Jessica Zegre-Hemsey and Colleagues Publish New Study With Alarming Findings

State-of-the-art monitors help critical care providers by sounding an alarm if a patient has abnormal heart beats (arrythmia), blood pressure, or breathing patterns. Yet the results of a new study conducted by assistant professor Jessica Zegre-Hemsey and her colleagues at UC San Francisco (UCSF) demonstrated that the same technology can be a threat to patient safety.

Dr. Zegre Hemsey was part of a 10 person team led by primary investigator Dr. Barbara J. Drew, PhD, RN. Together, they collected alarm data from five critical care units at the UCSF Medical Center. As one of four nurse scientists who analyzed the alarms, Dr. Zegre-Hemsey helped to determine if the alarms were true or false. During the one-month study period, more than 2.5 million alarms were recorded. Many of the alarms sounded in reaction to inappropriate settings or false arrhythmia. Out of the alarms that accurately detected a problem, most of the patients did not require treatment.

The high number of alerts can lead to alarm fatigue. This fatigue occurs when clinicians become desensitized to the alarms and the sounds become part of the “background noise” in a critical care unit. The nonprofit Emergency Care Research Institute lists alarm fatigue as the number one health technology hazard for 2014 because the incessant alarms increase the odds providers will miss a life-threatening change in a patient’s condition.

Based on their findings, the researchers suggest false alarms could be reduced if the monitors could be configured to individual patients. Everyone’s body is different and if the monitors could be adjusted, the machines would not mistake a normal condition for an abnormal one. Designing the monitors to suggest changes to the settings could also prompt providers to adjust the settings when a patient exhibits average readings that are outside of the default settings chosen by the hospital. For example, if a patient had an average heart rate of 135 beats per minute and the default setting for a high heart rate is 130 beats per minute, the machine could display an alert that reads, “Mean HR 135; do you want to increase high HR setting?”

Overall, the