Patient Safety Tip of the Week Archive

What’s New in the Patient Safety World

January 2024

Alarm Fatigue Better or Worse?

Alarm fatigue was the focus of our very first Patient Safety Tip of the Week almost 17 years ago. So, how are we doing in addressing this serious patient safety issue? Depends upon who you ask or where you work!

Rumpel et al. (Ruppel 2023) did a secondary analysis of the RN4CAST-NY/IL survey of registered nurses (RNs) working in 213 New York and Illinois hospitals. They evaluated associations between nurses’ reports of alarm burden (ie, feeling overwhelmed by alarms, delaying response to alarms, not responding to alarms, having work unnecessarily interrupted/delayed by alarms), appraisals of patient safety and quality of care, and hospital characteristics (eg, staffing, nurse work environment). They chose not to use the term “alarm fatigue”, instead using “alarm burden” as nurses’ perception of alarms as burdensome in their day-to-day practice. Almost 4000 nurses responded to the survey (n=3986), 61.2% of whom worked on med-surg units.

The majority of nurses frequently or occasionally felt overwhelmed by the number of alarms they experienced (82.9%), delayed response to alarms because they were unable to step away from another patient or task (75.6%), and frequently or occasionally were in situations where a patient needed urgent attention but no one responded to the alarm (55.4%). Forty-six per cent of nurses reported having work frequently or occasionally interrupted or delayed by false, non-actionable or non-urgent alarms. Nurses with over 10 years of experience were somewhat less likely to feel overwhelmed. Nurses on med-surg units experienced alarm overwhelm, delayed responses to alarms, and encountered situations where no one responds to patient alarms at significantly higher rates than nurses working in ICU’s. However, ICU nurses were significantly more likely to report having work interrupted by alarms (49.4% vs 43.9%, p<0.001).

The authors then compared nurse-reported alarm burden with measures of patient safety and quality of care. Poor patient safety grade and poor/fair quality of care ratings were both significantly associated with higher rates of nurses who felt overwhelmed by alarms, delayed responses to alarms, encountered situations where no one responds to patient alarms, and had work interrupted by alarms. Most strikingly, the proportion of nurses who gave their hospital a poor safety grade and reported frequently or occasionally encountering situations where no one responds to an alarm was nearly double that of nurses who gave their hospital a good safety grade (72.0% vs 38.4%, p<0.001). A similar finding was noted for overall quality of nursing care. Perceptions of high alarm burden were, in general, more frequent among nurses working in hospitals characterized by poor nurse work environments and staffing inadequacy.

Additionally, nurses who frequently or occasionally felt overwhelmed by alarms reported more missed care activities on average than those who rarely or never felt overwhelmed by alarms.

The authors note that their results demonstrate that nurse-reported alarm burden may be most pronounced outside the ICU. They note that, as monitoring technologies become less expensive and more compact, continuous monitoring is increasingly being adopted in non-ICU hospital settings, often with little regard for the impact of alarm burden on nursing. In addition, nurses outside the ICU typically care for more patients at a time, which may contribute to their reports of high alarm burden.

They conclude that the problem of alarms cannot be solved in isolation and must be addressed concurrently with foundational issues such as improving nurse staffing and work environments.

A less dire picture is painted in an article in AACN Advanced Critical Care. Albanowski et al. (Albanowski 2023) acknowledge that alarm fatigue is still a safety problem but highlight many of the advances in alarm management that have been implemented since publication of a seminal article on alarm fatigue 10 years ago (Sendelbach 2013). They note that alarm fatigue occurs when a user becomes desensitized to alarms as a result of excessive nonactionable alarms, ultimately resulting in a delayed or no response. They cite statistics we often use – that one study found 85% of ICU alarms to be clinically nonactionable and that studies in a pediatric ICU found only 13% of alarms to be actionable, and only 1% of alarms on the general pediatric floor were actionable. They also note a similar impact from invalid alarms (such as those occurring as the result of device artifact or error, such as an electrocardiographic result reporting ventricular tachycardia when the patient is actually in sinus rhythm and just has a loose ECG lead).

They go on to highlight an alarm management strategy released by the AACN in 2013 (AACN 2013, Turmell 2017) and updated in 2018 (AACN 2018) that has been used by clinical groups to successfully reduce the quantity of nonactionable alarms.

The Albanowski article has good discussions on:

· Measurement of Alarm Fatigue

· Individualizing and Redesigning Alarm Parameters

· Interprofessional Teams

· Engineering Interventions to Reduce Alarm Fatigue

· Multisensory Alarms

· Smart Alarms

They conclude that much progress has been made in the past 10 years to address alarm fatigue but that more work needs to be done.

Our many columns on alarm fatigue listed below tell us that alarm fatigue impacts not only nursing care but many other facets of patient safety. We also do a course “Why Accidents Happen” and highlight alarm fatigue as a contributing factor in accidents in many other industries and non-healthcare settings. Alarm fatigue remains an issue we must constantly be vigilant for and take steps to minimize its impact.

Prior Patient Safety Tips of the Week pertaining to alarm-related issues:

March 5, 2007 “Disabled Alarms”
March 26, 2007 “Alarms Should Point to the Problem”
April 2, 2007 “More Alarm Issues”
June 19, 2007 “Unintended Consequences of Technological Solutons”
April 1, 2008 “Pennsylvania PSA’s FMEA on Telemetry Alarm Interventions”
February 23, 2010 “Alarm Issues in the News Again”
March 2, 2010 “Alarm Sensitivity: Early Detection vs. Alarm Fatigue”
March 16, 2010 “A Patient Safety Scavenger Hunt”
November 2010 “Alarms in the Operating Room”
February 22, 2011 “Rethinking Alarms”
February 2013 “Joint Commission Proposes New 2014 National Patient Safety Goal”
May 2013 “Joint Commission Sentinel Event Alert: Alarm Safety”
July 2, 2013 “Issues in Alarm Management”
August 2013 “Joint Commission Formalizes 2014 NPSG on Alarm Management”
February 4, 2014 “But What If the Battery Runs Low?”
October 2014 “Alarm Fatigue: Reducing Unnecessary Telemetry Monitoring”
December 15, 2015 “Vital Sign Monitoring at Night”
February 9, 2016 “It was just a matter of time…”
August 16, 2016 “How Is Your Alarm Management Initiative Going?”
February 21, 2017 “Alarm Fatigue in the ED”
April 18, 2017 “Alarm Response and Nurse Shift Duration”
April 25, 2017 “Dialysis and Alarm Fatigue”
October 17, 2017 “Progress on Alarm Management”
November 21, 2017 “OSA, Oxygen, and Alarm Fatigue”
May 1 2018 “Refrigerator Alarms”
April 16, 2019 “AACN Practice Alert on Alarm Management”
September 2019 “Alarm Fatigue in the Emergency Room”
October 8, 2019 “Another Freezer Accident”
June 23, 2020 “Telemetry Incidents”
August 2020 “Pulse Oximetry in Children”
September 15, 2020 “An Eerily Familiar Incident”
January 26, 2021 “This Freezer Accident May Cost Lives”
February 7, 2023 “Reducing Unnecessary Telemetry”

References:

Ruppel H, Dougherty M, Bonafide CP, et al. Alarm burden and the nursing care environment: a 213-hospital cross-sectional study. BMJ Open Quality 2023; 12: e002342

https://bmjopenquality.bmj.com/content/12/4/e002342

Albanowski K, Burdick KJ, Bonafide CP, et al. Ten Years Later, Alarm Fatigue Is Still a Safety Concern. AACN Adv Crit Care 2023; 34 (3): 189-197

https://aacnjournals.org/aacnacconline/article/34/3/189/32176/Ten-Years-Later-Alarm-Fatigue-Is-Still-a-Safety

Sendelbach S, Funk M. Alarm fatigue. AACN Adv Crit Care 2013; 24(4): 378-386

https://aacnjournals.org/aacnacconline/article-abstract/24/4/378/14745/Alarm-FatigueA-Patient-Safety-Concern?redirectedFrom=fulltext

American Association of Critical-Care Nurses. Practice alert: alarm management. Crit Care Nurse 2013; 33(5): 83-86

https://aacnjournals.org/ccnonline/article-abstract/33/5/83/20417/Alarm-Management

Turmell JW, Coke L, Catinella R, Hosford T, Majeski A. Alarm fatigue: use of an evidence-based alarm management strategy. J Nurs Care Qual 2017; 32(1) :47-54

https://www.ingentaconnect.com/content/wk/ncq/2017/00000032/00000001/art00010

American Association of Critical-Care Nurses. Managing alarms in acute care across the life span: electrocardiography and pulse oximetry. Crit Care Nurse 2018; 38(2): e16-e20

https://www.aacn.org/clinical-resources/practice-alerts/managing-alarms-in-acute-care-across-the-life-span

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