-priority alarms, such as those indicating low battery power, need attention too. Bottar added, “there is no way to monitor for a heart attack, or low blood sugar, or low oxygen saturation, if the monitor is off.”

In one extreme case, a cardiac monitor blared 19 dangerous arrhythmia alarms for nearly 2 hours before staff silenced the alarms temporarily without treating the patient, who died. In other instances, staff have mis-programmed complicated monitors or forgotten to turn them on.

Southcoast Health System, which manages Tobey Hospital, is hiring nurses and giving them one assignment: responding and monitoring patient monitors. It has also established a policy that monitor batteries must be changed at a certain time each day.

At UMass Memorial Medical Center in Worcester, the hospital wants to eliminate unnecessary monitoring and has implemented new guidelines for when doctors should order cardiac monitoring. Among other changes, nurses are now receiving low-battery warnings about patients on their pagers and cell phones.

As hospitals make these changes, manufacturers are assessing their equipment and working on new "smart monitor" technology. Rather than measure just one symptom, the hope is these new monitors would assess multiple parts of the body before determining whether an alarm needs to sound. For its part, the Food and Drug Administration recently distributed videos about defective medical alarms and proper use to 4,500 hospitals and nursing homes.

“As is frequently the case, the health care industry can learn from the experience of the aviation industry,” Pronovost and Mathews write. “When a major airline wants an aircraft for its fleet, it does not painstakingly assemble it by deciding which seats, control systems, engines, communications systems, oxygen masks and other components to use. The airline does not try to determine the best way for these and hundreds of other components to fit together; rather, it relies on an industry integrator (such as Boeing) to build a low-cost, high-quality aircraft that is safe and meets the needs of its end users. The result is a lower-cost, higher-quality airplane with components that work together. Health care needs a similar systems-integration approach.”

Want to read more about a though process behind the solution?

Thomas J Balkin wrote a great scientific publication discussing this topic titled "The challenges and opportunities of technological approaches to fatigue management" last month.

There are a number of different strategies to mitigate the effects of alarm fatigue in hospital settings. Many are centered on regulatory or organizational approaches, such as work scheduling restriction and employer screening practices. While these generally benefit safety and productivity, there are clearly limitations to these approaches. Technologies that objectively detect or predict operator fatigue may be used to effectively complement or even supplant organizational or regulatory approaches. Over the past decade and a half, there have been considerable advances in relevant technologies, including onboard devices that monitor drivers’ state or level of performance as well as devices that predict fatigue in advance of a work cycle or trip. In this paper, we discuss the challenges and opportunities for technological approaches to fatigue management, beginning with a discussion of the “ideal” system, followed by some of the general issues and limitations of current technologies. We also discuss some of the critical and outstanding issues related to the human interaction with these systems, including user acceptance and compliance. Finally, we discuss future directions in next generation technology for fatigue management.