In critical care, the ever-increasing number of alarms—all possibly urgent—must be managed. Research from AAMI indicated an average of 350 alarms per bed, per day in a large American hospital. This number was as high as 771 alarms per bed, per day in one intensive care unit (ICU). The resulting alarm noise is a constant auditory stimulation for both clinicians and patients.
In addition, an estimated 80-99% of these alarms are false or non-actionable, adding an additional burden to already overwhelmed, overworked clinicians.
This leads to the phenomenon of alarm fatigue: when someone is exposed to a large number of frequent alarms, he or she becomes desensitized to them. Since 2014, the ECRI Institute has warned that alarm fatigue leads to increased risk of harm and dissatisfaction among patients and staff.
In addition to the sheer quantity of alarms, another concern is the noise level. In 1973, the World Health Organization suggested keeping noise levels at or below 40 decibels (dB) during the day and 35 dB at night. However, this was not achievable at the time, and remains a challenge today.
The noise level in critical care continues to rise with the ever increasing adoption of new technology (e.g., infusion pumps, ECMO, etc.). One study comparing ICU noise levels from 1960 to 2003 showed a daytime increase from 57 dB to 72 dB and a nighttime increase from 42 dB to 60 dB.
Noise contributes to keeping patients awake, which can lead to delirium. A majority of ICU patients are at risk of delirium and with delirium comes prolonged lengths of stay and long-lasting neurocognitive impairments.
With this data comes an increasing need to distribute alerts to clinicians in a more efficient, trustworthy manner.
Leveraging the latest interoperability profiles from Integrating the Healthcare Enterprise (IHE), several medical device manufacturers and clinical application market suppliers are collaborating to create quieter ICU rooms and better responses to actionable alarms.
The IHE Patient Care Device (PCD) group launched the Quiet Hospital designed to reduce the amount of noise disturbance. The underlying idea is that when a medical device—usually located by the patient bedside—needs the attention of a clinician, an audio pause is used and the patient room remains silent until a clinician is able to intervene.
Medical devices send all kinds of notifications, alarms, warnings and other messages. In a Quiet Hospital, an alert manager collects and transfers relevant alerts to nurse communication devices. Depending on other ancillary systems, for instance a nurse assignment, an alert communicator will alert the appropriate clinicians. Clinicians typically acknowledge or redirect notifications and this information is then transmitted back to the alert manager, which can then send a confirmation of alert delivery or even a clinician’s acceptance back to an alert reporter.
Flow of alert information and acknowledgement between medical devices and nurse communication devices
This confirmation enables the audible alert to be paused, reducing the noise level temporarily while the clinician responds appropriately to the event. If the clinician fails to respond to the alert in a timely manner, the medical device will produce audible noise at the bedside for safety reasons.
Much like a Quiet Hospital, a Quiet ICU is an ICU where the noise from medical devices is managed at the patient bedside, using technology and training. However there are still cases where the sound cannot be completely eliminated. In a Quiet ICU, the responsibility of alarm notification remains with the source medical device.
In contrast, a Silent ICU is an ICU where all sources of noise are eliminated at the patient bedside. To implement a Silent ICU room, all medical devices must support alarm delegation, which mandates major changes in medical devices and major revisions in risk management strategies from the hospital and the medical device industry.
For both Quiet ICUs and Silent ICUs, changes in design and organization—including training and understanding of human behavior—are essential.
While multiple medical device manufacturers and information system market suppliers are working to make this a reality, attaining the full benefits of Quiet and Silent ICUs will not happen overnight. But once achieved, these changes have the potential to improve the health and safety of patients and staff, leading to better health outcomes and improved satisfaction.
This developing IHE PCD profile will be demonstrated at the HIMSS Interoperability Showcase during the HIMSS20 Global Health Conference & Exhibition in Orlando, Florida.
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