False Alarms & Alert Fatigue: The Tragic Design of Hospital Alerts
Thousands of alerts are heard by doctors and nurses every day. Some of them are helpful, but most of them aren’t. What’s wrong, and how can we take steps to fix it?
We’ve reached the maximum of attention in the healthcare system.
Did you know that alert fatigue is one of the leading causes of burnout in hospital staff? Burnout leads to dissatisfaction in patient care, reduces the efficacy of treatment, and increases healing time.
One study of US hospitals showed that nurses take up to 40 minutes to respond to alarms, and another showed caregivers responding to only 10% of alarms. A further study demonstrated that, of all relevant alarms, caregivers could correctly identify only half of them.
An astonishing percentage of alarms in hospitals are either false or clinically insignificant.
These misleading alarms are largely created by a mismatch between the default threshold for the alarm and what is relevant for the patient based on their size, age, condition, or context, or introduced through poor connectivity between sensors and the patient.
Nuisance alerts make up over 90% of pediatric ICU alarms and over 70% of adult ICU alarms. An estimated 80–99% of ECG heart monitor alerts do not require clinical intervention. Hospitals are already noisy, chaotic environments, and the introduction of alerts can easily overwhelm workers. The Joint Commission on Patient Safety notes:
“The number of alarm signals per patient per day can reach several hundred depending on the unit… translating to thousands of alarm[s] [for each] unit and tens of thousands of alarm[s] throughout the hospital every day.”
How do we create environments where we open up more human time, and less attention fatigue?
The limits to our attention
Unless we block our ears or have limitations in our hearing, we cannot avoid hearing sounds. Because of the frequency with which healthcare workers are subjected to auditory notifications, they must be designed to be calm, positive, and relatively non-intrusive. Sounds should be designed so as to not exhaust the faculties needed to answer them, particularly in settings that require both attention and emotional sensitivity.
Alerts need not carry a negative connotation in order to carry information. If additional meaning, such as priority level, can be added to the alert through non-stressful, emotionally-neutral elements, such as increasing tempo or the number of instruments in a composition, then the alert becomes a special message decodable by doctors and nurses while remaining non-alarming and neutral to patients.
Rethinking the overall sound design for alerts is key. There are two principles of sound design that are particularly relevant to the hospital setting (find these in our upcoming book, Designing with Sound):
- The more often an alert or notification occurs, the less intense it should be.
- If the trigger event happens at irregular intervals, the notification should be longer.
Hospital alerts could be gentle but continuous until underlying situations are addressed. Alternate backups, such as texts sent to particular nurses and doctors, could ensure critical alarms are answered.
Medical devices require annoying frequencies
Most medical alarms are jarring, high-pitched and invasive. They may keep patients up at night, and may be silenced by nurses. Why are these alarms so annoying? Standards organizations require it.
Medical devices are regulated by standards organizations that specify that medical alerts must fit into a specific frequency band that target the most sensitive part of our hearing range. Many of these devices meet legal requirements and still fail massively in experience design.
The frequency and decibel requirements were set with the intention of enabling these alarms to be audible above background noise, but when placed in a context of hundreds of such alarms frequently sounding, the intended purpose is overwhelmed by the number of alarms vying for attention. It is reasonable to believe that this approach to audibility is simply unfit for the context.
To make matters worse, “many pieces of medical equipment currently use low-cost piezoelectric audible alarms for their signaling. These are the same kind of alarms used in smoke detectors or at checkout counters at grocery stores.” Low-quality speakers contribute to the cognitive burden on patients and healthcare workers by creating grating sounds. These low-cost alarms will eventually be phased out of medical equipment because they do not meet the complex frequency requirements of IEC 60601–1–8 — the new guidelines for medical manufacturers published in 2006.
Improving play-out is one important step, but will only address a portion of the problem.
Reducing False Alarms Through User Design
Reducing the number of nuisance alarms is a natural first step to mitigating alarm fatigue. In many cases, devices can be improved by simple user design, making them wireless, more discrete, more comfortable to wear and more comfortable to remove and replace.
Many sensors rely on an adhesive to maintain conductivity and need to be replaced every 24 hours. If removing these sensors is uncomfortable for the patient, nurses are more likely to change them less frequently, allowing the adhesive to dry out or loosen, producing artifacts in the signals. A new medical adhesive that is gentle and long lasting could be useful for increasing the reliability of sensors and ease of use.
Developing reliable methods of monitoring the patient remotely should be emphasized far more than it has in the past. Measuring carbon dioxide released in breath to capture breathing rate is one promising avenue.
Towards an Integrated System: Composition, Attention, and Accuracy
Much can be done to improve the quality and impact of hospital alerts. We are arriving in a time where new capabilities in integrated devices are available to us. Instead of each manufacturer separately adding sound to just one device, we could integrate robust connectivity in each device (with a backup) in order to integrate sounds in a network. This would allow the entire system to be crafted as a single cohesive auditory experience. It would allow the system to have settings to update depending on the unit of the hospital, the particular patient, even the location and preferences of that particular hospital.
An interconnected system would enable greater context-awareness, which is often critical to determining whether a particular reading is — or is not — clinically significant: “A heart rate of 170 on a treadmill test may warrant a low-priority condition whereas this same heart rate at an intensive-care monitoring station may be assigned a high priority.”
Additionally, an integrated system could analyze separate pieces of biometric data to generate condition-specific alarms, highlighting life-threatening conditions.
For example, the Cushing reflex is a hardwired response to increased intracranial pressure, caused by a traumatic brain injury or neurosurgery. It is a sign that there is a high probability of death within minutes or seconds.
The Cushing reflex is identified by a set of three symptoms known as the Cushing triad. These symptoms are a low heart rate, caused by dysregulation of heart function; decreased, irregular breathing, caused by impingement on brainstem function; elevated blood pressure coupled with a widening of the difference between systolic (“on beat”) and diastolic (“off beat”) arterial pressures; and may additionally be indicated by a fourth sign, a pathological waveform — known as Mayer waves — on cardiac monitors. It occurs only in response to acute and prolonged elevations of intracranial pressure and the combination of high blood pressure and low heart rate, occurred 93% of the time that blood flow to the brain dropped due to increased intracranial pressure. It requires immediate, life-saving intervention.
At present, the Cushing reflex is diagnosed by healthcare workers attending to multiple visual displays and independent alarms on separate medical devices, hopefully arriving at the correct diagnosis by summing independent pieces of information and thinking through the implications. Such a calculation on the part of the health care workers should be unnecessary. The Cushing reflex is both well understood and critical for care. It could easily be programmed into a system of integrated devices, and such a system could take advantage of new scientific research and findings to further refine the diagnostic system for greater precision. This process of feedback could evolve a truly effective, intelligent alert system.
It is likely we will not be able to achieve a functional integration of hospital alarms without such an approach. This could be tackled with the type of dedication currently being spent to create the driving system for automated vehicles, although likely with fewer novel problems to solve, and therefore with fewer unknown technological hurdles.
An integrated system could also allow for automatic tailoring of alert thresholds for individual patients using information entered into the hospital system, eliminating a large proportion of unnecessary alarms. For those with special conditions, it could even employ previously saved data to create an individualized baseline, particularly when the patient presents with chronic irregularities (for example, irregular heart rhythm) that do not require clinical intervention. Devices could rely on listening and learning to coordinate their actions around the user, rather than the other way around.
Localized Sound
Another advantage of an intelligently integrated system is that it can employ localized sound. Audio beamforming requires interconnected smart speakers within a room and enables sounds to be set to different volumes at different locations. This would quiet the impact of alarm sounds on patients while still allowing them to be audible. It could even allow specific sounds to be audible only when standing in a particular location, allowing the patient to rest in silence. Certain non-critical information, like current heart rate, breathing rate, and oxygen saturation could be beamed right outside of a room (see “Ambient Awareness” below for more on this). Imagine doctors and nurses being able to listen outside of a patient’s room to assess the patient’s general condition. It could be a non-interruptive, calm way to assess a patient without even opening the door.
Ultimately, changing current regulations and converting to an integrated system seems well worthwhile — instead of a piecemeal solution, it would provide a holistic and complete solution to the problem. It is important to overhaul the general framework used to create these alerts. Several strategies are listed below.
Informative Melodies
Could you imagine a joyful sound playing to bring a nurse or physician to a patient’s room? Perhaps a beautiful and complex aria? This approach has more to offer than just aesthetics.
Because we are good at picking out the relative number of instruments, tempo, and specific types of instruments even in complex compositions, it is possible to encode information simply by creating rules about what an increased number of instruments means, or increased tempo, what trumpets signify, or string instruments, or piano in a constantly changing composition.
A melody would be difficult to miss, and we enjoy listening to beautiful things, so our inherent preferences should reinforce attention to such alarms rather than detracting. The IEC 60601–1–8 guidelines for hospital alarms does allow for melodies, although overt, repetitive melody-making could run an additional risk of extreme annoyance from overuse.
It may be better to borrow principles of ambient awareness and sonification (see below) to create a series of non-repeating soundscapes that both calm and inform, disappearing seamlessly into the background, but also creating a readable and digestible auditory text for practitioners. Priority could be incorporated into the information in this system, with high priority for situations where death or irreversible injury could happen quickly, but low priority for discomfort or slow-developing conditions.
Beyond coding melodic alerts with information present in the composition, we could assign melodies to page individual doctors and nurses, which they would learn and over time and ultimately recognize instantaneously. In a hospital with such a system, instead of patients trying to block out interruptions from buzzing pagers and announcements, they would instead enjoy periodic melodies.
Ambient Awareness
To reduce the cognitive load for doctors and nurses, more information could be placed into ambient awareness. Designing an evolving information soundscape rather than a set of constant alarms would reduce alarm fatigue caused by listening to the same type of high-pitched beep.
Soft background noises like crickets could indicate “all is well” as a type of inverted-alert, where the absence of such sounds indicates the need for an intervention, perhaps for a low-priority condition. Soft rhythms could indicate the pace of breathing or the current heart rate.
This type of direct sonification of biometric information could inform and unburden both caregivers and patients, allowing them to focus on important details. The advantage of direct sonification of data such as heart rate and breathing is that it retains a high degree of specificity and variance. Over time, doctors and nurses will develop some subtlety in their ability to listen and interpret elements that are not well conveyed by conventional alarms, such level of emotional activation, which relates to heart rate and breathing. This soundscape would represent a true “fingerprint” for the patient, conveying multiple independent variables in a continuously generated composition.
Reducing Alarm Fatigue with Novelty
A curious fact about our neurology is that our brains begin to ignore sensations we receive too often to the point where it might altogether disappear from our conscious attention. If we are constantly around a certain smell, such as perfume, our brain will adapt to make it less apparent to us. If we get used to the sensation of glasses resting on our nose, we may forget we are wearing them. And, if we hear the same sound over and over, our brain will start to filter it out. A key element that has been missing in hospital alert design is allowing the sounds to be non-repeating.
Generative audio is the real-time creation of audio using input (patient data) combined with a set of rules, and would prevent habituation to specific sounds. Because our minds naturally prioritize novel stimuli, even if the alert is more subtle than traditional beeping alarms, the lack of repetitive sounds should allow doctors and nurses to notice the sounds with more acuity and sensitivity.
Using recognizable sounds from nature instead of abstract tones is one way we could aid memory and recognizability in alarms. Nature provides wonderful examples of sounds that are clearly recognizable, such as a peacock’s call, yet change subtly with each iteration. An alarm that uses a call from a mourning dove, an elephant, or a hawk could be distinctive and audible above background noise for those working in the hospital. But with any new soundscape, these assumptions should be tested in hospital environments before wider implementation.
Companion Technologies
Haptics are useful for anyone who may need to receive information without the use of their eyes and ears. They are a sensible backup to auditory notifications. A pager, phone, or smartwatch could add a buzz to alert the wearer to critical alarms.
A new system would take time to develop, but the result would be a truly functional system that meets the needs of the patients, workers and the aim of the hospital, which is to make people well.
The cacophony of beeps we have created as hospital alarms is simply poor design. It is ineffective and counterproductive.
Let us imagine a better, more healthful system of hospital alerts!
Acknowledgements
Thank you to Aaron Day for inspiration and insight into sound design. This article was written by Kellyn Standley based on conversations with Amber Case, whose original work crafting concrete principles for creating calm technology (laid out in her book Calm Technology: Patterns and Principles for Non-Intrusive Design, O’Reilly Media, 2016) formed the design framework for this article. The material is part of Chapter 4 in the upcoming book, Designing with Sound!
Designing with Sound
Sound is one of the most commonly overlooked components in product design, even though it’s often the first way people interact with many products. When designers don’t pay enough attention to sound elements, customers are frequently left with annoying and interruptive results.
This practical book covers several methods that product designers and managers can use to improve everyday interactions through an understanding and application of sound design. You can pre-order the book here!
Have ideas on making medical alerts better? Reach out to us on Twitter! Kellyn Standley @kellynstandley and Amber Case @caseorganic.
