Hear No Evil
A few months ago while I was working in the interventional gastrointestinal unit I noticed something because it was driving me nuts. One of the monitors in the holding area that slaved to one of the procedure rooms was beeping. Just a low, constant blip blip blip blip. The screen read : no data. So I asked one of the nurses “can we turn that monitor off? No one is using procedure room 3”. She says to me “Oh, nobody knows how to uncouple the slave”. I said “doesn’t that constant beeping bug you?”. “Oh we don’t even hear it anymore”.
Today on NPR I learned that Boston Medical Center is taking steps to decrease what is called “alarm fatigue”, in which people who work in the health care environment every day simply stop hearing all the beeping from all the various machines and monitors that are attached to patients. They don’t become deaf. They are victims of two psychological processes: habituation and learned helplessness.
Habituation of course is when you get so used to something it seems normal, or you get so used to something you don’t notice it anymore. The reason health care professionals stop noticing alarms is because they have learned that they are usually meaningless. If a patient is attached to a heart monitor the machine will alarm whenever it sees something that isn’t normal sinus rhythm. If the patient moves in the bed it goes off. If one of the leads falls off it goes off. If the patient coughs or rubs their nose it goes off. If the patient is not even in the room it will continually go off exclaiming loudly that there is “no data!”. If the patient has a condition in which their heart rate is unusually high the monitor will go off every three minutes, exclaiming “tachycardia!” If the patient is an athlete and has an unusually low heart rate the monitor will go off every three minutes exclaiming “bradycardia!”. “Patient not breathing!” says the monitor. Well that’s because there’s no patient hooked up to the breathing machine. “Asystole!” the machine says when one of the leads on the EKG is pulled off by accident. “ST elevation!” it will yell in the face of a normal EKG on an 18 year old. “Ventricular fibrillation!” it will scream if the surgeon is using cautery too close to your leads. If you work in an environment in which large numbers of alarms are going off, none of which are real, the tendency is to stop responding.
The other process is learned helplessness, and it was made famous by two guys named Seligman and Maier, who gave electric shocks to three groups of unfortunate dogs. One group got shocked no matter what they did, so eventually they quit trying to get away. Same with health care folks. Those alarms are going to go off all the time no matter what you do, so you just accept the background noise and go on with your day. The problem with all this of course is that every once in a while the monitor is right.
When I was a nurse in a telemetry unit back in the ’90’s we still had nurse’s assistants who worked as monitor watchers. It was the most awesome thing ever. This person would sit at a bank of monitors all day and actually look at and evaluate every alarm. She silenced the ones that were false, saved strips of things that looked real but were brief to show to the nurse, and yelled loudly when something was really wrong. This person did a number of things for the nurses; 1. she relieved them of the constant underlying anxiety of beeping monitors you can’t see; 2. she kept the noise down; and 3. she watched. She was there. Monitored patients were actually truly monitored. By a person. These monitor watchers no longer exist, of course. Too expensive. So now we are left with electronic monitoring by machines that are only as smart as the data they are presented with, out of context and without clinical correlation.
I don’t know exactly what BMC is doing to reduce alarm fatigue, but the only way to really do it is use PEOPLE. That’s right, hire people to help. To watch. To evaluate. Or hire more nurses so the nurses can watch more effectively. In the OR the alarms are not a problem because there’s an anesthesia provider who sole responsibility is to monitor one patient. So it’s easy to respond to every alarm appropriately. Anesthesiologists don’t get that same alarm fatigue because they have the ability to immediately respond and decide if an alarm is real or not based on the context of the situation. A nurse on the floor can’t do that with 6 patients whom she also has to feed, clothe, and medicate. To take care of people you really need other people. Eventually you run into the limits of technology.