ECRI Institute selected an innovative study conducted by patient safety researchers at The Children’s Hospital of Philadelphia who aimed to objectively measure alarm fatigue as a finalist for its 9th Annual Health Devices Achievement Award. The award recognizes an outstanding initiative undertaken by an ECRI Institute member healthcare institution that improves patient safety, reduces costs, or otherwise facilitates better strategic management of health technology.
When healthcare workers experience alarm fatigue, they become overwhelmed, distracted by, or desensitized to the numbers of alarms that monitors activate, which can lead to delayed response times or missed alarms. Addressing alarm fatigue is one of the key factors to improving the management of clinical alarm systems, according to the Joint Commission’s National Patient Safety Goal on alarm safety.
CHOP pediatrician and patient safety researcher Christopher Bonafide, MD, MSCE, submitted the entry, “Using Video to Evaluate Physiologic Monitor Alarm Characteristics and Nurse Responses to Alarms.” It described how the study team used a video-based approach to gather data on staff response times and false alarm rates.
After obtaining permission from nurses and patients’ parents or guardians, the team mounted cameras strategically in patient rooms to capture simultaneous views of the patient room, a close-up view of the patient, a full view of monitor screens and ventilator displays, and views of the caregivers responding to the alarms. Additional software generated a time-stamped list of alarms that occurred during the video sessions.
The team performed 40 video sessions and then analyzed the data generated by 4,962 alarms. They determined that caregiver response times increased as the number of false, or nonactionable, alarms increased. In the intensive care unit, 86.7 percent of alarms in heart and lung failure patients were characterized as false. In the general wards, 99 percent of alarms were false.
An article published in the ECRI’s online journal Health Devices described how Dr. Bonafide and a multidisciplinary team of biomedical engineers, physicians, nurses, researchers, and administrators designed and conducted the study.
“Studies such as these can help drive and inform interventions to reduce alarm burden and fatigue, thereby improving system and staff performance and ultimately improving the quality of care,” the article states.
Dr. Bonafide shared his reaction to the runner-up award: “Our team was thrilled to hear that the ECRI Institute selected our project for this tremendous honor. We are committed to using the findings of this study to inform new initiatives to eliminate alarm fatigue and improve the outcomes of hospitalized children.”
The National Heart, Lung, and Blood Institute recently awarded a five-year career development award to Dr. Bonafide, who is also an assistant professor of pediatrics at the Perelman School of Medicine at the University of Pennsylvania, to learn more about the science behind alarm fatigue and discover new ways to combat it.
See a PDF of the Health Devices article describing the CHOP initiative that was selected as a finalist for the 2014 Health Devices Achievement Award.