False Alarms & Alert Fatigue: The Hidden Cost of Bad Design on the Healthcare System

And five solutions to help improve it

I visited my dad as much as possible in 2016. He was battling Burkett’s Lymphoma and a number of complications at a hospital in Cleveland, Ohio.

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Just some of the beeping, chiming and disruptive machines my father was hooked up to during his hospital stay in 2016. Each device produced annoying alarms and constant tones.

The first thing I noticed was the alerts. He was hooked up to dozens of machines, each with a slightly different mosquito-like alarm. Chimes, dings, tones and stabs filled the background of his hospital room.

His roommate’s machines made the same sounds. When he pressed the button for an emergency (one of the nurses gave him the wrong painkiller, causing tremendous, all-night pain) the lag was noticeable. How were doctors and nurses managing these alarms? How many of them were meaningful? While writing Designing with Sound, I interviewed doctors, nurses, and patients about the sounds they heard. I also did some research into why the sounds were so annoying, and whether they were meaningful or not.

An astonishing percentage of alarms in hospitals are either false or clinically insignificant.

What I found was startling. Of the thousands of alerts heard by doctors and nurses every day, only some of them were considered helpful (and accurate!), but most of them were excessive. These extra alerts were leading to alert fatigue, one of the top causes of burnout in hospital staff. Burnout leads to dissatisfaction in patient care, reduces the efficacy of treatment, and increases healing time.

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.

We’ve reached the maximum of attention in the healthcare system.

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.

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.”

If we could calculate the extra dollar costs associated with responding to nuisance alarms, and the human costs of not responding to alarms when patients truly needed care, the economic and social toll would likely be enormous.

How do we create environments where we open up more human time, and less attention fatigue?

Understanding 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.

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Doctors and Nurses experience thousands of alarms a day. Nuisance alerts make up over 90% of pediatric ICU alarms and over 70% of adult ICU alarms.

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):

  1. The more often an alert or notification occurs, the less intense it should be.
  2. 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.

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Mesh networks are already used to connect devices wirelessly in hospitals. Image: all-free-download.com

How an Integrated System Can Improve Attention and Accuracy — And Help Address Alarm Fatigue

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” (source). Additionally, an integrated system could analyze separate pieces of biometric data to generate condition-specific alarms, highlighting life-threatening conditions.

Here’s five ways an integrated system could help improve the healthcare user experience through sound design:

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Audio beamforming can direct a specific sound to a location, making it less likely for sounds to persistently annoy everyone in an open office or hospital environment.

1. Localized Sound

One key 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.

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Melodies could be employed as informational soundscapes in hospitals, but it is important to not overdo it. One way to ensure better results is to have a data scientist, nurse and composer work together to improve the quality, listenability and context of the sonification.

2. Informative Melodies

Could you imagine a joyful (but non-intrusive) sound playing to bring a nurse or physician to a patient’s room? This approach has more to offer than just aesthetics.

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.

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.

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.

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Ambient awareness allows people to be attuned to many things without switching primary focus away from their current work.

3. 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.

4. 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.

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Sound design can take subtle cues from nature. Nature’s soundscapes change over time of day, season and year and can provide inspiration for generated soundscapes. With any soundscape borrowed from the environment, it is important to test a variety of sounds in real-world situations before blindly implementing specific soundscapes.

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.

5. Companion Haptic Alerts

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.

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Translating alerts from from an overloaded perceptual channel into a haptic one can help free up mental and visual space for more important tasks. Image: public domain.

An integrated system would take time to develop, but the result would be a truly holistic process 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. (These problems, unfortunately, are compounded by alert specifications imposed by standards organizations — but that’s a topic for another time.)

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 co-authored by Amber Case and Kellyn Standley. The material is part of Chapter 4 in the upcoming book, Designing with Sound!

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Designing with Sound, an upcoming book from Amber Case and Aaron Day, with significant help in structural and content editing from Kellyn Standley.

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.

Written by

Design advocate, speaker and author of Calm Technology + Designing With Sound. Research Fellow at Institute for the Future. Caseorganic.com

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