Obstetric Alarm Fatigue
Alarm fatigue is well reviewed as an unintended consequence of clinical information systems, but is especially noteworthy in obstetrics, particularly in the labor ward. Labor patients are routinely monitored with External Fetal Monitor (EFM) systems, as well as automatic blood pressure cuffs and also oxygen saturation monitors, all of which are designed to alarm audibly and visually both in the labor room and at the nursing station. Unfortunately, the alarms can be triggered by maternal or fetal movement causing loss of signal of parameters that are actually within normal limits when detected or resumed. The Joint Commission estimates that 85-99% of alarms do not require clinical intervention.
Scope of the Problem
These alarms, depending on how narrow the parameters are set, can go off several hundred times for each patient in a day, and on certain units these signals can be triggered thousands of times a day. This can result in physicians and nurses becoming desensitized to the sounds or signals, with providers turning down the volume, turning the alarm off, or setting the alert parameters outside of safety guidelines.http://www.jointcommission.org/assets/1/18/sea_50_alarms_4_5_13_final1.pdf
For low-risk patients (the vast majority of obstetric admissions), Kathleen Simpson, PhD, RNC, a well known perinatal nurse educator, advocates for not using EFM for laboring patients, and monitoring vital signs every 4 hours in early labor, and gradually increasing the frequency as labor progresses, following the Guidelines for Perinatal Care (p.177)https://evidencebasedpractice.osumc.edu/Documents/Guidelines/GuidelinesforPerinatalCare.pdf, as well as avoiding automatic blood pressures and oxygen saturation monitors except in high risk patients, thus radically reducing the number of potential alarms in the first place.http://journals.lww.com/mcnjournal/Citation/2013/11000/Alarm_Fatigue.18.aspx
For the maternity ward, a unique, simplified early warning system is advocated, the Maternal Early Warning Criteria (MEWC) as the rate of major morbidity and critical illness is so low. If any single listed parameter is triggered, a prompt bedside assessment is required. The parameters were specifically chosen to limit false alarms and facilitate implementation: Systolic BP (mm Hg) <90 or >160; Diastolic BP (mm Hg) >100; Heart rate (beats per min) <50 or >120; Respiratory rate (breaths per min) <10 or >30; Oxygen saturation on room air, at sea level, % <95; Oliguria, mL/hr for >2 hours, <35 Maternal agitation, confusion, or unresponsiveness; patient with preeclampsia reporting a non-remitting headache or shortness of breath https://www.researchgate.net/profile/Sharon_Holley/publication/281615789_The_Maternal_Early_Warning_Criteria/links/55f599c608ae6a34f66312e0.pdf, p.3
Submitted by Mitchell Strauss, MD