**5. Clinical Vignettes**

#### **5.1.** *Clinical Vignette #1***: 62-year-old female presenting with chronic obstructive pulmonary disease (COPD) exacerbation**

A 62-year-old female was admitted to the local hospital 5 days ago due to chronic obstructive pulmonary disease (COPD) exacerbation. She was diagnosed with COPD several years prior and remained stable with no history of exacerbations until 1 week ago when she developed a progressively worsening cough. Soon after her symptoms worsened, she began to feel shortness of breath that was not relieved by rest. At this point, her family insisted she go to the hospital for evaluation. Upon arriving in the emergency department, short-acting bronchodilators and oral corticosteroids were administered with only mild symptomatic improvement. Given the patient's dyspnea at rest, as well as decreased oxygen saturation of 86%, she was admitted to the pulmonology unit. Supplemental oxygen and intravenous corticosteroids were administered.

At admission, continuous pulse oximetry monitoring was started. The patient's hypoxemia seemed to improve slightly over the next 4 days, with oxygen saturation climbing to 88–90% range. Still, the patient's ventilatory monitor sent alarm signals to the hospital staff several times an hour due to high respiratory rate and episodic oxygen desaturations. Alarm signals were transmitted as either a single low tone (respiratory rate) or a double alarm (desaturations), alternating between low and medium tones. The difference of alarm tone indicated the range in which the patient's oxygen saturation was measured, but the assigned night-shift nurse found the tones to be too difficult to distinguish and would routinely just perform an in-person check of the saturation level upon entering the room. Throughout the first two nights, the same nurse responded to the alarms in a timely fashion, only to find the patient stable and with no signs of acute distress. Assuming that alarms are unlikely to represent any actionable clinical events, the same nurse then began to silence the sounds and began checking on the patient hourly. In the early morning hours of the fourth day, the nurse silenced the alarm once again, intending to assess the patient once the remainder of her rounding routine was completed. When the nurse finally came to the patient's room an hour later, she found the patient unresponsive and cyanotic. A rapid assessment showed an oxygen saturation of 79%. The patient was immediately intubated, transferred to intensive care unit, and mechanical ventilation was initiated.

presenting a barrier to prompt patient access. Elevated acuity and high patient throughput

**Figure 2.** Schematic representation of the classification of alarm types triggered by various patient monitoring systems,

including both actionable and nonactionable alerts (source: Ruskin [8]; Gorges [66]; and Tsien [67]).

Furthermore, technological advancements facilitated the development of increasingly sophisticated alarm systems, with novel features designed to decrease the nuisance factor of the alert mechanism while preserving the level of overall clinical vigilance [63, 64]. These are intended to provide a range of alarm tones that allow care providers to easily identify and prioritize alarms, typically as high, medium, or low priority. However, the implementation of such systems (e.g., IEC 60601-1-8 standard) has presented challenges in terms of recognizability of melodic alarm tones. More specifically, nurses found it difficult to accurately identify all of the melodic tones signifying high-priority alarms, in addition to the potential for confusion between certain alarm pairs [65]. An example of such phenomenon is presented in *Clinical Vignette #1* below, where two sets of tones were too difficult for the nurse to readily differentiate, rendering the alarm feature ineffective. Consequently, it is important for systems to have some degree of built-in learnability and flexible discriminative ability, with continued refinement, development, and testing of each clinical alarm, both alone and in tandem with other competing alarms [65]. Without exception, any observed deficits in patient monitor effectiveness and/or safety should prompt an immediate critical evaluation of both technical

are also important considerations in this context [62].

and clinical aspects of its implementation and function.

**5.1.** *Clinical Vignette #1***: 62-year-old female presenting with chronic obstructive** 

A 62-year-old female was admitted to the local hospital 5 days ago due to chronic obstructive pulmonary disease (COPD) exacerbation. She was diagnosed with COPD several years prior and remained stable with no history of exacerbations until 1 week ago when she developed a progressively worsening cough. Soon after her symptoms worsened, she began to feel shortness of breath that was not relieved by rest. At this point, her family insisted she go to the

**5. Clinical Vignettes**

98 Vignettes in Patient Safety - Volume 4

**pulmonary disease (COPD) exacerbation**

#### **5.2.** *Clinical Vignette #2***: 65-year-old male transferred to inpatient unit following a total knee arthroplasty**

A 65-year-old male with a history of osteoarthritis of the right knee and refractory pain underwent preoperative evaluation by an orthopedic surgeon. Given his adequate performance status and lack of comorbidities, the patient was determined to be a suitable candidate for total right knee arthroplasty. The surgical procedure was uneventful, with appropriate antibiotic and venous thrombosis prophylaxis administered perioperatively. Following a brief recovery in the postanesthesia care unit, the patient was transferred to the inpatient floor with expected discharge within 5 days postsurgery. Due to the nature of his surgery and apparent fall risk, the patient's room was fitted with weight-sensitive bed and chair alarms. During the first 3 days, he remained relatively sedated due to the frequent administration of pain medications. However, as the patient began to regain strength, his analgesia regimen was tapered. On day 4, the concurrent increase in patient's movement began to trigger his bed monitor to the point where the on-call nurse was receiving nearly constant alarm notifications. Multiple times, the nurse entered to assess the patient only to find him resting comfortably without apparent attempt to leave his bed. Later that night, after leaving the patient's room, the nurse was unexpectedly assigned to three additional patients due to an unplanned absence of a coworker. As the nurse hurried to assess the new patients, the bed monitor transmitted yet another alarm signal. Annoyed by the repeated negative alarms, the nurse disabled the alerts from the bed monitor, intending to check in after tending to her newly assigned patients. When she finally returned to the patient's room, she found him sprawled on the floor and writhing in pain. The patient, emboldened by his rapid recovery, had attempted to ambulate to the bathroom without assistance and lost his balance in the process. The intense pain prevented him from reaching the call button on the hospital bed, so he was forced to lie on the floor in pain for approximately 1 h. A subsequent skeletal survey revealed a left hip fracture, which required additional surgery, prolonged hospital stay, and the need for inpatient rehabilitation stay due to temporary disability involving bilateral lower extremities (e.g., right knee arthroplasty and left hip injury).

patient safety were utilized either ineffectively or incorrectly. In all three vignettes, a confluence of factors (environment, patient, medical personnel) subsequently led to AF and then adverse patient outcomes. In the following sections, we will further discuss the phenomenon

Combating Alarm Fatigue: The Quest for More Accurate and Safer Clinical Monitoring Equipment

http://dx.doi.org/10.5772/intechopen.84783

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After the general introduction of AF earlier in the chapter, the authors will now discuss this important concept in greater detail. The phenomenon of AF is multifaceted and includes increased clinician response time with simultaneous decreased response rate that is mainly attributed to excessive stimuli from clinical alarms [8]. Depending on patient acuity and clinical monitoring requirements, typical bedside health-care personnel may be exposed to as many as 1000 alarms during a single shift, of which as many as 95% can be nonactionable and thus do not require immediate clinical determination [8, 66, 67]. Given the multitude of clinical alarms, a provider has to sort through during a typical hospital shift, there will be a natural tendency to potentially dismiss certain alarms as insignificant through rationalization. This phenomenon is described in the literature as the natural human behavioral reaction to "deprioritize signals" that have often been proven to be either false or misleading. Thus, staff may begin reflexively disabling or silencing alarm systems, which could effectively mask other alarms that may be clinically significant [68, 69]. To some extent, this behavioral pattern was seen in all three *Clinical Vignettes*, where the actionable alarm was masked by the vast number of nonactionable alarms that preceded it. Ultimately, the resulting delay in response or inadequate response puts patient safety at risk and may result in morbidity and/or mortality [70, 71]. Technologically advanced physiologic monitors bring a lot of promise, both in terms of earlier and more sensitive detection of patient deterioration (or other clinically significant event); however, the sensory overload and desensitization associated with AF will

Certain other factors have been implicated in the increased incidence and severity of alarm fatigue, including greater staff workload, higher patient acuity, and the complexity of the modern health-care environment [10]. Nurses serve as key frontline staff in most clinical settings and play a pivotal role in overseeing patient care and monitoring. Moreover, nurses are subject to significant occupational stress that can be attributed to multiple causes, including heavy workloads [72]. This stress, as outlined in previous sections of this chapter, certainly influences AF by forcing nurses to instantaneously adjust their work activities (and priorities) according to perceived importance of near constant clinical alarm activity. Our *Clinical Vignette #2* illustrated the difficult task of ongoing patient triage, with the nurse having to prioritize between the three newly admitted patients and all of her other assigned patients. This constant need for clinical vigilance and prioritization is potentially disruptive to typical workflow, especially when high task complexity is involved. It can also contribute to the development of burnout [73]. Nurses have expressed the internal conflict between having to ignore the constant alarms simply to maintain sufficient focus to finish their routine tasks [74]. It is not surprising that increasing workload or task complexity has been associated with both suboptimal job performance and inconsistent alarm response [10]. Furthermore, the

of alarm fatigue, focusing on its impact on daily clinical practice.

likely continue to present a major opportunity for improvement.

**6. Alarm fatigue**

#### **5.3.** *Clinical Vignette #3***: 71-year-old male with history of multiple myeloma admitted for right lower extremity swelling associated with minor pain**

A 71-year-old male with a history of multiple myeloma was admitted to the urgent care center after noticing sudden onset of right lower extremity swelling associated with minor pain. The patient began induction therapy for multiple myeloma approximately 1 year prior, achieving adequate disease control. He was subsequently transitioned to maintenance treatment, which he continued for the past 6 months. Evaluation in the urgent care center with venous duplex studies revealed a deep venous thrombosis (DVT). Because of the patient's established history of malignancy, the triage clinician opted for hospital admission and therapeutic anticoagulation. While being transferred to the inpatient unit, unfractionated heparin anticoagulation was started. Per standard protocol, monitoring equipment was hastily fitted to the patient for noninvasive measurement of his blood pressure and heart rate. Overnight, the patient remained stable, with some resolution of lower extremity of pain despite persistent swelling. The on-call physician assessed the patient during morning rounds and ordered to repeat venous duplex for the afternoon to evaluate for resolution/progression of the DVT. Of note, throughout the night and into the morning hours, the patient's hemodynamic monitor had been sending intermittent alarm signals. With the first few alarms, the charge nurse promptly responded and quickly assessed the patient for any signs of instability or distress. However, as the shift progressed, the nurse increasingly dismissed repeated signals as "false alarms" due to a recurring pattern of mildly elevated blood pressure and heart rate secondary to episodic extremity pain. Because the inpatient unit continued to be understaffed during the morning shift, the charge nurse decided to disable the patient's repeated monitor alarms after the patient was assessed during morning rounds and found not to have any acute issues. It was hoped that this decision would eliminate the distraction of the nuisance alarms. However, during the patient's routine afternoon assessment, the rounding physician noted cold and diaphoretic extremities with markedly increased swelling. Interrogation of the monitor system revealed progressive bradycardia and hypotension over the past hour. An emergency CT angiogram showed a massive pulmonary embolism, prompting immediate thrombolytic therapy and patient transfer to intensive care. Despite aggressive management, the patient's shock became refractory, culminating in his death several hours later.

#### **5.4. Summation of Clinical Vignettes: finding common threads**

The three hypothetical clinical scenarios outlined above share a common theme: dedicated monitoring systems implemented to ensure early detection of clinical deterioration and thus patient safety were utilized either ineffectively or incorrectly. In all three vignettes, a confluence of factors (environment, patient, medical personnel) subsequently led to AF and then adverse patient outcomes. In the following sections, we will further discuss the phenomenon of alarm fatigue, focusing on its impact on daily clinical practice.
