Wow! Two of our all-time favorite topics alarm fatigue and healthcare worker fatigue in the same column!
Researchers have just published a very revealing study on response times to alarms in a childrens hospital (Bonafide 2017). They used video monitoring to assess how long it took nurses to respond to physiologic monitor alarms and assessed the factors associated with those response times. Of 11,745 alarms among 100 children, 50 (0.5%) were actionable. That probably should not come as a surprise since previous studies have also demonstrated very high volumes of alarms that trigger for events for which no action is indicated, though the percentage of actionable alarms in this study is one of the lowest weve seen. In our February 23, 2010 Alarm Issues in the News Again where we discussed alarm fatigue we noted a study by Siebig and colleagues (Siebig et al 2010) in medical intensive care units that found only 15% of alarms were considered clinically relevant. Our November 2010 Whats New in the Patient Safety World column Alarms in the Operating Room noted another study (Schmid 2011) on 25 consecutive cardiac surgery cases. They noted an average of 1.2 alarms per minute and noted that approximately 80% of the alarms had no therapeutic consequences, a figure remarkably similar to that found in the Siebig study mentioned above. The 2013 Joint Commission Sentinel Event Alert on alarm safety cited the statistic that between 85% and 99% of alarm signals do not require clinical intervention. And in our August 16, 2016 How Is Your Alarm Management Initiative Going? we noted the study from researchers at UCSF (Drew 2014) in which 88.8% of the 12,671 annotated arrhythmia alarms were false positives. So the large number of non-actionable alarms in the Bonafide study should not surprise anyone.
But the Bonafide study went further and assessed factors that were associated with responses to alarms. Alarm responses were assessed only when the nurse was outside the room when the alarm triggered (note that the alarm system in this hospital sent a text message to responsible nurses for some of the more clinically significant alarms). The observed (unadjusted) median response time to out-of-room alarms was 7.0 minutes (range 5.2-8.8 minutes). The adjusted median response time among nurses was 10.4 minutes but varied considerably.
Do the long alarm response times in the Bonafide study surprise you? They shouldnt. We previously noted a hospital found it took an average of 9.5 minutes for a clinician to respond to high-priority alarms before it implemented better communications systems to dramatically improve the response times (TJC 2011). We suspect if you were to do your own observational study (either direct observation or video recording) you may find similarly long response times.
But perhaps the most striking finding in the Bonafide study was that each hour that elapsed during a nurses shift was associated with a 15% longer response time, In hour #2 the response time was 6.1 minutes on average, compared to 14.1 minutes in hour 8.
Though the authors noted that some nurse work shifts were 12 hours, they did not report results for shifts longer than 8 hours. It also would have been interesting to see if those nurses having rest breaks or nap breaks had shorter alarm response times.
Other factors were also important:
Interestingly, the number of non-actionable alarms to which the nurse was exposed in the preceding 120 minutes was not associated with response time.
It would have been interesting to see whether the number of consecutive days worked had any influence on nurse response time. Prior studies in other industries have demonstrated that more errors are made on each consecutive day worked, a phenomenon we refer to as the consecutive day phenomenon. A study on shift workers in fields other than healthcare (Folkard 2003) showed that the risk of incidents increased each consecutive day worked. For example, on average for night shifts risk was 6% higher on the second night, 17% higher on the third night, and 36% higher on the fourth night (for morning/day shifts the corresponding risks were 2%, 7% and 17%). Extrapolating, one might suspect that we might see fewer errors if you only have to work 3 straight days rather than 4 or 5. The Folkard study demonstrated that risks are not uniform throughout the day but are greater at certain times, especially at night, and even vary based upon temporal relationship to breaks. Those authors stress that all these factors (number of successive night shifts, length of night shifts, and provision of breaks) must all be considered in combination. They note it is conceivable that a 12-hour night shift with frequent rest breaks might well prove safer than an 8-hour shift with only one mid-shift break. So wed be very interested to see if alarm response times increase each day consecutively worked.
Overall, the Bonafide study suggests that nurses apply heuristics to guide how they respond to alarms. The results also suggest that chronic alarm fatigue, the result of long term exposure to nonactionable alarms during a nurses career, may be a more important predictor of response time than short term exposure to non-actionable alarms. But the most important point is that mental or physical fatigue as nurses are further into their shifts may significantly impact alarm response times. The authors note that this and the nurse:patient ratio are likely the two most modifiable factors they found impacting alarm response times.
The accompanying editorial (Sowan 2017) called for using the perspective of nurses on the causes for alarm fatigue and long response times and soliciting their suggestions for improvement. Those authors had previously surveyed nurses in a transplant/cardiac ICU and found nurses believed that existing monitoring devices are complex, questioned the ability and adequacy of the new monitoring systems to solve alarm management issues, pointed to the lack of prompt response to alarms, and indicated the lack of clinical policy on alarm management (Sowan 2015).
The Bonafide study is really a great contribution to our growing knowledge base on alarm management. It also demonstrates the importance of direct observation techniques (video monitoring in this case) in your alarm management initiatives to better understand both the nature of alarm responses and the factors contributing to those alarm response times.
There are several takeaways from the Bonafide study. First, as you do your inventory of alarms to determine which ones are truly needed, you should also do direct observation (either physical observation or video recording) to assess response times to the various alarms. That will help you prioritize your alarms and eliminate those that are clinically non-actionable. Our many columns listed below will help you identify those that may simply be nuisance alarms that just foster alarm fatigue. But youll probably find the most useful information in our October 2014 What's New in the Patient Safety World column Alarm Fatigue: Reducing Unnecessary Telemetry Monitoring and our Patient Safety Tips of the Week for July 2, 2013 Issues in Alarm Management and August 16, 2016 How Is Your Alarm Management Initiative Going?.
Moving lower priority alarms from audible status to messaging status can go a long way to reduce alarm fatigue and excessive noise in a variety of settings. Just keep in mind that things can still go wrong. See our February 9, 2016 Patient Safety Tip of the Week for such an example.
The causes for prolonged response times may differ in your facility. The only way youll know is by collecting the information about those response times, soliciting input from your frontline staff about how to eliminate or mitigate the factors contributing to prolonged response times.
And you need to consider how you address the problem of healthcare worker fatigue, as weve discussed in the many columns below on the issue. Maybe when you do a detailed observational study you can also determine the impact of shifts longer than 8 hours and the impact of the consecutive day phenomenon and see whether interventions like allowing napping have any impact on alarm response times.
Prior Patient Safety Tips of the Week pertaining to alarm-related issues:
Some of our other columns on the role of fatigue in Patient Safety:
November 9, 2010
April 26, 2011 Sleeping Air Traffic Controllers: What About Healthcare?
February 2011 Update on 12-hour Nursing Shifts
September 2011 Shiftwork and Patient Safety
November 2011 Restricted Housestaff Work Hours and Patient Handoffs
January 3, 2012 Unintended Consequences of Restricted Housestaff Hours
June 2012 June 2012 Surgeon Fatigue
November 2012 The Mid-Day Nap
November 13, 2012 The 12-Hour Nursing Shift: More Downsides
July 29, 2014 The 12-Hour Nursing Shift: Debate Continues
October 2014 Another Rap on the 12-Hour Nursing Shift
December 2, 2014 ANA Position Statement on Nurse Fatigue
August 2015 Surgical Resident Duty Reform and Postoperative Outcomes
September 2015 Surgery Previous Night Does Not Impact Attending Surgeon Next Day
September 6, 2016
Bonafide CP, Localio AR, JH, et al. Video Analysis of Factors Associated With Response Time to Physiologic Monitor Alarms in a Childrens Hospital. JAMA Pediatr 2017; Published online April 10, 2017
Siebig S, Kuhls S; Imhoff M, et al. Intensive care unit alarms - How many do we need? Critical Care Medicine 2010; 38(2): 451-456
Schmid F, Goepfert MS, Kuhnt D, et al. The Wolf Is Crying in the Operating Room: Patient Monitor and Anesthesia Workstation Alarming Patterns during Cardiac Surgery. Anesth Analg 2011; 112(1): 78-83; published ahead of print October 21, 2010
The Joint Commission. Medical device alarm safety in hospitals. The Joint Commission Sentinel Event Alert 2013; 50: 1-3 April 8, 2013
Drew BJ, Harris P, Zθgre-Hemsey JK, et al. Insights into the Problem of Alarm Fatigue with Physiologic Monitor Devices: A Comprehensive Observational Study of Consecutive Intensive Care Unit Patients. PLOS One 2014; Published: October 22, 2014
The Joint Commission. Sound the Alarm: Managing Physiologic Monitoring Systems. The Joint Commission Perspectives on Patient Safety 2011; 11(12): 6-11 December 2011
Folkard S, Tucker P. Shift work, safety and productivity. Occupational Medicine 2003; 53: 95-101
Sowan AK, Reed CC. Alarm Fatigue in Adaptive Healthcare Systems. JAMA Pediatr 2017; Published online April 10, 2017
Sowan AK, Tarriela AF, Gomez TM, et al. Nurses perceptions and practices toward clinical alarms in a transplant cardiac intensive care unit: exploring key issues leading to alarm fatigue. JMIR Hum Factors 2015; 2(1) e3