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Service Delivery Innovation Profile

Multifaceted Initiative To Reduce "Alarm Fatigue" on Cardiac Unit Reduces Alarms and Increases Nurse and Patient Satisfaction


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Snapshot

Summary

Boston Medical Center implemented a series of interventions on its cardiac unit to reduce clinically insignificant alarms and make it easier for nurses to respond to genuinely problematic ones. Key actions included expanding the default parameters that trigger alarms due to low and rapid heart rates, elevating heart rate alarms and other rhythm violation alarms previously identified as "warning" alarms that do not require a nurse response to "crisis" alarms that do require such a response, adding an audible alarm for atrial fibrillation episodes to the existing visual alarm, and allowing two nurses to collaborate to change alarm parameters for individual patients (with a physician's approval). The initiative reduced audible alarms by 89 percent, with no adverse events attributed to the changes, and significantly increased satisfaction among both nurses and patients.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of alarms and nurse and patient satisfaction, as well as adverse events attributed to cardiac monitoring post-implementation.
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Developing Organizations

Boston Medical Center
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Use By Other Organizations

Representatives of several hospitals have visited Boston Medical Center to see the alarm procedures firsthand, and dozens more have made telephone inquiries about the initiative. In May 2012, Boston Medical Center was featured in a Joint Commission webinar on its alarm management strategies for other hospitals interested in learning more about the hospital's approach.

Date First Implemented

2012

Problem Addressed

While cardiac monitor alarms can be an effective tool for alerting nurses to heart rate and rhythm abnormalities in patients, the large number of clinically insignificant alarms that commonly occur can create a culture in which nurses delay their response to or ignore alarms altogether (a phenomenon known as alarm fatigue) and contributes to excessive noise levels that can have negative effects on patients and staff. Because of alarm fatigue, staff may not respond to critical alarms in a timely manner, leading to patient injuries and deaths.
  • Many insignificant alarms, leading to alarm fatigue: On many inpatient units where patients are recovering from surgery and/or serious illnesses, cardiac monitor alarms sound frequently, and in many cases these alarms do not indicate a health problem. The large number of clinically insignificant and false alarms can lead to alarm fatigue, with nurses ignoring alarms or taking other inappropriate actions, such as turning down the volume or turning off an alarm altogether.1 Prior to implementation of this initiative at Boston Medical Center (where nonintensive care unit patients are increasingly monitored on medical-surgical floors and up to 70 percent of patients admitted through the emergency department meet American Heart Association criteria for cardiac monitoring), nurses commonly delayed responding to warning alarms when involved in other important patient care activities, knowing these often were clinically insignificant alarms that would self reset when the alarm condition corrected.
  • Potential for patient injury and death: Turning off and/or ignoring clinically significant alarms can lead to patient injury and/or death. In 2011, the Food and Drug Administration (FDA) database for cardiac monitoring devices reported 565 incidents of patient harm due to alarm fatigue, 35 of which resulted in patient death.2 FDA leaders believe that the actual incidence of patient harm is significantly underreported. Although Boston Medical Center had not experienced any patient deaths attributed to missed cardiac alarms before implementation of this initiative, staff became concerned about the potential for such incidents. (More details about staff concerns can be found in the Context section below.)
  • Unnecessary anxiety for patients: The constant beeping of clinically insignificant alarms can heighten patient anxiety and disrupt the healing environment. In satisfaction surveys, patients at Boston Medical Center and other hospitals often indicate that high noise levels from alarms have a negative impact on the quality of their hospital experience.3

What They Did

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Description of the Innovative Activity

Boston Medical Center implemented a series of interventions on its cardiac unit to reduce clinically insignificant alarms and make it easier for nurses to respond to genuinely problematic ones. Key actions included expanding the default parameters that trigger alarms due to both low and rapid heart rates, elevating heart rate alarms and other rhythm violation alarms previously identified as "warning" alarms that do not require a nurse response to "crisis" alarms that do require such a response, adding an audible alarm for atrial fibrillation episodes to the existing visual alarm, and allowing two nurses to collaborate to change alarm parameters for individual patients (with a physician's approval). A detailed description of key elements of this initiative follows:
  • Expansion of default parameters that trigger heart rate alarms: The monitors' default parameters that trigger alarms based on a patient's heart rate were expanded, with the lower limit changed from 50 to 45 beats per minute (BPM) and the upper limit changed from 120 to 130 BPM. The new limits were selected with the recognition that nocturnal heart rates often drop to the upper 40s and that many hospitalized deconditioned patients have heart rates in the low 100s during daytime activity. These changes help to eliminate alarms caused by clinically insignificant issues, such as a temporary increase in heart rate from activity or a normal decline in heart rate when a patient falls asleep.
  • Elevation of heart rate alarms from warning to crisis status: Prior to this change, warning alarms were activated when a patient's heart rate violated alarm limits or lower level alarm rhythm violations occurred. These alarms consisted of repeating two short beeps that self-reset when the alarm condition was no longer met and reoccurred if the alarm violation happened again. Under the new initiative, there are no warning alarms, as all heart rate alarms under the revised parameters have been raised to crisis alarms that consist of three quick beeps that will not stop or reset until a nurse comes to the monitor, views and shuts off the alarm, and checks on the patient. If needed, the nurse takes action to address the patient's health issues or follows the procedure described under "parameter changes for individual patients" below.
  • Addition of audible alarm for atrial fibrillation episodes: Alarms for atrial fibrillation episodes (a relatively common disturbance in the rhythm of the heart beat) were changed from a visual-only message with no sound to an advisory alarm that consists of a visual message and a single repeating short beep. Nurses are required to respond to this alarm by assessing the patient and, if it is an actual episode, notifying the physician of the event. Even though atrial fibrillation is common, unrecognized episodes place patients at risk for stroke if they do not receive anticoagulation medicine, making it an important rhythm to capture. It is the only condition on the unit that prompts an advisory alarm, thus increasing the likelihood that staff will identify clinically significant episodes.
  • Parameter changes for individual patients: Two nurses can collaborate to change an alarm parameter, with a physician's approval. For example, if a patient's normal heart rate tends to be faster or slower than the default, two nurses can modify the heart rate parameters accordingly and communicate this to a physician for additional validation. Similarly, if a patient has atrial fibrillation that two nurses agree is not necessary to continuously monitor, they can submit a change order to a physician to disable the audible alarm for atrial fibrillation. Before a change can be made, two registered nurses must review the patient's alarm history and medical record and agree that different default parameters are appropriate. They then submit the change order to a physician to review and approve. If the physician disagrees with the change, the default setting is returned to its original value.

Context of the Innovation

Boston Medical Center is a private, not-for-profit, 508-bed academic medical center and the primary teaching affiliate for the Boston University School of Medicine. It has 10 adult medical-surgical units that collectively have 310 beds. The 24-bed cardiac unit that implemented this initiative serves patients who have had heart attacks and patients with heart failure, chest pain, irregular heart rhythms, and other cardiac conditions, as well as invasive interventional and electrophysiology procedures.

In 2008, the hospital purchased new cardiac telemetry monitoring equipment as part of a significant expansion of the number of beds with monitors and a simultaneous effort to standardize monitoring equipment and default parameters for alarms due to arrhythmias and abnormal heart rate. To ensure that this process went smoothly and to identify potential opportunities for improvement, the hospital formed a multidisciplinary telemetry task force made up of the hospital's chief medical officer, a cardiologist, the director of clinical engineering, the clinical service manager for cardiology (a nurse practitioner), nursing directors from critical care and medical-surgical nursing, clinical instructors responsible for telemetry training, a quality and patient safety specialist, and physicians from critical care, cardiology, medicine, and surgery.

In 2011, the task force reconvened after reports of several incidents at other Massachusetts hospitals in which patients were injured or died after staff did not respond to repeated heart rate alarms. Around the same time, the Boston Globe published an investigation that identified at least 216 deaths nationwide between January 2005 and June 2010 linked to alarms on patient monitors. Recognizing the potential for nurses to become desensitized to frequent alarms, the task force began examining what could be done to reduce the number of false alarms and ensure that nurses respond to those alarms indicating genuine problems.

Did It Work?

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Results

The initiative reduced audible alarms by 89 percent, with no adverse events attributed to the changes, and significantly increased satisfaction among both nurses and patients.
  • Significantly fewer alarms: The average number of weekly alarms on the cardiac unit fell by 89 percent, from 87,823 during the 2 weeks prior to implementation of the initiative to 9,967 per week during a 6-week pilot test of the initiative, and no adverse events were attributed to the initiative's changes. Most of the decline was attributable to a reduction in heart rate alarms. A subsequent expansion of the initiative to nine additional adult medical-surgical units generated an overall reduction of 60 percent in audible alarms (from about 1 million to 400,000 a week). The percentage reduction on the cardiac unit in the pilot was larger because the pilot test focused only on alarms related to heart rate and arrhythmias. By contrast, the expanded initiative also covered alarms related to oxygen saturation rates and blood pressure, which were not addressed as a part of this initiative.
  • Higher nurse satisfaction: The percentage of nurses who assessed the noise level as acceptable rose from 0 percent before the pilot began to 64 percent when it ended. Interviews with nurses yielded numerous positive comments about the initiative, such as the following:
    • The monitor alarms were just an irritant; they no longer seem that way.
    • I feel so much less drained going home at the end of my shift.
    • I can spend more time on patient care instead of answering meaningless alarms.
    • This unit is so much quieter than the other units; as a float nurse I want to work here.
  • Higher patient satisfaction: Surveys of cardiac unit patients during the 7 months before and after the pilot found significant improvements in overall patient satisfaction and in satisfaction with specific aspects of care related to the alarms, including nurse promptness in responding to call lights and the manner in which nurses respond to personal issues.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of alarms and nurse and patient satisfaction, as well as adverse events attributed to cardiac monitoring post-implementation.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Conducting task force review: In 2011, the task force conducted a comprehensive review of alarm fatigue at the hospital. The review included close examination of all alarm data and related technology, observations of nurses interacting with alarms, and a series of focus groups with nurses, physicians, and residents. This research found that roughly two-thirds of alarms occurred because of violations of default settings related to heart rate. It also found that nurses always answered crisis alarms, but often delayed responding to warning alarms because they were engaged in other patient care activities. A subsequent review of alarm histories found that some warning alarms that were ignored were in fact clinically significant. The task force's research also found that nurses viewed the large number of audible alarms to be an excessive burden, given that most did not require a clinical response.
  • Participating in summit: In October 2011, task force members attended a summit on alarm fatigue sponsored by the Joint Commission, the Food and Drug Administration, the Association for the Advancement of Medical Instrumentation, and the ECRI Institute. Participants shared ideas on various approaches to reducing alarm fatigue.
  • Developing pilot: In early 2012, the task force began planning a 6-week pilot to test a series of changes to their alarm procedures. They chose the four components outlined earlier based on the aforementioned internal review and the approaches discussed at the summit. Because all hospital nurses were required to take a class about recognizing heart rate variability and arrhythmias and score 90 percent or above on a subsequent competency exam, the task force felt confident that the changes would not compromise patient safety. The task force decided to implement the pilot on the cardiac unit because a number of physicians and nurses on the unit were enthusiastic supporters of efforts to reduce alarm fatigue.
  • Preparing for and rolling out pilot: In advance of the planned rollout in August 2012, project leaders held a series of educational meetings with staff on the unit to explain the purpose of the alarm changes and show them how their roles would change. Project leaders also redesigned the monitoring order sets to incorporate the new heart rate defaults and inserted order prompts that cued physicians to change default alarm levels on admission for patients with known atrial fibrillation or short runs of ventricular tachycardia less than six beats. On the "go-live" date, clinical engineering staff adjusted the default values at the central monitoring station and on all bedside monitors. Throughout the pilot, clinical engineers were available to help nurses get accustomed to the changes, and a nurse practitioner worked closely with physicians and nurses to ensure that monitoring orders accurately reflected the new heart rate limit defaults and to troubleshoot alarm settings as necessary.
  • Expanding to additional units: After it quickly became apparent that the changes were working, the task force decided to maintain the changes on the cardiac unit once the pilot ended and to expand the initiative to nine additional adult medical-surgical telemetry units. From January to March 2013, the alarm changes were gradually rolled out on the additional adult units, which included surgical oncology, orthopedic surgery, bariatric surgery, respiratory/pulmonary, and trauma. As part of the pilot rollout, task force members had briefed clinical leaders on these units about the initiative. As a result, these leaders were already prepared to implement it. As with the pilot, education of all staff preceded the rollout on each unit, and engineering staff and senior-level nurses were available to ensure the transition to the new system went smoothly.

Resources Used and Skills Needed

  • Staffing: The initiative did not require hiring any additional staff. Task force members and unit staff perform activities related to this initiative as part of their regular job responsibilities.
  • Costs: The major costs associated with the initiative consisted of staff time to develop and implement the changes to alarm procedures and training staff to use them. While the initiative could not have been implemented without the purchase of new cardiac telemetry monitoring equipment, this purchase was part of a planned expansion of the number of hospital beds with monitors and would have occurred in the absence of this initiative.
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Funding Sources

Boston Medical Center
The hospital provided a $25,000 patient safety grant to fund expansion of the initiative to the nine additional units, which allowed the assignment of a registered nurse with expertise in the initiative to support the first week of each floor's rollout.end fs

Tools and Other Resources

On May 1, 2013, Boston Medical Center hosted a webinar with the Joint Commission for other hospitals interested in learning more about the hospital's approach to alarm fatigue. Slides presented at the webinar are available at: http://www.jointcommission.org/assets/1/6/JCAlarmwebinar2013BMCb.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

Additional news segments about the innovation are available at the following links:

Adoption Considerations

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Getting Started with This Innovation

  • Establish multidisciplinary task force: The task force considering changes in alarm procedures should include a broad range of representatives, including administrators, clinical engineers, physicians, and nurses.
  • Examine existing alarm procedures: Having an accurate understanding of how and why nurses respond to existing alarms—including barriers to timely response—is critical before any changes are made. To gain this understanding, closely examine all available alarm data, observe how nurses interact with alarms, and hold focus groups with nurses in a manner that makes them comfortable giving their perspective.
  • Identify potential changes: Once a clear picture emerges, consider system improvements that will address major problem areas, such as eliminating self-resetting audible alarms, making clinically insignificant alarms inaudible, and making all clinically significant alarms actionable by requiring staff to respond to silence them. Make sure clinicians closely consider each change's effect on patient safety, and seek to standardize alarm defaults across units wherever possible.
  • Emphasize nurse buy-in: Changing alarm procedures has a major effect on nurses' job responsibilities and represents a significant cultural change. Consequently, nurses must understand and support the modifications. To gain their support, take time to explain the rationale behind each change, provide relevant data justifying the change, and answer any questions they may have.
  • Support nurses in making transition: Nurses on all shifts need comprehensive training on new procedures, and, after implementation, they need access to senior staff who can help address any problems that arise. At Boston Medical Center, the transition went so smoothly that several days after implementation nurses informed their supervisors that they did not want to return to the former system.

Sustaining This Innovation

  • Share success stories: Share data with nurses on reductions in the number of alarms and adverse events related to cardiac monitoring as a way to highlight the positive impact of their efforts. Similarly, circulate press coverage on the improvements to help maintain enthusiasm for the project among key stakeholders.
  • Identify additional opportunities for improvement: Once initial changes have been successfully implemented, consider expanding the initiative to other types of alarms. For example, Boston Medical Center is now working on reducing the number of unnecessary pulse oximetry alarms.

Use By Other Organizations

Representatives of several hospitals have visited Boston Medical Center to see the alarm procedures firsthand, and dozens more have made telephone inquiries about the initiative. In May 2012, Boston Medical Center was featured in a Joint Commission webinar on its alarm management strategies for other hospitals interested in learning more about the hospital's approach.

More Information

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Contact the Innovator

Deborah Whalen, MSN, MBA, APRN
Clinical Services Manager, Cardiology
Boston Medical Center
One Medical Center Place
Collamore 8 Section of Cardiology
Boston, MA 02118
E-mail: deborah.whalen@bmc.org

James Piepenbrink, BS
Director, Department of Clinical Engineering
Boston Medical Center
One Medical Center Place
Boston, MA 02118
(617) 638-8000
E-mail: jim.piepenbrink@bmc.org

Innovator Disclosures

Ms. Whalen and Mr. Piepenbrink reported having no financial interests or business/professional affiliations relevant to the work described in this profile.

Recognition

Boston Medical Center's work on reducing alarm fatigue earned designation as a finalist for the ECRI Institute's 2013 Health Devices Achievement Award. More information about this award is available at: https://www.ecri.org/hdaward.

References/Related Articles

Kowalczyk L. Boston Medical Center reduces monitor alarms: a model in meeting US safety standards. The Boston Globe. December 23, 2013. Available at: http://www.bostonglobe.com/lifestyle/health-wellness/2013/12/23/boston-medical-center-reduces-monitor-alarms-says-care-safer-for-patients-less-stressful-for-staff/szqFan1sE7CgHnfsuT2fEL
/story.html
.

McKinney M. Hospital's simple interventions help reduce alarm fatigue. Modern Healthcare. February 1, 2014. Available at: http://www.modernhealthcare.com/article/20140201/MAGAZINE/302019996
/hospitals-simple-interventions-help-reduce-alarm-fatigue
.

Whalen DA, Covelle PM, Piepenbrink JC, et al. Novel approach to cardiac alarm management on telemetry units. J Cardiovasc Nurs. 2013 Dec 19. [Epub ahead of print.] [PubMed]

Footnotes

1 Joint Commission. Sound the alarm: managing physiological monitoring systems. Jt Comm Perspect Patient Saf. 2011;11(12):4-11. Available at: http://www.jointcommission.org/assets/1/6/Perspectives_Alarm.pdf.
2 Welch J. Alarm fatigue hazards: the sirens are calling. Patient Saf Qual Healthc. 2012:9(3):26-33. Available at:
http://www.psqh.com/mayjune-2012/1291-alarm-fatigue-hazards-the-sirens-are-calling.html.
3 Montague KN, Blietz CM, Kachur M. Ensuring quieter hospital environments. Am J Nurs. 2009;109(9):65-7. [PubMed]
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Original publication: June 18, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 18, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.