May 18, 2017 | | Comments 0
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Throwback Thursday: Boston Medical Center reduces alarm fatigue by recalibrating alarm limits


Editor’s Note: The following is a free Patient Safety Monitor Journal article from yesteryear! If you like it, check out more of our work covering quality and patient safety!

If you walk onto the medical-surgical units in Boston Medical Center (BMC), you may notice something strange: silence.

On a unit that is typically a cacophony of beeping emanating from cardiac monitors, silence is a strange occurrence. But thanks to BMC’s pilot study that began in August 2012, the unit is significantly quieter, the nurses are noticeably happier, and the hospital has positioned itself as a national model for reducing alarm fatigue-a recent hot topic in the patient safety world.

What began as a pilot study on one unit transformed into a hospitalwide initiative that reduced alarms on all medical-surgical units from 1 million to 400,000 per week.

“Our nurses threatened us that if we ever went back to the old settings; they never wanted us to end the pilot program,” says Deborah Whalen, MSN, APRN, ANP-BC, clinical service manager and cardiology nurse practitioner at BMC, and one of the coauthors of the study published in the Journal of Cardiovascular Nursing. “Initially they were terrified that there would be all these crisis alarms, but in fact, we made the changes and did it on a Monday at noon, changed the order sets on the pilot unit and educated staff, and then we stood there and there were no alarms.

“As a matter of fact I called Jim, our clinical engineer, at 2 a.m. to say the system was broken.”

The proof was in the pilot

The overwhelming success of the pilot study on one unit prompted BMC to expand the program to every medical-surgical unit and the hospital quickly became identified as a national leader in alarm management, during a time of heightened awareness and a new National Patient Safety Goal from The Joint Commission. Over the past several months The Boston Globe, NPR, and two local news channels have done stories about the hospital’s program. In May 2013, BMC’s work was featured in a Joint Commission webinar, exemplifying the steps hospitals could implement to better manage alarms and improve patient safety.

The results of the pilot program were published online in December in the Journal of Cardiovascular Nursing, which showed a reduction of 89% in total mean weekly audible alarms by dropping averages from 12,546 per day to 1,424. Weekly alarms averaged 87,823 but dropped to 9,967 during the pilot. The most significant decrease came from changes for bradycardia, tachycardia, and heart rate parameter limits, which started at 62,793 per week and dropped to 3,970 per week.

Perhaps the most telling statistic: The decibel level on the floor dropped from 90 decibels before the pilot to 72 decibels, the equivalent of noise levels generated by heavy traffic to normal conversation.

“It’s not silent by any stretch of the imagination, but it’s quiet and there aren’t these alarms constantly going off in the background,” Whalen says.

What made the study particularly appealing to other hospitals searching for ways to better manage alarms in their own facility was the fact that there were no adverse events related to missed cardiac events, and the pilot study required no additional resources or technology.

“While some hospitals are looking to add technology to combat this issue, BMC’s approach demonstrates the opportunity for clinicians to interact with current alarm systems more effectively to decrease clinical alarm fatigue while simultaneously capturing and displaying all important alarms,” James Piepenbrink, BSBME, director of clinical engineering at BMC and a study coauthor, said in a press release.


Mining your data and changing your defaults

Key to the success of this initiative without carrying the burden of financial resources was utilizing the alarm data that already existed within the documented alarm history.

Even before BMC launched its pilot program, it began harvesting data from its vendor, a difficult task since manufacturers always held this data but didn’t usually release it to the hospital. But Piepenbrink had formed a good relationship with the vendor, Whalen says, and he was able to acquire the alarm history, which gave them the objective, baseline numbers they needed to make changes.

At BMC there were three major alarms:

  • Crisis: The highest level of alarm that continues to sound until a nurse manually resets it
  • Warning: Signals an issue that does not need an immediate response, but indicates a change in the patient’s condition
  • Advisory: Low-level alarms that signal once and are recorded in the alarm history

After studying the data-and secretly observing nurses and how they responded to alarms-Whalen and her colleagues noticed that staff rarely answered the warning alarms, knowing the machine would reset on its own. However, they wouldn’t have a chance to individualize the machine for that patient to prevent further warning alarms, so the machine would continue to sound after it had reset.

“It was really crazy to have these warning alarms. We need an alarm where if it goes off and it’s going to be audible, we want you to go see it,” Whalen says.

A multidisciplinary committee of clinicians and engineers set out to safely eliminate those warning alarms and readjust the parameters of the crisis alarms. They focused specifically on alarms that sounded for bradycardia, tachycardia, and heart rate changes by setting the crisis alarms to sound when a patient’s heart rate dropped below 45 (instead of 50) or above 130 (instead of 120). BMC also set specific alarm parameters for arrhythmia.

Even these simple changes drastically reduced the amount of alarms. As the pilot progressed, they also empowered nurses to adjust the settings of the monitor when they felt it was necessary. Any changes must be confirmed with another nurse and then relayed to the physician. Previously, nurses had to get orders from the physician before they could adjust the monitor.

“To be a nurse at BMC, you have to pass a test of 20 of these heart rhythms at 90%, so the chance of one nurse making a mistake and getting it wrong, that can happen to any of us on a bad day,” Whalen says. “But the chance of two nurses doing it together and making a bad judgment is pretty low.”

In January 2013, BMC expanded the program to include more than 300 beds across multiple medical-surgical units.

To reduce alarm fatigue, many hospitals have purchased additional technology or hired additional staff members to monitor alarms, but Whalen argues that those are unnecessary measures if you have the data from the alarm history at your fingertips.

“The thing about technology, and what I keep telling people, is more is not necessarily better,” she says. “We essentially had 89% of these alarms that were coming from bad data.”

Whalen believes the hospital can reduce unnecessary alarms even further. In February, it planned an additional intervention that would tweak the alarms that unnecessarily sound for tachycardia. In March, BMC planned more interventions regarding alarms for oxygen saturation.

“If this tachycardia project works for the whole hospital, it will eliminate another 30,000 alarms,” she says.

Nurse satisfaction

Prior to the pilot, alarms were a constant source of stress for nurses at BMC. They often caused unnecessary distractions, took away from bedside care, and nurses often ignored them altogether, knowing that it was not a crisis alarm. Some nurses even said they dreamed about alarms at night.

Anonymous nurse surveys conducted before and after the study indicated that 0% of nurses thought the noise level was acceptable before the pilot, compared to 64% after.

“It’s a coded message, but it’s really hard when you have three beeps, two beeps, one beep, and a foghorn,” Whalen says. “They are all going off together, and that’s all the cardiac monitoring equipment. That’s not even the call light or the IV pump or whatever other alarms you have. So it’s pretty stressful especially when you have sick patients and you realize that someone’s life really depends on that.”

Advice for other hospitals

Since the pilot study was published in December, BMC has been receiving calls from hospitals around the country asking for advice on how to implement this program. Fortunately, Whalen says, BMC wrote the study so that it would be a step-by-step resource for others that wanted to address the problem. Facilities that want to know what the process looked like can simply read the study published in the Journal of Cardiovascular Nursing.

But Whalen offers two crucial bits of advice for hospitals in the midst of improving alarm fatigue:

  • First, harvest and utilize your alarm history data and determine how staff members are reacting to those alarms through the use of “secret shoppers”
  • Second, never accept the default settings for monitoring equipment

“Always go over each alarm and say, ‘Is this what we want for our patients at this institution?’ ” she says.

Alarm fatigue is a top concern

Usually when The Joint Commission releases a new standard, hospitals pay attention. So it’s no surprise that following the announcement of NPSG.06.01.01, alarm fatigue and safety is a top priority among healthcare institutions.

A recent survey presented at the Society for Technology in Anesthesia (STA) Annual Meeting in January confirmed that this issue is at the forefront of patient safety initiatives. The survey indicated that 19 of every 20 hospitals in the country rated alarm fatigue as a top concern.

“Hospitals are greatly concerned about alarm fatigue because it interferes with patient safety, and it exposes patients-and the hospitals themselves-to grave harm,” Michael Wong, executive director of the Physician-Patient Alliance for Health & Safety, said in a press release. Wong presented alarm fatigue results from the First National Survey of Patient-Controlled Analgesia Practices at the STA meeting.

Eighty-eight percent of hospitals believe that reducing false alarms would increase their use of patient monitoring devices for capnography and/or pulse oximetry, the survey shows.

Additionally, of the hospitals that currently monitor pulse oximetry and capnography, 65% have experienced a reduction in overall adverse events, as well as costs and expenses. (You can read more about PCA alarms in the February issue of Patient Safety Monitor Journal.)

More survey data is expected to provide additional information about alarm safety. Currently, the Association for the Advancement of Medical Instrumentation is conducting a survey about parameters for the following biomedical alarms:

  • Pulse ox%
  • Heart rate BPM
  • BP systolic mmHg
  • BP diastolic mmHg
  • BP mean mmHg
  • ST Elev/Dep
  • Resp rate Breaths/min
  • EtCO2 kPa/mmHg

“I think we all agree that one death resulting from alarm fatigue is one too many-and that’s why it’s encouraging to see that hospitals are taking proactive steps to improve alarm management,” Wong said in the release.

Meeting Joint Commission requirements for alarm fatigue (Part 2)

Editor’s note: NPSG.06.01.01 was approved by The Joint Commission in June 2013 as a new 2014 National Patient Safety Goal. The final standard included two phases: Phase I, beginning January 2014, required hospital leaders to “establish alarm system safety as a [critical access] hospital priority” by July 1, 2014. Phase II, which will not begin until January 1, 2016, requires hospitals to “educate staff and licensed independent practitioners about the purpose of proper operation of alarm systems for which they are responsible.”

In an effort to help hospitals understand the requirements of Phase I, Patient Safety Monitor Journal spoke with Rikin Shah, senior associate in the Applied Solution Group at ECRI Institute in Plymouth Meeting, Pa., about what hospitals need to do to comply with The Joint Commission’s requirements by July 1. Below is the second installment of that conversation. The first part can be found in the March Patient Safety Monitor Journal.


Q: What can hospitals do to reduce alarm fatigue?

Shah: Hospitals need to look at ECRI’s four tenets:

  • Culture provides the foundation that makes improving alarm management possible. It involves the belief, attitude, ownership, and behavior by all staff. Ideally, the culture should demonstrate that patient safety is a core value and that effective alarm management is essential to patient safety.
  • Infrastructure provides the framework in which improving alarm management takes place. It refers to elements like staffing patterns and care models, alarm coverage models, architectural layout, and policies that are in place.
  • Practices include all alarm management processes that are actually used in each care area. It is important to understand the processes for alarm notification, verification, and response. For example, what steps take place when a crisis alarm occurs? Who is responsible and accountable for each step? Is responsibility clearly delineated, or is it diffuse?
  • Technology is essential to improving alarm management; however, technology should not be perceived as a panacea for solving alarm issues. We need to better understand the impact of these technologies and their capabilities and configuration.

These four areas can help hospitals understand some of the issues and help reduce alarm fatigue.

Q: How can hospitals set themselves up to comply with Phase II of the requirement, which doesn’t take effect until January 2016?

Shah: Hospitals need to reduce nuisance alarms and create an environment of clinically actionable alarms. There needs to be an action plan to actively look at how alarm levels need to be adjusted per unit and even at the individual patient level. The multidisciplinary team must work with each unit to establish appropriate alarm practices to ensure that the elements of Phase II are appropriately executed and appropriate policies are established.

Q: What kind of staff training will be required for compliance?

Shah: Staff education is going to be vital for any success. Staff need to know the devices they are using; there needs to be a thorough understanding of the technology and how many devices can be configured, so as to not create more alarms than necessary. Establishing appropriate competence testing and making sure that all new policies put in place to adhere to Phase II is appropriately propagated among all staff members. Policies and practices need to follow each other, and there needs to be a level of accountability to make sure there is success in tackling alarm management.

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About the Author: Brian Ward is an Associate Editor at HCPro working on accreditation, patient safety, and quality news.

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