Boston Medical Center reduces monitor alarms
A model in meeting US safety standards
Boston Medical Center has dramatically cut down on unneeded alarms from patient monitors, providing a national model for other hospitals as new safety rules on "alarm fatigue" take effect Jan. 1.
Nurses' desensitization to incessantly beeping alarms — hundreds of alerts a day, many false — is a national problem. It is blamed for dozens of deaths each year, as overwhelmed staff fail to respond with urgency, or at all.
Boston Medical Center adopted significant yet simple changes. Starting last year, it got rid of many lower-level alarms that didn't require an immediate response, reducing the number of alarms from an average of 88,000 a week to 10,000 a week on 7 North, a 24-bed cardiac unit. That more manageable number made it possible for nurses to respond quickly to all alarms, reducing patient risk. The success was to be reported online Monday in the Journal of Cardiovascular Nursing.
The changes, later implemented in all medical and surgical units at BMC, so far have cut alarms hospital-wide from 1 million a week to 400,000 a week, said James Piepenbrink, director of clinical engineering.
The reduction provides one blueprint that hospitals around the nation can adopt to comply with the new national safety requirements going into effect next week. "The noise level was overwhelming,'' said Betsy O'Brien, a cardiac unit nurse. "Sometimes I would hear alarms in my sleep.''
Nurses were stressed out because they could not respond to every alarm to see if a patient was really headed toward trouble, she said. They were constantly worried they would miss an important alert. If a nurse was busy providing care when warning beeps sounded for another patient, "you just hoped someone else would get it,'' said Kathleen Kyle, another longtime nurse in the unit.
"It's so much better and safer now,'' she said.
ECRI Institute, a Pennsylvania-based nonprofit research and consulting organization that specializes in medical devices, has commended the Boston Medical Center program.
The Joint Commission, an industry-supported organization that inspects health care facilities and holds them to standards, has made alarm safety a national patient safety goal starting in 2014, signaling that hospitals must give it top priority. By January 2016, hospitals must have plans in place to better manage alarms, including deciding whether specific alarms are needed or unnecessarily contribute to safety concerns, when alarms can be disabled, and who has authority to disable them.
The health care industry began to examine alarm fatigue more closely in 2010, after a man suffered a fatal heart attack at Massachusetts General Hospital while the crisis alarm on his cardiac monitor was turned off. Staff did not respond to numerous lower-level alarms warning of a low heart rate, and nurses told state investigators they had become desensitized to the alarms.
The commission's new rules were also prompted in part by a Globe investigation in 2011 that identified at least 216 deaths nationwide from January 2005 to June 2010 linked to alarms on patient monitors. At UMass Memorial Medical Center in Worcester, two patients died over four years, including a man, 60, whose monitor alarms signaled a fast heart rate and potential breathing problems that went unanswered for nearly an hour in 2010.
Because of these cases, Mass. General and UMass Memorial overhauled how they monitor patients and reduced unnecessary alarms, in part by placing fewer borderline patients on monitors. On one Mass. General medical and surgical unit, average daily alarms dropped from 2,038 to 727 in 2011, while UMass Memorial reduced cardiac alarms in the hospital's acute care units by 28 percent that same year, nurse leaders said.
The hospitals also programmed their monitors to be less sensitive to routine physiologic changes, such as when a patient's heart rate speeds up slightly upon getting out of bed.
Boston Medical Center's more recent success expands on those efforts.
Despite improvements at select hospitals, national leaders say alarm hazards remain a stubborn, and deadly, problem. In each of the past four years, hospitals have reported 20 alarm-related patient deaths to the Joint Commission, a rate Dr. Ronald Wyatt does not expect to slow soon. The reports are voluntary, so the actual number is probably larger.
Wyatt, a medical director at the organization, said hospital executives need to take the problem more seriously and focus more on "better outcomes as opposed to revenue.''
"Do they understand that people die and people are permanently harmed as a result of these events?'' he said. "Typically when an issue becomes a national patient safety goal, leaders and board members sit up and take notice.''
Boston Medical Center leaders began examining the problem in 2008, around the time the hospital decided to significantly increase the number of beds with cardiac monitors. They secretly observed nurses at work and reviewed monitor logs showing which alarms sounded and whether anyone responded.
Staff always answered crisis alarms, which indicate the most serious heart problems. Nurses must shut off those alarms, which consist of three quick beeps, before the alarm will stop, and must check on the patient. But this wasn't always true for warning alarms, two short beeps that cease on their own and then reset and start up again later.
"The warning alarms don't make any sense . . . so it's time to get rid of them,'' said Deborah Whalen, clinical service manager for cardiology.
The hospital elevated some warning alarms for fast and slow heart rate and certain arrhythmias to crisis level. This means nurses have to respond to them, rather than assume a warning alarm is false and prompted by a patient moving in bed, for example, and let it reset and beep again. In other cases, doctors and nurses now adjust monitors to make them less sensitive if a patient 's heart rate, for example, normally runs fast or slow.
One day last week, 7 North, BMC's cardiac unit, was full with 24 patients and yet it was quiet enough to converse softly at the nurses' station. Since the changes were put in place in August 2012, patient satisfaction scores have improved and staff say they are happier.