Clinical Corner
by Scott Giles
It’s Sunday morning. A patient checks in just before dawn, complaining of chest pain. She’s rushed into an EKG, but it doesn’t show any alarming ST elevation and the initial troponin is negative. Your team decides to monitor the patient and repeat the troponin level at four hours – a standard care plan.
Because it’s an early weekend morning, your small ER has three nurses and two physicians tending to patients. The ER is nearly full, keeping your team busy; one nurse is in CT with a patient, another is checking on a new ambulance arrival, and the third nurse is hanging an antibiotic on a likely septic patient.
Then an alarm rings on the monitor in bed three – the patient who complained of chest pain. You’re busy with other patients, and you know the initial EKG and troponin were benign. Do you check the alarm? Do you even hear it, focused as you are on other patients?
Becoming Desensitized to Alarms
An article in AACN-Advanced Critical Care defines alarm fatigue as “sensory overload when clinicians are exposed to an excessive number of alarms, which can result in desensitization to alarms and missed alarms. Patient deaths have been attributed to alarm fatigue. Patient safety and regulatory agencies have focused on the issue of alarm fatigue, and it is a 2014 Joint Commission National Patient Safety Goal.”[1]
Let’s be honest: most of us working in the Emergency Room, ICU and other hospital units have experienced alarm fatigue on some level. The scary part is, we may not even realize it. It’s so easy to physically hear an alarm but become desensitized to it, thanks to the high volume of alarms that go off around the clock in our presence.
A few years ago, I was involved in an alarm fatigue committee at a Level II Trauma hospital. It was a long project, involving research on alarm fatigue, monitoring all unit response (or lack of response) and time to response on every unit of the hospital. We issued recommendations on updating existing monitoring settings and among other action items. One of our findings: the ED seemed to be the most affected by alarm fatigue.
Fighting Alarm Fatigue
So back to our hypothetical patient with chest pain: did you check the alarm?
In a very similar recent situation, a nurse did check on the patient – and found her sitting on the edge of the bed, clutching at her left upper chest and moaning. The monitor was alarming with a vfib/vtac showing at 255/bpm.
Another nurse moved the code cart over to the bay, with the patient’s doctor right behind. Before a repeat EKG could even be performed, the patient’s pulse became un-palpable. The team started CPR while another nurse asked the flight team on the field to early activate and come to the ER for assistance. In the end, ROSC was gained and lost four times, and the flight crew and ER nurses alternated between continuing CPR manually for a very long time. The patient was intubated, additional IVs were placed, a Foley catheter was placed, OG placed, repeat labs were drawn, and a multitude of push dose medications and drugs were given. Only after four hours of very skillful CPR/ACLS work was the patient stabilized.
The patient would never have survived if the nurse did not hear the alarm and respond to it. And these scenarios play out every day. You never know until you get to the bedside if that alarm is life threatening or not! Let’s commit to staying fighting alarm fatigue every day, every shift, by working together – because if we do, we can tell more families that their loved ones will be okay.
[1] Sendelbach S, Funk M. Alarm fatigue: a patient safety concern. AACN Adv Crit Care. 2013 Oct-Dec;24(4):378-86; quiz 387-8. doi: 10.1097/NCI.0b013e3182a903f9. PMID: 24153215.
