Acta Pædiatrica ISSN 0803-5253
EDITORIAL DOI:10.1111/apa.12953
The potential for harm from alarm fatigue in single-room NICUs Increasing numbers of NICUs have designed single-familyrooms to create individualised environments for critically ill newborns and their families. While many advantages of these environments have been identified, one challenge is the ability to safely and effectively alert caregivers to alarms generated when physiologic derangements occur (1,2). When moving from a multibed environment to single rooms, there is a tendency for teams to select conservative alarm limits to reassure staff concerned about the loss of immediate visual contact with the child. While well intentioned, this may lead to an excessive number of alarms and what has been termed alarm fatigue: the tendency for caregivers to miss true alarms because the frequency of false alarms is overwhelming and dwarfs the number of true alarms (3). Alarm fatigue has been linked to patient deaths and has become a major patient safety issue. In the United States, the Joint Commission published a Sentinel Event Alert in 2013 noting that the ‘tens of thousands of alarm signals’ heard daily in a hospital desensitises the staff and leads to ‘a failure to respond to appropriate alarm signals in a timely manner’, which can result in ‘serious, often fatal, consequences’ (3). The commission subsequently designated alarm management as a priority national patient safety goal in 2014 and has set compliance deadlines for inpatient units, including the NICU, to establish procedures and educate staff about alarm management (4). Similarly, the international nonprofit patient care organisation ECRI Institute has ranked alarm hazards as the top health technology hazard for 2015 (5). In this issue, Pul and colleagues conducted a high-quality evaluation of the development and outcomes of a decentralised monitoring system in a small 18 bed Level 3 NICU with 380 admissions per year. The monitoring system used included a monitor in the room, an interbed communication system, and a central monitor. Alarms from the central monitoring system were transferred to an Emergin server, and then distributed to hand-held devices via a wireless call system. The nursing ratio varied by shift between 6 and 8 nurses caring for an average of 13 patients. Each nurse was assigned a buddy nurse who received a repeat alarm if the first nurse did not respond within 45 sec. Before implementing the system, the multidisciplinary team conducted a risk analysis of the proposed new system using Healthcare Failure Mode and Effect analysis (HFMEA). The team assessed the risks of different types of alarms, possible failure modes and the severity of possible outcomes ranging from no effect to severe injury or death. Using this classification system, alarms were assigned two levels of alarm urgency: red alarms – acute derangements that could lead to life threatening conditions; or yellow alarms – not
436
life threatening but out of predefined physiologic limits. Only red alarms were distributed to the nurses’ hand-held devices. Red alarms over a one-year period were the subject of this evaluation. Over a one-year period, 222 751 alarms were generated, equivalent to 25 alarms per hour or 2 alarms per patient per hour. The leading cause of this staggering number of red alarms was alerts from pulse oximeters for oxygen desaturation. 97% of all alarms were answered within 45 sec. The study did not catalogue the number of yellow alarms, but it is highly likely that these occurred at even higher rates. The authors conclude that monitoring in a single-room environment is challenging, but safe and possible. The authors are to be commended for their systematic approach to the implementation of a new NICU environment. What can we learn from this work? The potential for alarm fatigue is real and equally serious to the possibility of missing a true but relatively minor alert. When designing new monitoring systems, teams must resist the natural feardriven tendency to increase the number of alarms. A technique such as the HFMEA in a multidisciplinary team that includes a professional skilled in technology will allow the unique features of each NICU to be accurately assessed with an individualised plan developed for that specific NICU. In addition, work is needed on the impact of individualising alarms to the unique patient circumstances. More work is needed from designers and vendors of monitoring system. Current systems do not incorporate a time factor but only a threshold – thus, a red alarm would be generated at the same saturation level whether it lasted 1-sec or 30 sec. The addition of a time criteria to a threshold criteria would filter out many loss of signal alarms and other brief but self-limited events. In neonates, multiple parameters derange together – for example, an apnoea will lead to a desaturation and a bradycardia. Enhanced systems could recognise these time-linked events and correctly recognise them as one event – again minimising alarm fatigue and enhancing the recognition of true events. To further supplement physiologic assessments, some NICUs have added web cameras, which are focused on the face of the
ª2015 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2015 104, pp. 436–437
Editorial
baby and displayed outside the room. In this way, nurses can quickly assess the position of the infant, cyanosis, and the status of the airway – enhancing the information received from the physiologic monitor. Perhaps the broader lesson to be learned is that adapting the NICU environment to improve one element such as the ability to individualise light and sound, and to enhance family centred care, can have other consequences. Alarm fatigue may be one of those consequences. Other reported unintended consequences of single-family-room designs include a decrease in the infant’s exposure to meaningful speech with effects lasting to 1 year of age (6,7). Physicians and nurses must be mindful of this and speak to the infant during assessments, as well as encourage families to interact with the baby with speech and reading. Another unintended consequence is disruption of informal training of younger nursing and physician staff by more senior staff. In a multibed environment, younger staff had the opportunity to witness how more senior staff assessed complex patients or interacted with families in stressful settings. This informal learning system is disrupted in a single-room environment in ways that we are only beginning to learn and address. Single-room NICUs are welcomed by families and by staff, but we must be mindful of unintended consequences.
Editorial
Michele C. Walsh ([email protected]), Elizabeth Powers, Jonathan Fanaroff, Case Western Reserve University, Rainbow Babies & Childrens Hospital, Cleveland, OH, USA
References 1. White RD. The newborn intensive care unit environment of care: how we got here, where we’re headed, and why. Semin Perinatol 2011; 35: 2–7. 2. Walsh WF, McCullough KL, White RD. Room for improvement: nurses’ perceptions of providing care in a single room newborn intensive care setting. Adv Neonatal Care 2006; 6: 261–70. 3. The Joint Commission Sentinel Event Alert: Medical device alarm safety in hospitals. Issue 50, April 8, 2013. 4. The Joint Commission: National Patient Safety Goals 2014. Perspectives 33:14, 2013. 5. ECRI Institute: Alarm safety resource center: Guidance and tools to help healthcare facilities improve alarm safety. Health Devices, November 2014. Accessed on line at https://www.ecri.org/ resource-center/Pages/Alarms.aspx, January 13, 2015. 6. Caskey M, Stephens B, Tucker R, Vohr B. Adult talk in the NICU with preterm infants and developmental outcomes. Pediatrics 2014; 133: e578–84. 7. Pineda RG, Stransky KE, Rogers C, Duncan MH, Smith GC, Neil J, et al. The single-patient room in the NICU: maternal and family effects. J Perinatol 2012; 32: 545–51.
ª2015 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2015 104, pp. 436–437
437
Copyright of Acta Paediatrica is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
EDITORIAL DOI:10.1111/apa.12953
The potential for harm from alarm fatigue in single-room NICUs Increasing numbers of NICUs have designed single-familyrooms to create individualised environments for critically ill newborns and their families. While many advantages of these environments have been identified, one challenge is the ability to safely and effectively alert caregivers to alarms generated when physiologic derangements occur (1,2). When moving from a multibed environment to single rooms, there is a tendency for teams to select conservative alarm limits to reassure staff concerned about the loss of immediate visual contact with the child. While well intentioned, this may lead to an excessive number of alarms and what has been termed alarm fatigue: the tendency for caregivers to miss true alarms because the frequency of false alarms is overwhelming and dwarfs the number of true alarms (3). Alarm fatigue has been linked to patient deaths and has become a major patient safety issue. In the United States, the Joint Commission published a Sentinel Event Alert in 2013 noting that the ‘tens of thousands of alarm signals’ heard daily in a hospital desensitises the staff and leads to ‘a failure to respond to appropriate alarm signals in a timely manner’, which can result in ‘serious, often fatal, consequences’ (3). The commission subsequently designated alarm management as a priority national patient safety goal in 2014 and has set compliance deadlines for inpatient units, including the NICU, to establish procedures and educate staff about alarm management (4). Similarly, the international nonprofit patient care organisation ECRI Institute has ranked alarm hazards as the top health technology hazard for 2015 (5). In this issue, Pul and colleagues conducted a high-quality evaluation of the development and outcomes of a decentralised monitoring system in a small 18 bed Level 3 NICU with 380 admissions per year. The monitoring system used included a monitor in the room, an interbed communication system, and a central monitor. Alarms from the central monitoring system were transferred to an Emergin server, and then distributed to hand-held devices via a wireless call system. The nursing ratio varied by shift between 6 and 8 nurses caring for an average of 13 patients. Each nurse was assigned a buddy nurse who received a repeat alarm if the first nurse did not respond within 45 sec. Before implementing the system, the multidisciplinary team conducted a risk analysis of the proposed new system using Healthcare Failure Mode and Effect analysis (HFMEA). The team assessed the risks of different types of alarms, possible failure modes and the severity of possible outcomes ranging from no effect to severe injury or death. Using this classification system, alarms were assigned two levels of alarm urgency: red alarms – acute derangements that could lead to life threatening conditions; or yellow alarms – not
436
life threatening but out of predefined physiologic limits. Only red alarms were distributed to the nurses’ hand-held devices. Red alarms over a one-year period were the subject of this evaluation. Over a one-year period, 222 751 alarms were generated, equivalent to 25 alarms per hour or 2 alarms per patient per hour. The leading cause of this staggering number of red alarms was alerts from pulse oximeters for oxygen desaturation. 97% of all alarms were answered within 45 sec. The study did not catalogue the number of yellow alarms, but it is highly likely that these occurred at even higher rates. The authors conclude that monitoring in a single-room environment is challenging, but safe and possible. The authors are to be commended for their systematic approach to the implementation of a new NICU environment. What can we learn from this work? The potential for alarm fatigue is real and equally serious to the possibility of missing a true but relatively minor alert. When designing new monitoring systems, teams must resist the natural feardriven tendency to increase the number of alarms. A technique such as the HFMEA in a multidisciplinary team that includes a professional skilled in technology will allow the unique features of each NICU to be accurately assessed with an individualised plan developed for that specific NICU. In addition, work is needed on the impact of individualising alarms to the unique patient circumstances. More work is needed from designers and vendors of monitoring system. Current systems do not incorporate a time factor but only a threshold – thus, a red alarm would be generated at the same saturation level whether it lasted 1-sec or 30 sec. The addition of a time criteria to a threshold criteria would filter out many loss of signal alarms and other brief but self-limited events. In neonates, multiple parameters derange together – for example, an apnoea will lead to a desaturation and a bradycardia. Enhanced systems could recognise these time-linked events and correctly recognise them as one event – again minimising alarm fatigue and enhancing the recognition of true events. To further supplement physiologic assessments, some NICUs have added web cameras, which are focused on the face of the
ª2015 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2015 104, pp. 436–437
Editorial
baby and displayed outside the room. In this way, nurses can quickly assess the position of the infant, cyanosis, and the status of the airway – enhancing the information received from the physiologic monitor. Perhaps the broader lesson to be learned is that adapting the NICU environment to improve one element such as the ability to individualise light and sound, and to enhance family centred care, can have other consequences. Alarm fatigue may be one of those consequences. Other reported unintended consequences of single-family-room designs include a decrease in the infant’s exposure to meaningful speech with effects lasting to 1 year of age (6,7). Physicians and nurses must be mindful of this and speak to the infant during assessments, as well as encourage families to interact with the baby with speech and reading. Another unintended consequence is disruption of informal training of younger nursing and physician staff by more senior staff. In a multibed environment, younger staff had the opportunity to witness how more senior staff assessed complex patients or interacted with families in stressful settings. This informal learning system is disrupted in a single-room environment in ways that we are only beginning to learn and address. Single-room NICUs are welcomed by families and by staff, but we must be mindful of unintended consequences.
Editorial
Michele C. Walsh ([email protected]), Elizabeth Powers, Jonathan Fanaroff, Case Western Reserve University, Rainbow Babies & Childrens Hospital, Cleveland, OH, USA
References 1. White RD. The newborn intensive care unit environment of care: how we got here, where we’re headed, and why. Semin Perinatol 2011; 35: 2–7. 2. Walsh WF, McCullough KL, White RD. Room for improvement: nurses’ perceptions of providing care in a single room newborn intensive care setting. Adv Neonatal Care 2006; 6: 261–70. 3. The Joint Commission Sentinel Event Alert: Medical device alarm safety in hospitals. Issue 50, April 8, 2013. 4. The Joint Commission: National Patient Safety Goals 2014. Perspectives 33:14, 2013. 5. ECRI Institute: Alarm safety resource center: Guidance and tools to help healthcare facilities improve alarm safety. Health Devices, November 2014. Accessed on line at https://www.ecri.org/ resource-center/Pages/Alarms.aspx, January 13, 2015. 6. Caskey M, Stephens B, Tucker R, Vohr B. Adult talk in the NICU with preterm infants and developmental outcomes. Pediatrics 2014; 133: e578–84. 7. Pineda RG, Stransky KE, Rogers C, Duncan MH, Smith GC, Neil J, et al. The single-patient room in the NICU: maternal and family effects. J Perinatol 2012; 32: 545–51.
ª2015 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2015 104, pp. 436–437
437
Copyright of Acta Paediatrica is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
