Managing alarm fatigue in cardiac care

Abstract

Alarm safety is one of healthcare's most high-profile and intractable problems. A phenomenon known as “alarm fatigue”, including limited capacity to identify and prioritize alarm signals, has led to delayed or failed alarm responses and deliberate alarm de-activations. Alarm fatigue has been implicated according to federal agency reports as well as in the lay press, in patient deaths, some highly publicized. It has been reported that between 200 and 566 patient deaths have resulted between 2005 and 2008; these numbers are likely to be underestimates.Many factors contribute to alarm fatigue, but perhaps most significant is a reported false alarm rate as high as 83–85%; these large numbers of clinically irrelevant signals directly contribute to staff desensitization. In addition, high background noise levels in critical care and variable acuity units and in operating rooms contribute to alarm response failures. They do this by further increasing the cognitive load on staff, escalating distraction and irritability, and complicating discernment, attribution and communication. Noise levels in hospitals have been rising for decades and are far higher than guideline values established by the World Health Organization.This paper identifies multiple levels of influence and opportunities for system intervention and innovation to facilitate timely alarm responses. These include addressing the broader acoustic context, clinician responsibility, deployment and teamwork training, threshold-setting guidelines, improved user interfaces, and algorithms balancing alarm specificity and sensitivity.Monitoring devices that process complex data streams should produce clinically relevant alarm signals, in environments optimized for discernment and attribution, with user interfaces designed for timely interpretation, prioritization and prompt action. Addressing alarm fatigue requires regulators, manufacturers and clinical leaders to recognize the importance and context of human factors and staff behavior, with design and evaluation of devices accomplished through clinical simulations and rigirous usability testing. We review steps clinicians and managers can take to minimize nuisance alarms and maximize the safety and effectiveness of clinical monitors.