The Wolf Is Crying in the Operating Room: PatientMonitor and Anesthesia Workstation AlarmingPatterns During Cardiac Surgery
Felix Schmid, MD,* Matthias S. Goepfert, MD,* Daniela Kuhnt,† Volker Eichhorn, MD,*Stefan Diedrichs, MD,* Hermann Reichenspurner, MD, PhD,‡ Alwin E. Goetz, MD, PhD,*and Daniel A. Reuter, MD, PhD*
Vital sign monitors and ventilator/anesthesia workstations are equipped withmultiple alarms to improve patient safety. A high number of false alarms can lead to a “cryingwolf” phenomenon with consecutively ignored critical situations. Systematic data on alarmpatterns and density in the perioperative phase are missing. Our objective of this study was tocharacterize the patterns of alarming of a commercially available patient monitor and aventilator/anesthesia workstation during elective cardiac surgery.
We performed a prospective, observational study in 25 consecutive elective cardiacsurgery patients. In all patients, identically ﬁxed alarm settings were used. All incoming patientdata and all alarms from the patient monitor and the anesthetic workstation were digitally recorded. Additionally, the anesthesia workplace was videotaped from 2 different angles to allowretrospective annotation and correlation of alarms with the clinical situation and assessment of the anesthesiologists’ reaction to the alarms.
Of the 8975 alarms, 7556 were hemodynamic alarms and 1419 were ventilatory alarms. For each procedure, 359
158 alarms were recorded, representing a mean density of alarms of 1.2/minute.
Approximately 80% of the total 8975 alarms had no therapeutic consequences.Implementation of procedure-speciﬁc settings and optimization in artifact and technical alarmdetection could improve patient surveillance and safety. (Anesth Analg 2011;112:78–83)
he use of alarming systems in patient monitoringdevices, such as ventilator/anesthesia workstations,is of paramount importance for patient safety. Thisaccounts for both perioperative anesthesia and monitoringin the intensive care unit (ICU). Inadequate use or failure torespond to intraoperative alarms may result in patienthazard and undesirable outcomes.
The majority of alarms are so-called threshold alarms, i.e., a violation of apredefined threshold leads to an acoustic and/or opticalalarm. Therefore, it is crucial to set alarming thresholdscorrectly. Thresholds have to be tight enough to detectpotential deteriorations in vital functions as early as pos-sible. However, tight thresholds are naturally prone to ahigh number of false-positive alarms. Therefore, con-versely, they have to be set wide enough to account forphysiologic inter- and intrapatient variations. In addition,artifacts (e.g., patient movement or manipulation of sen-sors) may lead to false-positive alarms. Depending on thesurgical procedure, differing patterns and frequencies of alarms have been described.
For the situation in theoperating room (OR), the rate of false alarms was describedto even exceed the number of correct alarms, so that theactual function of the alarms was lost and they became adistraction.
Furthermore, studies in different adult andpediatric ICUs found false alarm rates ranging from 72% to99%.
The dangerous consequence is the “crying wolf phenomenon,” i.e., that because of the density of totalalarms and the high number of false alarms, correct andimportant alarms are ignored.
Thus, an important goal, inparticular for clinical situations with high-risk procedures,is to reduce false alarm rates to a minimum by an opti-mized setting of alarm thresholds. However, there are onlyfew data on quantity and quality of alarming in a complexperioperative setting.Therefore, this study was performed to characterize thepatterns of alarms of a current patient monitor (Kappa XLT;Dra¨ger, Lu¨beck, Germany) and an anesthesia workstation(Zeus, Dra¨ger) during elective cardiac surgery with the useof extracorporeal circulation (ECC). The objective was toquantify and to characterize all occurring alarms includingidentification of their origin during the entire perioperativephase. Furthermore, we sought to quantify the number of false-positive alarms produced by the monitoring system.
The protocol of this observational study was approved andauthorized by the local ethics committee, the IRB, and theprivacy protection commissioner of the hospital. Afterproviding informed consent, 25 consecutive patients sched-uled for elective cardiac surgery (aortocoronary bypassgrafting and valve surgery) were included. Perioperativecare was given by an anesthesiologist who was informed of
From the Departments of *Anesthesiology, and ‡Cardiovascular Surgery,University Medical Center Hamburg-Eppendorf, Hamburg; and †HochschuleAnhalt, Ko¨then, Germany.Accepted for publication August 30, 2010.Supported by an unrestricted grant from Dra¨ger, Lu¨beck, Germany.FS and MSG contributed equally to this work.The authors report no conflicts of interest.Address correspondence and reprint requests to Daniel A. Reuter, MD,PhD, Department of Anesthesiology, Hamburg-Eppendorf UniversityHospital, Martinistr. 52, 20246 Hamburg, Germany. Address e-mail firstname.lastname@example.org.Copyright © 2010 International Anesthesia Research Society
www.anesthesia-analgesia.org January 2011