Ask a nurse: Dealing with hospital noise

Hospitals can be noisy places, with many patient monitor alarms sounding. How do hospital staff learn to tune out the noise when they have to, but also listen closely for alarms that signal a possible emergency? Two nurses answered your questions, below.

Jeanette Ives Erickson

Jeanette Ives Erickson, RN, is chief nurse and senior vice president for patient care at Massachusetts General Hospital in Boston and a doctoral student at the MGH Institute for Health Professions. She is also a member of the US Health & Human Services National Advisory Council on Nurse Education and Practice.

Q. Three years ago I had a knee replacement surgery at Brigham & Woman's Hospital. The first night of my surgery, I was hooked up to a monitor that would beep if I stopped breathing -- I would wake to the sound of the loud beeping -- When no one came to shut off the alarm, I would ring the nurse's bell. No one still came into the room. I rang the bell several times and finally a nurse called over the speaker for me to stop ringing the bell as she could hear the alarm. Finally when someone did come into the room and shut it off, I asked if they would show me how to shut off the alarm.They said no they could not do that. Well this went on all night until an aid came on duty. Fortunately, I would wake up with the alarm and could breath just fine, however it was a very difficult night without hardly any sleep. I think the aides showed more caring than some of the nurses. I was thrilled to see a column on "€œPatient alarms often unheard, unheeded." After reading the story, I realized this issue is common and a problem that needs to be solved. No one should have to die because of a battery dying or unheeded attention to the alarms that are meant to save lives. What is being done about this issue in the hospitals?

A. First, let me say that I’m sorry you had such an upsetting experience, and I hope you are now doing well after your knee replacement surgery. As you read in the recent Globe series, the issue of clinical monitoring is a complex and multi-faceted one. Please be assured that hospitals are constantly working to improve their systems and take appropriate measures to see that patients are well cared for and safe. The short answer to your question about what is being done to address the challenges with monitors is that hospitals are taking a multi-pronged approach to the issue – and indeed, we are making significant progress. We’re cultivating a culture of alarm sensitivity, ensuring that all alarms are responded to, raising awareness and educating staff. Across the country there are many efforts under way to work with industry to design monitors that are highly sensitive to relevant changes in the patient's health status with greater accuracy. We’re also looking at how the specific alerts are delivered to caregivers – whether at the patient's bedside, hardwired to a central monitoring area, sent via a wireless signal or displayed on an electronic signs notifying the entire care team. We’re re-examining clinical criteria for monitor use, with an eye toward reducing the unnecessary use of alarms. And we’re tailoring alarm settings for the individual patient. The ultimate and universal goal is to use this important technology in a way that best supports clinical care and patient safety.

Q. How many patients is a nurse responsible for on a typical shift? What is the optimal patient/nurse ratio? At what level does the ratio become dangerous for patients and/or nurses?

A. Nurse staffing is intricate and nuanced, and requires very careful attention to details that most people are not aware. My personal value system is that the staff nurses who are with the patient in the moment know best about that patient’s need for nursing care. While there are certainly prescriptive formulas for determining how many nurses are needed to take care of a specific number of patients, these formulas are often too rigid. Determining the ideal staffing level is part art and part science. Staffing can vary from patient to patient and from unit to unit, and can change over time throughout any health care institution. The goal with staffing is to have the right nurse with the right skill for the right patient at the right time. The local team on a unit is in the best position to determine the ideal staffing. Formulas can be helpful guideposts, but making the right staffing decision requires keen awareness, critical thinking and perspective. The factors that must be considered when making decisions are the acuity of the patient, the experience of the nurse, systems that support nursing practice and the geographical design of the unit. And Nursing cannot do this alone. We are fortunate to work with nursing assistants, therapists, physicians, secretaries, chaplains, interpreters, social workers, technicians and many others in the care of our patients. What is important to consider here is the nurse’s professional responsibility for clinical assessment, expert judgment and creative planning to ensure the best nursing assignments and staffing levels. The bottom line is that the patients’ needs must determine the staffing level at any given moment.

Q. How important is technology aimed at reducing clinically insignificant (nuisance) alarms?

A. You raise an important question. High-level clinical monitoring involves designing a highly reliable system that takes into consideration several working parts: the human factor (staff and patients), the environment of care, and the technology. What you’ve read in the Globe about the current state of clinical alarms is that there is too much overall “noise” in the system. Alarms go off with great frequency, and the vast majority of these alerts are “false alarms.” Any technological advance that can help separate the noise from the useful information would be invaluable. By reducing the number of false alarms, we enable the monitors to do what we need them to do: alert clinicians to relevant clinical changes in the patient at the earliest possible moment.

Lisa M. Sawtelle

Lisa M. Sawtelle, RN, has worked at Boston Medical Center for 23 years, caring for patients in the medical, surgical, surgical step-down and surgical intensive care units. She is a member of the hospital bargaining committee for Massachusetts Nurses Association and a member of the MNA political action committee. She is married to a Braintree deputy fire chief, and has one son and two stepsons.

Q. Three years ago I had a knee replacement surgery at Brigham & Woman's Hospital. The first night of my surgery, I was hooked up to a monitor that would beep if I stopped breathing -- I would wake to the sound of the loud beeping -- When no one came to shut off the alarm, I would ring the nurse's bell. No one still came into the room. I rang the bell several times and finally a nurse called over the speaker for me to stop ringing the bell as she could hear the alarm. Finally when someone did come into the room and shut it off, I asked if they would show me how to shut off the alarm.They said no they could not do that. Well this went on all night until an aid came on duty. Fortunately, I would wake up with the alarm and could breath just fine, however it was a very difficult night without hardly any sleep. I think the aides showed more caring than some of the nurses. I was thrilled to see a column on "€œPatient alarms often unheard, unheeded." After reading the story, I realized this issue is common and a problem that needs to be solved. No one should have to die because of a battery dying or unheeded attention to the alarms that are meant to save lives. What is being done about this issue in the hospitals?

A. The alarm that was probably used was an oxygen saturation monitor. The alarm is set to go off when someone's oxygen saturation drops below a desired level. Often after surgery patients are sedated due to anesthesia and narcotics for pain. Where as it is not always the practice, this monitor will actually alarm at the patient's bedside and will awaken the patient when their saturations drop too low. This prevents the need for further and often emergency intervention. This monitor in my institution alarms at a central monitor station, we attempt to keep volumes lower at the bedside, as to not disturb the patients. However, if a patient is sedated, or is experiencing apnea (brief lapses in respirations) it would be important to keep patients awake until the sedation has worn off. Technology has a important role in medicine and nursing. It truly saves lives from where we were 20 years ago. Hospitals are educating staff to keep them up to date on new monitors and equipment. Where I work we trial a new piece of equipment, the company comes in to service it, then we institute super-users to continue to be resources for the staff.

Q. How many patients is a nurse responsible for on a typical shift? What is the optimal patient/nurse ratio? At what level does the ratio become dangerous for patients and/or nurses?

Unfortunately in Massachusetts we currently have no set ratios for safe staffing, and we desperately need them. Research shows that when a nurse is assigned too many patients to care for, it potentially increases your risk as a patient to suffer a complication or even death. Poor staffing ratios is a major contributor to the problem of alarm fatigue. When a nurse has the time to care for all his or her patients and monitor them properly there is less chance of those alarms sounding. We can assess the problems before they arise. In Massachusetts, my professional organization, the Massachusetts Nurses Association has filed legislation which would establish specific limits on nurse's patients assignments. This would ensure safe staffing based on acuity, or intensity of your illness. Medical/surgical nurses would never have more than four patients at a time and nurses in the ICU's would never have more than two.

Q. How important is technology aimed at reducing clinically insignificant (nuisance) alarms?

A. It is very important for technology to continue to hone their products, these are patients lives, no one wants to be pulled from a patients bedside for a false alarm, but it happens repeatedly and often. The thing to remember is you can not substitute a nurse with technology. The monitor should enhance our jobs, not eliminate them. I breath a sigh of relief knowing that my patients are on a monitor. I can see something before it happens. There is no substitute for a registered nurse to be in the patients rooms on a regular basis, where he or she can use their well honed assessment skills to interpret what the machines are telling me. This is what allows us to make moment to moment decisions for those critical outcomes.