Working in an environment where there are multiple aural alerts constantly going off makes clinicians weary; eventually, they become desensitized to the alarm and tune it out, turn it down, and in some cases turn it off. In this case the clinician is really saying, “I don’t need the alarm, I’ll keep my eye on the patient and I’ll be able to see if something is wrong.”
On the other end of the spectrum of responses exists the opposite of alert fatigue, which is called primary/backup inversion. Here the clinician is saying, “Not only do I depend on the alarm, but I trust the alarm implicitly.”
An example of this occurs when a nurse elects to cover up a dialysis access site by placing a blanket on a patient because they are cold. The nurse rationalizes that if the connection with the patient’s Permacath™ is disrupted, although the connection is not visible, the danger of exsanguinating is nonexistent because the low-pressure alarm on the dialysis machine will alert her. Unfortunately, we know that patients have exsanguinated from this very situation because the low-pressure alarm either did not go off or did so after the patient lost significant volume. This is the danger with primary/backup inversion; it is a form of complacency where the relationship between human vigilance, which is the primary surveillance system, is switched with automation and technology, which is the backup surveillance system. Making this switch is dangerous because technology and automation can be unpredictable and occasionally fail.
Technology does not allow higher levels of SA, and for this reason we should embrace it in patient care. However, we cannot blithely accept that it will always do the right thing and function as advertised. Any situation involving an interface with automation and technology requires continuous monitoring, cross-checking, and evaluation.
On the flight deck, standard operating procedure is that the autopilot will be used for all approaches to airports in low visibility. The pilot shall not hand-fly the aircraft because we know the computer can do it much better than a human being; but it is being closely monitored at all times and never trusted implicitly. Attitudes and actions to manage physiologic monitoring systems effectively are:
- Use automation and technology when available
- Automated systems allow for higher levels of clinical SA
- Keep monitoring systems on (unless malfunction is verified)
- Set patient realistic and patient specific alarm parameters to avoid nuisance alerts
- Never disable clinical alarms
- Do not trust monitoring systems implicitly; cross-check with the patient when able
- Always assess the patient; this is the primary detection system
Always follow standard policy and procedure. Bending on standards while thinking that an automated monitoring system will “save me” is setting the stage for poor outcomes.
Gary L. Sculli, RN, MSN, ATP
David M. Sine, MA, CSP, ARM, CPHRM