Alarm fatigue in nursing is a term familiar to most in healthcare, but many don't fully understand why it's a real and present danger to patient safety, or how to systematically fix the problem.

Alarms and alerts are designed to help healthcare professionals, especially nurses and patient care techs, stay attuned to patient health. When there is unrelenting noise in the clinical environment, desensitization to individual alarms, alerts, and notifications begins to occur. 

And this can be dangerous.

Alarm and alert overload causes harm

According to Kathleen Gaines, BSN, RN, BA, CBC, writing for nurse.org, “Alarm fatigue is one of the most troubling and highly researched issues in nursing.” A search for recent scholarly articles on the issue garners little data, but Gaines wrote that, over the last two decades, research has uncovered staggering statistics related to alarm fatigue and false alarms, including the following:

  • The Food and Drug Administration reported more than 560 alarm-related deaths in the U.S. between 2005 and 2008.

  • Between January 2009 and June 2012, hospitals nationwide reported 80 deaths and 13 severe injuries.

  • One study showed that more than 85% of all alarms in a particular unit were false.

  • One hospital reported an average of one million alarms going off in a single week.

  • A children’s hospital reported 5,300 alarms in a day—95% of them false.

  • A hospital reported at least 350 alarms per patient per day in the intensive care unit.

Alarm, alert, and notification overload was listed as number six in The Top Ten Health Technology Hazards for 2020, published by ECRI. According to the executive brief, notification overload focuses on the cumulative cognitive load of all notifications that clinicians experience and how it affects their work. The brief suggests that healthcare should consider the global notification burden as a legitimate factor affecting work, along with time pressures and competing administrative or clinical tasks.

Finally, the brief states that while improving clinical alarm system safety is a Joint Commission National Patient Safety Goal, universal solutions have yet to be identified to provide a systematic and coordinated approach to alarm management.

The bottom line is that alarm fatigue is a real and present danger, and in healthcare we see it daily.

Oh, wait—it’s a false alarm

“Medical alarms are meant to alert medical staff when a patient’s condition requires immediate attention,” according to Jordan Rosenfeld for Patient Safety and Quality Healthcare (PSQH). “Unfortunately, there are so many false alarms...as much as 72% to 99% of the time.” A study published in 2016 by Healthcare Informatics Research cited medical staff that encountered 771 patient alarms per day.

As an example, hospitals often use telemetry to measure and transmit information about patient conditions. Electrocardiogram (ECG) monitors, blood pressure monitors, respiratory rate monitors, and SpO2 (oxygenation) and dialysis machines are examples of telemetry equipment that issue alarms and alerts. False alarms can happen for a wide variety of reasons, including:

  • Highly sensitive monitors
  • Inadequate leads or wires
  • Leads detaching from the patient
  • Alarm settings not tailored for the individual patient
  • Hospital default settings left in place
  • Deficiencies in programming algorithms

Bedside monitors can and do generate false alarms as well. To the high number of false alarms,  add the general noise in the clinical environment. For nurses, it’s difficult enough to pay attention to tasks at hand amid the high level of noise constantly coming at you throughout your shift. But false alarms make it even harder to know when you are dealing with a critical situation. As a result, let’s dig a little deeper into the dangers.

Why is alarm fatigue dangerous?

I wrote about the types of alarms and alerts, and notifications hospitals use to monitor patients in the first post in this series. The combination of notifications, multiplied by the high number of patients assigned in a typical 12-hour shift, can desensitize a nurse. This desensitization can cause issues in the following primary areas:

  • Patient safety events

  • Nurse burnout

  • Patient dissatisfaction

1. It can lead to patient safety events

We've discussed that extended exposure to a cacophony of noise throughout a shift can cause nurses and others to become desensitized to the sounds of alarms. But they also may find it challenging to differentiate between urgent and less urgent warnings.

“As a result, nurses may miss necessary alarms, which interrupts care, contributes to job-related burnout, and compromises patient safety,” states Jordan Rosenfeld, writing for Patient Safety & Quality Healthcare (PSQH.)

Rosenfeld wrote that the FDA reported 566 alarm-related deaths in 2005-2008, and 80 deaths and 13 severe alarm-related injuries between January 2009 and June 2012. According to the article, the problem had become so significant that in 2008 ECRI began including false alarms on its list of Top 10 Health Technology Hazards.

The Joint Commission, the nation’s most followed hospital accrediting body, attributed 80 deaths and 13 serious injuries to alarm-related failures in a recent four-year period. Hospitals accredited by The Joint Commission must comply with this National Patient Safety Goal related to alarms, which was a significant announcement when it debuted in 2014 and was enforced beginning in 2016. In 2020, alarm, alert, and notification overload ranked sixth in hazard status according to The Joint Commission.

The root of the alarm fatigue problem is that as provider, we monitor patients to watch trends in their clinical data, especially for physiologic monitors. Let's break down a realistic example of how alarm fatigue can jeopardize patient safety:

  • A nurse happens to miss that a patient’s heart rate is slowly rising over time, and she is ignoring and/or silencing the alarms, missing the patterns.
  • The nurse may not see that the pulse ox is trending down (e.g., it might dip to the lower eighties and then pop back up and dip down again)
  • She may not be aware because she is getting inundated with so many alerts that they become meaningless to her, and she misses an early warning that something is going on with this patient.
  • Because she’s gotten multiple signals for each of her patients, she’s struggling to absorb all of it and to cognitively differentiate between the noises and the ones that are vital indicators of real problems.

In fact, federal investigators concluded that alarm fatigue experienced by nurses working among constantly beeping monitors contributed to the death of a heart patient at Massachusetts General Hospital in January 2010. 

2. It can lead to nurse burnout

Not only are nurses are a vital part of healthcare, but they also compose the largest segment of healthcare providers. According to the World Health Statistics Report, there are approximately 29 million nurses and midwives globally, with 3.9 million of those individuals in the U.S. The World Health Organization had estimated that close to one million additional nurses would be needed by 2020. And that was before the onset of the COVID-19 Pandemic.

For myriad reasons, nurses are burning out. According to Thomas Reith, in his peer-reviewed article, “Burnout in United States Healthcare Professionals: A Narrative Review,” burnout is a combination of exhaustion, cynicism, and perceived inefficacy resulting from long-term job stress. “The consequences of burnout are not limited to the personal well-being of healthcare workers,” he wrote. “Many studies have demonstrated that provider burnout is detrimental to patient care.”

In 2019, privately-held healthcare research and consulting firm PRC published a study focusing on the implications of nurse burnout. According to the research, “Trends and Implications with Nursing Engagement,” 15.6% of all nurses reported feelings of burnout, with the percentage rising to 41% of “unengaged” nurses. The PRC study defined unengaged nurses as nurses who:

  • May not be part of a team with their colleagues

  • Have diminished morale

  • Feel emotionally checked out from their work (which ultimately affects their patient care)

“What’s really interesting as well, is that 50% of nurses who reported feeling burned out also reported that they had no plans to leave their organization—pointing to the importance of supporting and meeting nurses where they are at in the workforce,” wrote Chaunie Brusie, for nurse.org.

Alarm fatigue has been documented as adding to nurse burnout. Nurses try to manage the high levels of noise and distraction while providing high-quality patient care to as many as eight patients during a 12-hour (or longer) shift. Nurses struggling with alarm and alert fatigue can slide into burnout and decreased engagement, and then run the risk of missing important notifications on their patient’s conditions.

3. It can cause patient dissatisfaction

Patients struggle with alarm fatigue too, which negatively affects patient satisfaction. The constant alerting and the overwhelming noise surrounding them prevents them from resting and sleeping. They often wait for long periods until a nurse or an aide comes to turn off a beeping monitor or blaring alarm.

Noise is often a top complaint for hospitals. Patients express that they are left stranded, having to endure the noise while nurses and aides attend to other patients or other responsibilities. “Tens of thousands of alarms shriek, beep, and buzz every day in every U.S. hospital,” Melissa Bailey wrote for Kaiser Health News. “All sound urgent, but few require immediate attention or get it. Intended to keep patients safe alerting nurses to potential problems, they also create a riot of disturbances for patients trying to heal and get some rest.”

“Patient satisfaction is an important and commonly used indicator for measuring the quality in healthcare,” according to Bhanu Prakash in an article published in the Journal of Cutaneous and Aesthetic Surgery. And of course, he’s right. For the hospital, patient satisfaction can affect clinical outcomes, patient retention, frequency of medical malpractice claims, and more. As Prakash pointed out, patient satisfaction affects the timely, efficient, and patient-centered delivery of quality healthcare. It reflects on the patient’s perception of the care he or she has received and may even impact healing.

“Some studies have found during a day at the hospital, noise levels are 72 decibels, which is the same as running a vacuum cleaner,” according to Morgan Haefner for Becker’s Hospital Review. A study published by Johns Hopkins counted the number of alarms that went off over 12 days, and it amounted to an average of 350 alarms per patient each day. For one type of breathing monitor, 90% of the warnings were false positives.

Hospitals across the country are actively searching for methods of reducing the noise levels–for clinicians and patients. That means finding ways to decrease the number of alarms, alerts, and notifications while at the same time finding ways to lower the volume on the remaining alarms. It’s a work in progress.

In my third post, I describe how organizations are developing solutions to reduce the number and volume of the alarms, alerts, and notifications generated in-hospital patient monitoring.

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