International Emergency Nursing xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Emergency Nursing journal homepage: www.elsevier.com/locate/aaen
Whats that noise? Bedside monitoring in the Emergency Department Rob B. Way MSc PG Dip Ed RNT RN, Consultant Nurse a,⇑, Sally A. Beer Dip RN, Research Nurse a, Sarah J. Wilson FCEM, Consultant b a b
Emergency Department, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, United Kingdom Emergency Department, Wexham Park Hospital, Slough, Bucks SL2 4HL, United Kingdom
a r t i c l e
i n f o
Article history: Received 10 September 2013 Received in revised form 7 January 2014 Accepted 12 January 2014 Available online xxxx Keywords: Monitor alarms Alarm noise Patient monitoring Patient deterioration Alarm fatigue Emergency
a b s t r a c t Objective: To determine the frequency, duration and type of audible monitor alarms in an ED, utilising the standard manufacturer’s classification. Methods: The audible monitor alarms and the timing of any intervention related to the patient monitoring was observed and recorded. Results: 110 Patients admitted to the Majors area or Resuscitation Room were observed for a total of 93 hours. One monitor was observed at a time. Alarm noise was generated 29% of the observation time. Overall, 429 alarms lasting 21 hours 27 minutes were judged to be positive and 143 alarms lasting 5 hours 47 minutes, negative. 74% of Resuscitation Room and 47% of Majors alarms were silenced or paused. Alarm limit parameters were only adjusted after 5% of alarms in Resuscitation Room and 6% of alarms in Majors. Conclusions: Whilst high level monitoring is desired from a patient safety perspective, it contributes to a significant ambient noise level, which is recognised by all who pass through an ED, and can be detrimental to patients, relatives and staff. We have demonstrated that there is a high probability of near-continuous alarm noise from patient monitoring in a 10-bedded Majors area. We make suggestions for methods of noise reduction and intend to implement some of these within our own ED. Ó 2014 Elsevier Ltd. All rights reserved.
Introduction Semi-automated bedside monitors have been in use in critical care units within hospitals for many years, in line with health planning guidance (Department of Health, 2003, 2013a). This has enabled continuous monitoring of heart rate, ECG, respiratory rate, oxygen saturation, end-tidal carbon dioxide, invasive blood pressure and intermittent non-invasive blood pressure. In Emergency Departments (ED) there are clear clinical standards for monitoring patients undergoing procedural sedation in Resuscitation Rooms (College of Emergency Medicine & Royal College of Anaesthetists, 2012). However, there is no generic recommendation about the level of monitoring required in ED from the Royal College of Nursing, College of Emergency Medicine, or in the Health Building Notes 15-01; Emergency Departments (Department of Health, 2013b). This has probably been a contributing factor to the sporadic and relatively recent adoption of integrated monitoring systems across ED witnessed by the authors. As part of redevelopment programme in 2002, the ED of the John Radcliffe Hospital, Oxford University Hospitals NHS Trust ⇑ Corresponding author. Tel.: +44 01865 741166. E-mail address: [email protected] (R.B. Way).
had an integrated monitoring system installed in the Resuscitation Room and Majors area. The Resuscitation Room is a 4-bedded area, staffed by two registered nurses, providing the highest level of care in the ED. Majors is a 10-bedded area, staffed by two registered nurses, providing the next level of care for adults, but excluding those patients with minor injuries or illness. This improved access to equipment has provided the opportunity to continuously monitor a larger number of patients. Monitors are wall mounted, at the bedside, with a central station on the nurses’ desk echoing the bedside alarm. Whilst the availability of equipment at each patient’s bedside in an ED can be viewed as a positive step in meeting the standard for early recording of vital signs (National Institute for Health and Care Excellence, 2007; College of Emergency Medicine, 2012). Little or no evaluation of using continuous monitoring systems in UK emergency care has been undertaken. Patients in the ED where the study was completed have continuous vital sign monitoring using these monitors. As part of the standard safety features, the monitors have manufacturerset alarms associated with abnormally high and low values for each of the vital sign parameters recorded, and for ECG interpretation. These alarms can be set to a new value, as determined by the nurse, although they reset to the factory settings once the monitor has been turned off.
http://dx.doi.org/10.1016/j.ienj.2014.01.001 1755-599X/Ó 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Way, R.B., et al. Whats that noise? Bedside monitoring in the Emergency Department. Int. Emerg. Nurs. (2014), http:// dx.doi.org/10.1016/j.ienj.2014.01.001
2
R.B. Way et al. / International Emergency Nursing xxx (2014) xxx–xxx
Within the ED staff and patients are subjected to a high frequency of multiple alarms causing disturbing background noise. Background noise, including that generated due to transient artefact from the automated recordings, has been measured in an Intensive Care Unit (ICU) setting to reach 80 dB(A) (Balogh et al., 1993; Christensen, 2007). Christensen (2007) also notes that the Health and Safety Executive (2005) stipulates that noise levels within a work place should not exceed 85 dB(A). Moreover, the frequency of false alarms can lead to a situation where alarms are ignored, as was found in three international studies of critical care monitoring systems (Phillips and Barnsteiner, 2005; Graham and Cvach, 2010; Siebig et al., 2010). Whilst these studies are useful in identifying the nature and frequency of these alarms in critical care settings, there have been no published papers related to these phenomena in ED. This audit was completed as part of the background work related to our research into an integrated monitoring system using data fusion technology to detect deterioration in patients (REC no. 08/H1307/56). For this reason we did not consider alarms from other sources or the noise level of the alarms. Objective Determine the frequency, duration and type of the monitor alarms in an ED, utilising the standard classification provided by the manufacturer. Methods This study was assessed by the local ethics committee chair not to require ethical approval. Three research nurses who are experienced in emergency care and are known to the remainder of the clinical staff undertook
Table 2 Study time in each area. Number of observation periods Resuscitation Room Majors Total
Total time
61 49
53 hours 59 minutes 39 hours 3 minutes
110
93 hours 2 minutes
observation over a six-week winter period. This period sees a higher throughput of patients, which enabled an analysis of the nurses’ ability to respond when they were most busy, although they were never caring for more than five patients, as defined in departmental policy. The research nurses were non-participant observers with the caveat that they would intervene if they observed a life-threatening problem, however this did not occur during the audit. To reduce the possibility of sampling bias, monitored patients in four pre-selected cubicle spaces in the ED, two in ‘‘Majors’’ and two in the ‘‘Resuscitation Room’’, were observed. The allocation of patients to a specific cubicle was outside of the control of the research nurses, as was the staff : patient ratios in the department. One monitored patient was observed at a time, either until they were transferred from the cubicle or for a maximum period of one hour. The frequency, duration and type of any audible alarm related to the patient monitoring was noted. These alarms were classified using the manufacturer’s standard alarm definitions (see Table 1, Phillips, 2002). The timing of any intervention by the clinical emergency nurses in relation to the monitoring alarm was also observed and recorded. A silenced alarm had no audible tone for 1 minute, and a paused alarm had no audible tone for 3 minutes. The audible tone would recommence after this time interval if the alarm condition still existed, and was classified as another episode of alarm noise.
Table 1 Nature of alarms summarised from the manufacturer’s classification (Phillips, 2002). Colour
Sound
Condition
Summary
Red
High pitched sound, repeated once per second
Asystole Extreme Bradycardia Extreme Tachycardia Ventricular fibrillation Desaturation (10, R on T PVC, ST segment monitoring). In our study this would have reduced noise by 49 minutes (57 alarm episodes). We have now made this change within our own department. Earlier intervention by nursing staff to silence alarms (whilst taking note of their clinical relevance). From our data the nurses did silence 74% of Resuscitation Room alarms and 47% of Majors alarms, but there were delays in response time, as shown in Fig. 2. With an arbitrary target for response to an alarm of 30 seconds for red, 2 minutes for yellow, inoperative and ‘‘other’’, and removal of yellow short alarms, there is a potential noise saving of 14 hours 21 minutes, which is over half of the total duration of alarms recorded in this study. Adjustment of alarm parameters to suit each individual patient, as advised by the manufacturer’s guidance (Phillips, 2002) and from the literature (Phillips and Barnsteiner, 2005; Graham and Cvach, 2010). For example, adjusting the oxygen saturations alarm in a patient with COPD, or heart rate in a patient with tachycardia (where there is a management plan for that tachycardia). In our study, nurses only readjusted the alarm parameters in 5% of Resuscitation Room and 6% of Majors alarms of those that were silenced. In relation to individualising
Fig. 2. Probability of at least one monitor alarming at any point in time, based on a binomial probability of a monitor alarming at any point in time and the assumption that the monitors are independent of each other.
alarm thresholds for patients we cannot quantify the potential reduction this would result in, but these threshold-type alarms account for approximately one-third of all alarms that sounded in this audit. Avoiding ‘‘negative’’ alarms. For example apnoea in a breathing patient where the chest excursion is insufficiently detected by the ECG electrodes. This can be corrected by careful positioning of the monitoring leads (Phillips, 2002; Drew et al., 2004). In our sample, if all negative alarms were removed, this would reduce the alarm noise by 5 hours 29 minutes (138 alarms). Anticipation of alarms and silencing the monitor in advance (Siebig et al., 2010). For example when suctioning an intubated patient, taking a sample from an arterial line, or placing a saturation probe on the opposite arm to the blood pressure cuff would all assist in reducing noise. Consider whether all patients in the ED need to be continuously monitored, over and above timely intermittent recording of vital signs with the use of an early warning scoring system. Currently there is no evidence to support either of these strategies in preference to the other in the detection of deteriorating patients in the ED. We accept that some of this may be idealistic when the reality is that one nurse in Majors can be responsible 5 patients at a time,
Please cite this article in press as: Way, R.B., et al. Whats that noise? Bedside monitoring in the Emergency Department. Int. Emerg. Nurs. (2014), http:// dx.doi.org/10.1016/j.ienj.2014.01.001
R.B. Way et al. / International Emergency Nursing xxx (2014) xxx–xxx
and potentially overseeing 10 when a colleague is away from the area transferring a patient. However, we suggest that any noise reduction would improve the environment for both patients and staff. In addition, a reduction in frequency and duration of alarm noise may increase the likelihood of a timely response to a ‘‘true’’ alarm. Limitations Within this study we focused on the frequency and duration of alarms from monitors, as this was linked to our wider research interests in early detection of deterioration in patients in the ED. We chose not to record the actual noise level (dB(A)), as it would have included noise from many other sources. However, we acknowledge that the measurement of the noise level in ED would be useful as part of an overall strategy for reducing noise. Whilst the probability of near-continuous monitor alarm noise was found in our study, there are other alarms that contribute to the overall noise in ED. It would be useful to measure the frequency and duration of these; for example: patient call bells, attack alarms, emergency call alarms, ambulance priority phone, other phones, infusion pumps, fridge alarms and staff pagers. Within the study we recorded the timing and type of response to the alarm made by the nurse. Exploring what influences a nurse’s response to alarm noise would be an interesting area for further study that we believe would help in understanding and changing behaviour associated with alarms. Conclusion This study demonstrates that whilst high level monitoring is desired from a patient safety perspective, it contributes to a significant ambient noise level, which is recognised by all who pass through an ED, and can be detrimental to patients, relatives and staff. There is a high probability of near-continuous background alarm noise in a 10-bedded Majors area. We suggest that significant noise reduction can be achieved through a combination of turning off unhelpful alarms, setting target times to respond to alarms, adjusting alarm parameters to individual patients, reducing negative alarms by careful application of monitoring sensors and silencing alarms in anticipation of procedures known to cause alarms. We intend to implement some of these within our ED. This will require a significant culture change amongst all staff to become used to individualising alarms, responding to alarms in a timely way and learning to silence predictable alarms (e.g. before an intervention).
5
Acknowledgements Rymell, Soubera BSc RN and Warnes, Karen BSc RN, Research Nurses, Emergency Department participated in data collection for the study. Jacqueline Birks, Centre for Statistics in Medicine, University of Oxford, assisted with data analysis. The work described in this paper has been funded by the National Institute for Health Research Biomedical Research Centre, Oxford. The funder played no part in the design of the study or in the analysis of the results. References Balogh, D., Kittinger, E., Benzer, A., Hackl, J.M., 1993. Noise in the ICU. Intensive Care Medicine 19, 343–346. Christensen, M., 2007. Noise levels in a general intensive care unit: a descriptive study. Nursing in Critical Care 12 (4), 188–197. College of Emergency Medicine & Royal College of Anaesthetists, 2012. Safe Sedation of Adults in the Emergency Department. (accessed 30.12.13). College of Emergency Medicine, 2012. Clinical Standards for Emergency Departments. (accessed 30.12.13). Department of Health, 2003. Health Building Note 57: Facilities for Critical Care. (accessed 30.12.13). Department of Health, 2013a. Health Building Note 04-02: Critical Care Units. (accessed 30.12.13). Department of Health, 2013b. Health Building Note 15-01: Accident & Emergency Departments. (accessed 30.12.13). Drew, B.J., Califf, R.M., Funk, M., Kaufman, E.S., Krucoff, M.W., Laks, M.M., Macfarlane, P.W., Sommargren, C., Swiryn, S., Van Hare, G.F., 2004. Practice standards for electrocardiographic monitoring in hospital settings: an American heart association scientific statement from the councils on cardiovascular nursing, clinical cardiology, and cardiovascular disease in the young: endorsed by the international society of computerized electrocardiology and the American Association of Critical Care Nurses. Circulation, (accessed 30.12.13). Graham, K.C., Cvach, M., 2010. Monitor alarm fatigue: standardizing use of physiological monitors and decreasing nuisance alarms. American Journal of Critical Care 19, 28–34. Hannibal, G.B., 2011. Monitor alarms and alarm fatigue. ACCN Advanced Critical Care 22 (4), 418–420. Health and Safety Executive, 2005. Noise at Work Regulations. (accessed 14.05.13). National Institute for Health and Care Excellence, 2007. Acutely Ill Patients in Hospital: Recognition of and Response to Acute Illness in Adults in Hospital. (accessed 14.5.13). Phillips, 2002. IntelliVue Patient Monitoring Guidance. (accessed 14.5.13). Phillips, J., Barnsteiner, J.H., 2005. Clinical alarms. Improving efficiency and effectiveness. Critical Care Nursing Quarterly 28 (4), 317–323. Siebig, S., Kuhls, S., Imhoff, M., Scholmerich, J., Wrede, C., 2010. Intensive care unit alarms – how many do we need? Critical Care Medicine 38 (2), 451–456.
Please cite this article in press as: Way, R.B., et al. Whats that noise? Bedside monitoring in the Emergency Department. Int. Emerg. Nurs. (2014), http:// dx.doi.org/10.1016/j.ienj.2014.01.001
Contents lists available at ScienceDirect
International Emergency Nursing journal homepage: www.elsevier.com/locate/aaen
Whats that noise? Bedside monitoring in the Emergency Department Rob B. Way MSc PG Dip Ed RNT RN, Consultant Nurse a,⇑, Sally A. Beer Dip RN, Research Nurse a, Sarah J. Wilson FCEM, Consultant b a b
Emergency Department, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, United Kingdom Emergency Department, Wexham Park Hospital, Slough, Bucks SL2 4HL, United Kingdom
a r t i c l e
i n f o
Article history: Received 10 September 2013 Received in revised form 7 January 2014 Accepted 12 January 2014 Available online xxxx Keywords: Monitor alarms Alarm noise Patient monitoring Patient deterioration Alarm fatigue Emergency
a b s t r a c t Objective: To determine the frequency, duration and type of audible monitor alarms in an ED, utilising the standard manufacturer’s classification. Methods: The audible monitor alarms and the timing of any intervention related to the patient monitoring was observed and recorded. Results: 110 Patients admitted to the Majors area or Resuscitation Room were observed for a total of 93 hours. One monitor was observed at a time. Alarm noise was generated 29% of the observation time. Overall, 429 alarms lasting 21 hours 27 minutes were judged to be positive and 143 alarms lasting 5 hours 47 minutes, negative. 74% of Resuscitation Room and 47% of Majors alarms were silenced or paused. Alarm limit parameters were only adjusted after 5% of alarms in Resuscitation Room and 6% of alarms in Majors. Conclusions: Whilst high level monitoring is desired from a patient safety perspective, it contributes to a significant ambient noise level, which is recognised by all who pass through an ED, and can be detrimental to patients, relatives and staff. We have demonstrated that there is a high probability of near-continuous alarm noise from patient monitoring in a 10-bedded Majors area. We make suggestions for methods of noise reduction and intend to implement some of these within our own ED. Ó 2014 Elsevier Ltd. All rights reserved.
Introduction Semi-automated bedside monitors have been in use in critical care units within hospitals for many years, in line with health planning guidance (Department of Health, 2003, 2013a). This has enabled continuous monitoring of heart rate, ECG, respiratory rate, oxygen saturation, end-tidal carbon dioxide, invasive blood pressure and intermittent non-invasive blood pressure. In Emergency Departments (ED) there are clear clinical standards for monitoring patients undergoing procedural sedation in Resuscitation Rooms (College of Emergency Medicine & Royal College of Anaesthetists, 2012). However, there is no generic recommendation about the level of monitoring required in ED from the Royal College of Nursing, College of Emergency Medicine, or in the Health Building Notes 15-01; Emergency Departments (Department of Health, 2013b). This has probably been a contributing factor to the sporadic and relatively recent adoption of integrated monitoring systems across ED witnessed by the authors. As part of redevelopment programme in 2002, the ED of the John Radcliffe Hospital, Oxford University Hospitals NHS Trust ⇑ Corresponding author. Tel.: +44 01865 741166. E-mail address: [email protected] (R.B. Way).
had an integrated monitoring system installed in the Resuscitation Room and Majors area. The Resuscitation Room is a 4-bedded area, staffed by two registered nurses, providing the highest level of care in the ED. Majors is a 10-bedded area, staffed by two registered nurses, providing the next level of care for adults, but excluding those patients with minor injuries or illness. This improved access to equipment has provided the opportunity to continuously monitor a larger number of patients. Monitors are wall mounted, at the bedside, with a central station on the nurses’ desk echoing the bedside alarm. Whilst the availability of equipment at each patient’s bedside in an ED can be viewed as a positive step in meeting the standard for early recording of vital signs (National Institute for Health and Care Excellence, 2007; College of Emergency Medicine, 2012). Little or no evaluation of using continuous monitoring systems in UK emergency care has been undertaken. Patients in the ED where the study was completed have continuous vital sign monitoring using these monitors. As part of the standard safety features, the monitors have manufacturerset alarms associated with abnormally high and low values for each of the vital sign parameters recorded, and for ECG interpretation. These alarms can be set to a new value, as determined by the nurse, although they reset to the factory settings once the monitor has been turned off.
http://dx.doi.org/10.1016/j.ienj.2014.01.001 1755-599X/Ó 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Way, R.B., et al. Whats that noise? Bedside monitoring in the Emergency Department. Int. Emerg. Nurs. (2014), http:// dx.doi.org/10.1016/j.ienj.2014.01.001
2
R.B. Way et al. / International Emergency Nursing xxx (2014) xxx–xxx
Within the ED staff and patients are subjected to a high frequency of multiple alarms causing disturbing background noise. Background noise, including that generated due to transient artefact from the automated recordings, has been measured in an Intensive Care Unit (ICU) setting to reach 80 dB(A) (Balogh et al., 1993; Christensen, 2007). Christensen (2007) also notes that the Health and Safety Executive (2005) stipulates that noise levels within a work place should not exceed 85 dB(A). Moreover, the frequency of false alarms can lead to a situation where alarms are ignored, as was found in three international studies of critical care monitoring systems (Phillips and Barnsteiner, 2005; Graham and Cvach, 2010; Siebig et al., 2010). Whilst these studies are useful in identifying the nature and frequency of these alarms in critical care settings, there have been no published papers related to these phenomena in ED. This audit was completed as part of the background work related to our research into an integrated monitoring system using data fusion technology to detect deterioration in patients (REC no. 08/H1307/56). For this reason we did not consider alarms from other sources or the noise level of the alarms. Objective Determine the frequency, duration and type of the monitor alarms in an ED, utilising the standard classification provided by the manufacturer. Methods This study was assessed by the local ethics committee chair not to require ethical approval. Three research nurses who are experienced in emergency care and are known to the remainder of the clinical staff undertook
Table 2 Study time in each area. Number of observation periods Resuscitation Room Majors Total
Total time
61 49
53 hours 59 minutes 39 hours 3 minutes
110
93 hours 2 minutes
observation over a six-week winter period. This period sees a higher throughput of patients, which enabled an analysis of the nurses’ ability to respond when they were most busy, although they were never caring for more than five patients, as defined in departmental policy. The research nurses were non-participant observers with the caveat that they would intervene if they observed a life-threatening problem, however this did not occur during the audit. To reduce the possibility of sampling bias, monitored patients in four pre-selected cubicle spaces in the ED, two in ‘‘Majors’’ and two in the ‘‘Resuscitation Room’’, were observed. The allocation of patients to a specific cubicle was outside of the control of the research nurses, as was the staff : patient ratios in the department. One monitored patient was observed at a time, either until they were transferred from the cubicle or for a maximum period of one hour. The frequency, duration and type of any audible alarm related to the patient monitoring was noted. These alarms were classified using the manufacturer’s standard alarm definitions (see Table 1, Phillips, 2002). The timing of any intervention by the clinical emergency nurses in relation to the monitoring alarm was also observed and recorded. A silenced alarm had no audible tone for 1 minute, and a paused alarm had no audible tone for 3 minutes. The audible tone would recommence after this time interval if the alarm condition still existed, and was classified as another episode of alarm noise.
Table 1 Nature of alarms summarised from the manufacturer’s classification (Phillips, 2002). Colour
Sound
Condition
Summary
Red
High pitched sound, repeated once per second
Asystole Extreme Bradycardia Extreme Tachycardia Ventricular fibrillation Desaturation (10, R on T PVC, ST segment monitoring). In our study this would have reduced noise by 49 minutes (57 alarm episodes). We have now made this change within our own department. Earlier intervention by nursing staff to silence alarms (whilst taking note of their clinical relevance). From our data the nurses did silence 74% of Resuscitation Room alarms and 47% of Majors alarms, but there were delays in response time, as shown in Fig. 2. With an arbitrary target for response to an alarm of 30 seconds for red, 2 minutes for yellow, inoperative and ‘‘other’’, and removal of yellow short alarms, there is a potential noise saving of 14 hours 21 minutes, which is over half of the total duration of alarms recorded in this study. Adjustment of alarm parameters to suit each individual patient, as advised by the manufacturer’s guidance (Phillips, 2002) and from the literature (Phillips and Barnsteiner, 2005; Graham and Cvach, 2010). For example, adjusting the oxygen saturations alarm in a patient with COPD, or heart rate in a patient with tachycardia (where there is a management plan for that tachycardia). In our study, nurses only readjusted the alarm parameters in 5% of Resuscitation Room and 6% of Majors alarms of those that were silenced. In relation to individualising
Fig. 2. Probability of at least one monitor alarming at any point in time, based on a binomial probability of a monitor alarming at any point in time and the assumption that the monitors are independent of each other.
alarm thresholds for patients we cannot quantify the potential reduction this would result in, but these threshold-type alarms account for approximately one-third of all alarms that sounded in this audit. Avoiding ‘‘negative’’ alarms. For example apnoea in a breathing patient where the chest excursion is insufficiently detected by the ECG electrodes. This can be corrected by careful positioning of the monitoring leads (Phillips, 2002; Drew et al., 2004). In our sample, if all negative alarms were removed, this would reduce the alarm noise by 5 hours 29 minutes (138 alarms). Anticipation of alarms and silencing the monitor in advance (Siebig et al., 2010). For example when suctioning an intubated patient, taking a sample from an arterial line, or placing a saturation probe on the opposite arm to the blood pressure cuff would all assist in reducing noise. Consider whether all patients in the ED need to be continuously monitored, over and above timely intermittent recording of vital signs with the use of an early warning scoring system. Currently there is no evidence to support either of these strategies in preference to the other in the detection of deteriorating patients in the ED. We accept that some of this may be idealistic when the reality is that one nurse in Majors can be responsible 5 patients at a time,
Please cite this article in press as: Way, R.B., et al. Whats that noise? Bedside monitoring in the Emergency Department. Int. Emerg. Nurs. (2014), http:// dx.doi.org/10.1016/j.ienj.2014.01.001
R.B. Way et al. / International Emergency Nursing xxx (2014) xxx–xxx
and potentially overseeing 10 when a colleague is away from the area transferring a patient. However, we suggest that any noise reduction would improve the environment for both patients and staff. In addition, a reduction in frequency and duration of alarm noise may increase the likelihood of a timely response to a ‘‘true’’ alarm. Limitations Within this study we focused on the frequency and duration of alarms from monitors, as this was linked to our wider research interests in early detection of deterioration in patients in the ED. We chose not to record the actual noise level (dB(A)), as it would have included noise from many other sources. However, we acknowledge that the measurement of the noise level in ED would be useful as part of an overall strategy for reducing noise. Whilst the probability of near-continuous monitor alarm noise was found in our study, there are other alarms that contribute to the overall noise in ED. It would be useful to measure the frequency and duration of these; for example: patient call bells, attack alarms, emergency call alarms, ambulance priority phone, other phones, infusion pumps, fridge alarms and staff pagers. Within the study we recorded the timing and type of response to the alarm made by the nurse. Exploring what influences a nurse’s response to alarm noise would be an interesting area for further study that we believe would help in understanding and changing behaviour associated with alarms. Conclusion This study demonstrates that whilst high level monitoring is desired from a patient safety perspective, it contributes to a significant ambient noise level, which is recognised by all who pass through an ED, and can be detrimental to patients, relatives and staff. There is a high probability of near-continuous background alarm noise in a 10-bedded Majors area. We suggest that significant noise reduction can be achieved through a combination of turning off unhelpful alarms, setting target times to respond to alarms, adjusting alarm parameters to individual patients, reducing negative alarms by careful application of monitoring sensors and silencing alarms in anticipation of procedures known to cause alarms. We intend to implement some of these within our ED. This will require a significant culture change amongst all staff to become used to individualising alarms, responding to alarms in a timely way and learning to silence predictable alarms (e.g. before an intervention).
5
Acknowledgements Rymell, Soubera BSc RN and Warnes, Karen BSc RN, Research Nurses, Emergency Department participated in data collection for the study. Jacqueline Birks, Centre for Statistics in Medicine, University of Oxford, assisted with data analysis. The work described in this paper has been funded by the National Institute for Health Research Biomedical Research Centre, Oxford. The funder played no part in the design of the study or in the analysis of the results. References Balogh, D., Kittinger, E., Benzer, A., Hackl, J.M., 1993. Noise in the ICU. Intensive Care Medicine 19, 343–346. Christensen, M., 2007. Noise levels in a general intensive care unit: a descriptive study. Nursing in Critical Care 12 (4), 188–197. College of Emergency Medicine & Royal College of Anaesthetists, 2012. Safe Sedation of Adults in the Emergency Department. (accessed 30.12.13). College of Emergency Medicine, 2012. Clinical Standards for Emergency Departments. (accessed 30.12.13). Department of Health, 2003. Health Building Note 57: Facilities for Critical Care. (accessed 30.12.13). Department of Health, 2013a. Health Building Note 04-02: Critical Care Units. (accessed 30.12.13). Department of Health, 2013b. Health Building Note 15-01: Accident & Emergency Departments. (accessed 30.12.13). Drew, B.J., Califf, R.M., Funk, M., Kaufman, E.S., Krucoff, M.W., Laks, M.M., Macfarlane, P.W., Sommargren, C., Swiryn, S., Van Hare, G.F., 2004. Practice standards for electrocardiographic monitoring in hospital settings: an American heart association scientific statement from the councils on cardiovascular nursing, clinical cardiology, and cardiovascular disease in the young: endorsed by the international society of computerized electrocardiology and the American Association of Critical Care Nurses. Circulation, (accessed 30.12.13). Graham, K.C., Cvach, M., 2010. Monitor alarm fatigue: standardizing use of physiological monitors and decreasing nuisance alarms. American Journal of Critical Care 19, 28–34. Hannibal, G.B., 2011. Monitor alarms and alarm fatigue. ACCN Advanced Critical Care 22 (4), 418–420. Health and Safety Executive, 2005. Noise at Work Regulations. (accessed 14.05.13). National Institute for Health and Care Excellence, 2007. Acutely Ill Patients in Hospital: Recognition of and Response to Acute Illness in Adults in Hospital. (accessed 14.5.13). Phillips, 2002. IntelliVue Patient Monitoring Guidance. (accessed 14.5.13). Phillips, J., Barnsteiner, J.H., 2005. Clinical alarms. Improving efficiency and effectiveness. Critical Care Nursing Quarterly 28 (4), 317–323. Siebig, S., Kuhls, S., Imhoff, M., Scholmerich, J., Wrede, C., 2010. Intensive care unit alarms – how many do we need? Critical Care Medicine 38 (2), 451–456.
Please cite this article in press as: Way, R.B., et al. Whats that noise? Bedside monitoring in the Emergency Department. Int. Emerg. Nurs. (2014), http:// dx.doi.org/10.1016/j.ienj.2014.01.001
