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The Fatigue Factor: Too Many Alarms, Too Little Downtime

Monday September 6, 2010
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Critical care nurses must remain vigilant and alert for the slightest changes in patients’ conditions, but unfortunately mistakes can and do happen. A major factor in errors that affect patient care is fatigue — both alarm and physical. But there are solutions to combat the problem that consider the well-being of patients and their caregivers.

Bells, Whistles, Trouble
An overabundance of beeps and chirps on critical care units has led to alarm fatigue — tuning out the sounds that are supposed to alert nurses to a patient’s need for care. In some cases, it has led to nurses turning off alarms, resulting in deadly consequences. More and more devices sound alerts to warn nurses about heart rhythm changes, an empty IV bag or a patient getting out of bed. “It’s amazing how many alarms occur and how nurses can multitask, hear the alarms and react to them,” says Maria Cvach, RN, MS, CCRN, assistant director of nursing and clinical standards at The Johns Hopkins Hospital in Baltimore.

Linda Bell, RN, MSN, clinical practice specialist at the American Association of Critical-Care Nurses, Aliso Viejo, Calif., reports an increasing number of devices with alarms have nurses becoming more aware of the dangers of alarm fatigue. A cardiac patient requiring continuous heart rate and rhythm monitoring at Massachusetts General Hospital in Boston died in January after developing a lethal arrhythmia for 22 minutes and asystole for 17 minutes before being found by staff members who were unable to resuscitate the patient, according to a report released in April by the Centers for Medicare & Medicaid Services. Investigators found the bedside alarm volume had been turned off; however, two beeps sounded on the central nurses’ station cardiac monitors and digital displays in the hallways signaled “HR LO.”

Nurses told CMS investigators they did not remember hearing the alarm or seeing the HR LO display. They also said they were “experiencing alarm fatigue and a desensitization to alarms after hearing them throughout the workday,” according to the report.

Jeanette Ives Erickson, RN, senior vice president for patient care and chief nurse at MGH says the hospital has since modified cardiac monitors so alarms cannot be turned off. “You should never be able to turn an alarm off,” Bell says. “You should be able to silence it until you know what the problem is.”

Alarm accuracy presents another issue. If a device is so sensitive it indicates asystole time and again, but the patient is fine, the nurse will tend to ignore that alarm in the future, Cvach says.

Erickson agrees, saying the number of false positives must be decreased, because “they degrade the ability of clinicians to decipher important alarms.” In addition, she says, nurses may overutilize monitors and keep patients on them longer than necessary.

Hiring someone to watch the monitors at a central location is a best practice, but many hospitals cannot afford that, Cvach says. Next best is to customize alarms and assess trends to determine the fidelity or accuracy of the alarm.

When nurses on a medical progressive care unit at Johns Hopkins Hospital realized their desensitization to alarms, they undertook a quality improvement project to improve safety. “There was a fear alarms were not being heard and were being missed,” Cvach says.

The quality improvement team measured alarm sounds and staff attitudes, educated staff and instituted customizable changes to the alarms designed to decrease alerts, such as changing the default settings to a parameter appropriate for the patient — as in the case of a patient with COPD who has a baseline oxygen saturation of 85%. In some cases, eliminating similar alarms is necessary, such as for high heart rate and tachycardia, which assess similar abnormalities differently.

“Customization is important, because when the alarm comes through, you act upon it,” Cvach says.

The medical PCU reduced high-priority monitor alarms 43% from baseline data. Now Johns Hopkins is rolling out the program to other units.

Bell agrees about the importance of preventing nuisance alarms by individualizing settings to the patient. She also recommends placing cardiac monitoring leads appropriately with adequate contact gel and ensuring blood pressure cuffs are correctly sized. “Everyone must be attuned to the fact an alarm is going off,” she says. “They cannot assume it’s someone else’s patient. They have to be proactive.”

Lillee Gelinas, RN, MSN, FAAN, vice president and CNO of VHA Inc., in Irving, Texas, recommends involving staff nurses in process improvements — whether to deal with fatigue or alarms — to create a high-reliability ICU. “What works is awareness, education, engagement of the staff in change,” Gelinas says. “Circling that is leadership support.”

Rest for the Weary
Although alarm fatigue recently has been in the forefront, a constant concern in past years regarding RNs has been general fatigue — a concern rooted in the long shifts and short rest periods between shifts characteristic of RNs’ schedules — and its connection to medical errors. “There’s research that tells us when we work more hours than we should, patient safety is an issue,” says Linda Plank, RN, PhD, NEA-BC, a lecturer at Baylor University’s Dallas-based Louise Herrington School of Nursing. “An exhausted nurse is more likely to make errors in giving medication or in judgment calls.”

Ann E. Rogers, RN, PhD, FAAN, a former adjunct professor at the University of Pennsylvania School of Nursing in Philadelphia, now at Emory University in Atlanta, and colleagues reported in 2004 that the likelihood of making an error increased with longer work hours and was three times higher when nurses worked shifts lasting 12.5 or more hours. In addition, working more than 40 hours per week significantly boosted the risk of error.

A seminal study by Australians Drew Dawson and Kathryn Reid in 1997 showed after 17 hours of wakefulness, performance can deteriorate to the equivalent of a blood alcohol concentration of 0.05%. And the National Association of Neonatal Nurses issued a position statement in 2008, outlining recommendations for nurses to limit their work hours to no more than 12 hours in a 24-hour period and to no more than 60 hours in a seven-day period, and to employers to schedule sensibly, mirroring a recommendation made by the Institute of Medicine in 2003.

Jeanne Geiger-Brown, RN, PhD, associate professor at the University of Maryland School of Nursing in Baltimore, recently found, in studying RNs, that neurobehavioral functioning, including reaction time, declines as nurses work additional 12-hour shifts. The average sleep time between shifts was 5.5 hours, leading to sleep deprivation, which can cause microsleep periods, little lapses in attention. “Whether it translates into nursing performance is hard to know,” says Geiger-Brown, adding that accuracy is often preserved at the expense of speed.

Geiger-Brown advocates for a return to the eight-hour day. However, she acknowledges, that’s a hard sell, because nurses like having more days off. In the meantime, she advises nurses not to clump several shifts together and managers not to call nurses in on their days off.

Plank adds the literature suggests three 12-hour shifts in a row is the maximum a nurse should work. “If nurses work 12-hour shifts on Monday through Wednesday and are asked to work Thursday, they need to politely decline and maybe say, ‘How about Friday instead?’” Plank says. “I think every manager will try to help with that.”

When nurses understand the risks, Plank adds, they will feel good about putting the patient first and refusing that extra shift. Gelinas agrees, indicating nurses want to do the right thing, but many remain unaware of the effect of fatigue and other human factors. “Nurses are very ethical and moral, and if they know they are working impaired, they will step back,” Gelinas says. “We need to increase the awareness of the critical association between human factors and safety. It becomes even more critical in ICU.”

Debra Anscombe Wood, RN, is a freelance writer.

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