Physiologic Alarms in the ED - Time to turn down the volume.
The soundscape of the ED is chaotic - filled with voices, bodily sounds, and too frequently the constant din of patient alarms. The problem with alarm fatigue is well known and reducing it is part of the Joint Commission's national patient safety goals. But how frequent do alarms happen in the ED and how often do they change management?
A recent, observational study sought to answer this question. The study setting was an urban, academic, ED with an annual census of >100,000 patients. They spent 53 hours observing the ED during peak use and noted 1,049 individual alarms sounding during the stay of 149 monitored patients. Of these alarms, only 8 (0.8%) prompted management changes in 5 patients. The alarms which did prompt management changes were high blood pressure, low blood pressure, high end-tidal CO2, and tachypnea. The most frequent individual alarm was premature ventricular contractions. "Sensor off" alarms for oximetry and telemetry leads were the most frequent equipment associated alarms.
This data is consistent with other ED and inpatient studies examining the burden of alarms and the rate they prompt clinicians to take action. Some alarm best practices can help mitigate the volume:
- Ensure the monitoring equipment is appropriate for patient size.
- If a telemetry or SPO2 adhesive falls off, change the pad or oximetry probe.
- If allowed by hospital and departmental guidelines, adjust the alarm paramters to fit the patient in order to improve the specificity of the alarm.
- Participate in the hospital survey of alarming devices and work to eliminate alarms which do not pose risk to patient or staff safety.
As physiologic monitoring software improves and is combined with machine learning and artificial intelligence, physiologic alarms will be more integrated with one another to improve their overall performance. Patterns showing risk for early decompensation will be better recognized instead of relying on individual pieces of data such as telemetry, BP, or oximetry in isolation.
Reference: Fleischman W, Ciliberto B, Rozanski N, Parwani V, Bernstein SL. Emergency department monitor alarms rarely change clinical management: An observational study. Am J Emerg Med. July 2019:158370. doi:10.1016/j.ajem.2019.158370.