ICUs continue to be challenged by alarm fatigue, which can desensitize staff to ventilator warnings while disrupting patients and increasing risks of poor outcomes.

By Bill Pruitt


Adult ICUs across the nation continue to be challenged by alarm fatigue despite years of work to alleviate this problem. Frequent alarms can result in sensory overload along with desensitization to alarms, which can lead to delayed (or no) response by the healthcare team, adjustment of alarm thresholds to inappropriate levels, turning off alarms, difficulty in evaluating and prioritizing alarms, increased stress on staff, and disruption of circadian rhythm plus increased stress for patients.1

In research, alarms have been classified into three categories:1

  1. Technically false alarms (the alarm does not correspond to reality;
  2. Technically correct but clinically irrelevant alarms (no need for taking action); and
  3. Technically correct/clinically relevant alarms that call for a response.

Studies have shown that from 72% to 99% of alarms are either in the first or second category (false or clinically irrelevant).1 A systematic review of research on alarms published in 2022 looked at 56 articles and described the types and frequency of alarms uncovered in the review. A total of 85% of the alarms  occurred in four major areas:1

  1. Heart rate or arrythmias;
  2. Arterial blood pressure;
  3. Low SpO2 form pulse oximetry;
  4. Respiration issues (too high/low, or apnea).

Another study analyzed the number of alarms in one week in a large academic medical center. Looking at a total of 199 beds in eight different units (including in the mix four ICUs and the adult emergency department), they found there was a total of 74,535 alarms — an average of 7,453 alarms per day.2

Possible Solutions for Alarm Fatigue

There are many approaches being evaluated to try and reduce/eliminate alarm fatigue. The National Coalition for Alarm Management Safety found that a minority of patients are the cause for most alarms. By focusing interventions  to prevent alarms in  those particular patients the number of alarms can be reduced.2 There is a tendency to set alarms on generalized protocols and patient populations instead of focusing on the patient and their specific conditions. By setting up protocols that rely on the patient’s current condition to establish more appropriate alarm limits, there can be a reduction of nuisance alarms and increased in patient safety.3

Researchers suggest that facilities establish training and workshops for the ICU staff to increase the understanding of proper set up of monitoring devices (including probes, skin applications, placement), adjustment of the thresholds, appropriate ways to reduce nuisance alarms, and establish/review algorithms for alarm management.1 Monitoring compliance with protocols and algorithms can also improve the issue of alarm fatigue. One study that looked at the impact of performing audits to check alarm settings found that audits improved compliance by 84%.3

Addressing how alarm alerts are provided can reduce alarm fatigue. One strategy adjusts alarm volume based on ambient noise – for example, during quiet periods, the alarm volume would sound at a lower volume. Another strategy provides alarms directly to the responsible caregiver through a wearable device place on the upper arm that would use vibration, a flashing light, and sound delivered through bone conduction, instead of broadcasting a general alarm to the entire unit.1 Changing the auditory prompt from general beeps, bells, or sounds to specific sounds can help staff evaluate and interpret what is happening. For example, providing a “lub-dub” pattern for a cardiovascular issue, an inhalation/exhalation sound for issues with ventilation, three wine cork pops for problems in oxygenation, and an improper start of a cold motor (pull cord) to alert the staff of equipment failure.3

Smart alarm packages are being developed to utilize a combination of alarms to predict patient deterioration and alert the staff of an impending event such as a code blue, an acute hypotensive episode, or other changes in monitored variables that when combined into a more overall view of the patient would point to impending events.1 Improvement in technology has brought a move away from reactive monitoring to more comprehensive analysis and use of a combination of monitored variables. This approach can provide earlier action from the staff to prevent an adverse event and prevent alarms from being triggered.3

Another novel approach in smart technology has been in the development of smart rooms that can identify the presence of a health care provider, the type of provider, a family member, or patient movement. Monitors in the room are also able to detect if handwashing has occurred, the time and type of medication being administered and provide some form of intervention if an error was about to occur.3

Focusing on Mechanical Ventilation

The Emergency Care Research Institute list of the top 10 health technology hazards (from 2017) has ventilator alarm management listed as third in the list.4 Ventilator alarms are associated with high risk issues considering that patient disconnection or malfunction of the ventilator could result in permanent harm of death and are considered high-priority  alarms due to the critical nature of the support.3

Ventilator manufacturers have provided various strategies to help  in alarm management. Many provide an auto-set feature that sets various alarms based on operator inputs (ie, sex, age, height, weight, mode of ventilation, etc.) or based on information about the patient’s condition (ie, auto-set of the minute ventilation alarm to +30% of the current minute ventilation). Many also provide a suction input to select when performing this procedure that will silence the alarm for a period and set the FiO2 to 1.00 during that period, then reactivate the alarm and restore the original setting for FiO2 when the period has ended.3

Ventilators also incorporate a hierarchy of alarms that provide more urgent or intense alarms for more serious situations and provide an increasing alert (ie, more frequent auditory prompts, increasing volume, changing colors on the ventilator alarm screen) as time goes by that urges the staff to respond.

To help reduce alarm fatigue many respiratory therapy (RT) departments are using protocols to set alarms based on a particular patient’s condition. For example, after performing a quality improvement project, Johns Hopkins Hospital’s RT department provided the following guidelines for staff to use in setting ventilator alarms:

  • High inspiratory pressure set at 15-20 cmH2O above PIP;
  • Minute volume set at 4-6 LPM below measured minute volume and 6-8 LPM above;
  • Tidal volume (high and low) set at + 200 mL of measured tidal volume;
  • High respiratory rate set at 15-20 above measured rate;
  • Apnea set at 20 seconds unless ordered by physician or adjusted and documented by RT due to extraordinary circumstance (ie, DNR).

Conclusion

Alarm fatigue is a problem that must be addressed in several ways. As described by Walsh and Waugh in an article from 2020 in Respiratory Care regarding effective strategies, “These include targeted education with reinforcement, standardized alarm policies that respect patient differences and include peer follow-up, and the adoption of assistive technology.”3 In pursuing the goal of reducing alarm fatigue, we must keep in mind, “Primum non nocere”, a Latin phrase that means, “First, do no harm.”

RT

Bill Pruitt, MBA, RRT, CPFT, FAARC, is a writer, lecturer, and consultant. He has over 40 years of experience in respiratory care and has over 20 years teaching at the University of South Alabama in Cardiorespiratory Care. Now retired from teaching, he continues to provide guest lectures and write professionally. For more information, contact [email protected].

References

  1. Chromik J, Klopfenstein SA, Pfitzner B, Sinno ZC, Arnrich B, Balzer F, Poncette AS. Computational approaches to alleviate alarm fatigue in intensive care medicine: A systematic literature review. Frontiers in Digital Health. 2022 Aug 16;4:843747.
  2. Cvach M, Kitchens M, Smith K, Harris P, Flack MN. Customizing alarm limits based on specific needs of patients. Biomedical instrumentation & technology. 2017 May;51(3):227-34.
  3. Walsh BK, Waugh JB. Alarm strategies and surveillance for mechanical ventilation. Respiratory care. 2020 Jun 1;65(6):820-31.
  4. Stokes JE, Manzoor SH, Cvach MM. Ventilator alarms: challenges and opportunities for improvement. Biomedical Instrumentation & Technology. 2017 Sep;51(5):390-7.