Does alarm fatigue really kill?

Does alarm fatigue really kill?

Patient safety and hospital quality is a scary topic. I’ll go easy. I’m just a doctor. I don’t know much.

Entire departments, filled with cubicles, computers and well-meaning people, now exist to keep hospitals tightly regulated and running perfectly. There is data to analyze, regulations to read, and oh so many meetings to attend. This place of healing will be safe—and perfect.

The recent sentinel alert issued from the Joint Commission caught my eye. It appears we have a problem with hospital monitors.

First the monitors, then the matter of whether patients are dying from medical errors.

From the Commission: “Hospital monitors are monitoring too much; they beep too loudly and more than 80% of the time, the alarm was false. These facts have led caregivers, who all are humans, and many are commonsense seekers, to turn them off or down, or in some cases, to levels that are not appropriate. The sentinel alert tells us widespread alarm fatigue has been associated with patient deaths.”

I’ll start with this as a given: Patient safety and quality care are serious issues.

But now, let me tell you the story of two hospital settings.

The first is the CCU. In the coronary care unit, there are closely spaced rooms filled with quite ill patients. Lights are turned to the brightest setting, ventilators chirp, monitors beep, alarms scream. I hate big words, but cacophony, comes to mind. Plus, the culture of the CCU holds that patients will die any second, even though the CCU of the 80s are much different than now. (For one, a not insignificant number of current CCU patients are there because no one has had the gumption to tell them the truth about their illness, or that another line of treatment exists–namely, one that emphasizes symptom relief.)

Compare the CCU to my electrophysiology (EP) lab during an ablation. Here we have a patient, paralyzed and under general anesthesia, while a doctor manipulates a catheter in the heart. The patient’s life is totally dependent on machines—even more so perhaps than many in the CCU. The difference is that it is quiet and rhythmic in the EP lab. The sounds that reach the caregivers’ ears are methodical and regular. When an alarm sounds, people notice it.

“What’s wrong?” I ask. Oh, it’s a low oxygen level or blood pressure. In this setting, alarms are useful because the background noise is regular and modest.

So, I am not arguing that alarms are bad. It’s just that stories like this one remind me what’s being lost in many of the hyper-alert processes surrounding quality and safety. Common sense has been moved too far down the checklist and protocol.

Recently, researchers from Yale presented an abstract in which they found that patients were over-exposed to monitors. It was a small study, but the conclusions were important: let’s use common sense about whom we monitor, and, perhaps we should study things that we think are good quality measures, but may not be.

We must also comment about the claim that patients are dying because of alarm fatigue (or hospital errors). The example cited in the Joint Commission alert told the story of a man with severe brain injury who died because of a delayed response to a true (not false) alarm. Here is where a lack of clarity of words leads to real trouble. That patient did not die because of alarm fatigue: he died because of the severe brain injury that caused his hospitalization.

Yes, medical errors need to be minimized, and systems surely can help caregivers. But clarity is everything. Disease and trauma kill patients. Medical practice is imperfect and sometimes fails to cure. Sometimes even, in the attempt to cure, we make matters worse.

The words of a wise surgeon who once counseled a young doctor distraught over a procedural complication bear repeating. If you don’t want any bad outcomes, don’t treat anything.

So please, can we fix the words about how hospitals and medicines and surgeries are killing people. Imperfection must be recognized and minimized. Trying always to avoid it can lead us farther from where we want to be.

Let’s work together. Let’s be honest, clear and, above all else, employ common sense in the treatment and monitoring of others.

John Mandrola is a cardiologist who blogs at Dr John M.

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  • Guest

    I would disagree with the EP example. Alarms are going off inanely in EVERY area of the hospital. Having both been a patient and a physician I can attest to this.

    So cool that JCAHO finds alarm fatigue to be a concern! Then, if you turn off alarms, they will cite you for not having appropriate alarms.

    We are moving further and further away from good patient care and common sense everyday (much to my chagrin).

  • Sara Stein MD

    It’s not really fatigue, it’s accommodation – our brains turn off a response to a constant signal. Part of the problem is the exquisite sensitivity of monitoring devices. The patient turns or scratches or coughs and alarms go off. Maybe we need to stop trying to catch every PVC, and turn down the sensitivity so they alarm when needed, when there’s a sustained change. Ohhhh, but that would cause the nervous hospital attorney alarm to sound!

  • rbthe4th2

    The best line: “Lets work together”. I said that on my last doc. It didn’t work out, he was the captain of the ship, and I was the deck hand. When my life was not considered, he wondered why I didn’t obey every command like a 3rd year med student. Did I obey as much as possible? Yes, but it got too much because I couldn’t pay for everything or accomodate all his wishes. My work and family would have no idea what was going on, we were never informed about what was happening. We turned to the internet.
    and we turned to passing the word along that this doc maybe needed fewer patients so he could provide better quality care to all.

  • Rob Burnside

    Interesting post, Dr. Mandrola, and I can immediately think of several other examples of alarm fatigue that should be studied. Although we’re talking a 20-30 year career vs. a week in CCU, professional firefighters are, in my opinion, at extreme risk. Of the ten men I began work with in 1977, half are dead, and only one made it into his 70s. Another, our Lieutenant, coded in the fire station just as the alarm sounded. On the flip side, high rise residents sometimes suffer another form of alarm fatigue: frequent false alarms cause them to ignore the sound of the fire alarm, with potentially dire consequences. Alarms are absolutely necessary in certain settings, but somehow, they need to be made less alarming, if that makes any sense at all. I can offer this: we had a wonderful fire dispatch operator, Paula, who had a voice similar to Hal the Computer in “2001 -Space Odyssey” and the sound of her voice alone would drop our heart rates from “off the charts” to near normal–exactly the way you want to be, rolling down the street in a 15 ton fire engine.

  • medicontheedge

    “How often does the train go by?” “So often you won’t even notice it.”
    Jake & Elwood Blues

    Alarm fatigue is a REAL issue that needs to be addressed, whatever terminology we use. In our ED, it is a problem, that HAS caused patient harm, and will contribute again if we don’t fix it.
    Too many patients are on monitors that don’t need to be, and those that do are hooked up to monitors that are not “customized” to reflect that particular patients issues. As an example, the monitor will alarm for the pacemaker malfunctioning, when the patient does not have a pacer. Add to that, our admin has determined that the ED secretary is to “watch” the monitors. Few of them actually have had the training to recognize a problem, and often either totally ignore the alarm, or just silence it. Even after a “Sentinel event”, where actual patient harm occurred, and many meetings were held, nothing has been done, because that would actually involve holding nurses and other staff accountable for monitor alarms and parameters, and we don’t want to hurt anyone’s feelings.
    I am no fan of the Mafia-like extortionist tactics of JHACO, but this is one area where they may actually be effective in making positive changes.

  • T H

    Some things don’t need alarms. The ultrasound machine? The GlideScope? No. If they are unplugged, they don’t need to beep until the battery level hits low. Yet, this adds to the background noise that suppresses ‘true alarms.’ And in the ER, for pity’s sake, have the cops, the EMTs, and the other first responders TURN DOWN THEIR DAMN RADIOS!

    There is data to support most any position: the signal to noise ratio for EBM about proper monitoring is just as bad as the monitoring itself.