The five levels of alarm management in today’s era of the Internet of Hospital Things

Sept. 26, 2017
Benjamin Kanter MD, FCCP, CMIO, Vocera Communications

Despite their reputation as highly-regulated workplaces with many barriers to entry, hospitals have a long history as a testing ground for innovative communication technologies. Whether it was for the adoption of the first modern paging system in the 1950s, or the more recent adoption of secure texting via smartphones, being able to connect the right care team members to the right information in a timely fashion is critical to achieving safer, more reliable healthcare. Unfortunately, with the increasing influx of health IT solutions and apps entering the hospital environment, clinical workflows are at risk of becoming much more complex, rather than being simplified by these “helpful” new IT tools. Without the right technology in place to coordinate and prioritize all the various forms of communication that clinicians receive from systems as disparate as physiologic monitors, beds, IV pumps, and ventilators, hospitals risk fatiguing their physicians and nurses with constant interruptions to patient care.

Alarm management has become progressively more complex over the past decade as previously “dumb” standalone medical systems and devices have developed the ability to send status messages across hospital networks (the “Internet of Hospital Things”—IoHT). Now that hospitals have started providing smartphones to their clinical staffs, communication workflows, which previously depended upon human intervention and coordination at the level of the ward clerk and telemetry technician, can now bypass those roles with alarm messages going directly to the patient’s immediate caregivers. While reducing some potential points of delay or failure within the communication chain, eliminating manual roles has removed a buffer that protected busy clinicians, giving rise to the impression (if not the fact) that clinical care seems to have gotten more complex and interruptive. With mobile communication adding another layer of complexity, hospitals and health systems have an even greater need than before to standardize processes, and develop a systematic approach to alarm management.

Courtesy of Vocera

Alarms that cry wolf

Rapid technological developments, including the implementation of medical-grade handheld smart devices, pose a double-edged sword. While they are extremely useful, they also have the potential to disrupt clinical operations; their use creates entirely new communication pathways and nursing workflows. Although these new technologies have the capacity to provide patient and care team benefits, if the transition to the new workflows is not managed with the proper governance, it can potentially lead to chaos and patient harm. As with the introduction of any new clinical tool, Primum Non Nocere rules the day: First, do no harm.

But with an exponentially expanding set of networked systems fighting for the attention of doctors and nurses, it’s hard to distinguish those alarms that are signaling urgent patient peril from those alarms that are, well, crying wolf. A dislodged sensor, a temporary, nondangerous change in vital signs, or other beeps and signals that aren’t urgent can distract healthcare providers from those that are life and death.

If all alarms are equally important, then they all risk becoming equally meaningless. Hospital leaders must develop a strategy to prioritize alarms, focusing clinician attention where it is most needed.

Taking on alarm interruption and fatigue

Alarm fatigue has been repeatedly recognized as one of the major technological safety hazards in the hospital environment. Alarm signals compete with all other message sources for a clinician’s attention, and with each alarm notification, there is inevitable distraction. Since each clinician has a limited attention bandwidth, messages (whether text or voice) must be considered in aggregate: Alarms with ad hoc messages, text messages with voice communications, and so on.

A strategic approach to alarm management requires careful planning. A journal article published in the May/June 2016 edition of Biomedical Instrumentation & Technology1 focuses on an incremental approach to alarm management based on a model originally developed by the Software Engineering Institute at Carnegie Mellon University to improve software development. In the journal article, my co-authors and I define five progressive levels of alarm management, and how each builds on the one preceding it.

Stage 1: Ad hoc strategy

Stage 1 reflects an organization that has a predominately ad hoc approach to alarm management issues. Stage 1 organizations are unlikely to have formed an alarm management committee and have not developed robust polices to guide alarm settings or subsequent responses. Data to objectively guide alarm management are not present.

Stage 2: Gaining buy-in, building infrastructure

Stage 2 organizations have developed the infrastructure to tackle alarm management issues at an institutional level. These organizations have acknowledged that improving alarm management is an important initiative, and have established an executive champion and an alarm management committee.

The committee should be multidisciplinary and empowered to tackle policies and procedures. The committee must also perform an assessment of alarm sources, settings and responses, and be prepared to organize a pilot project to reduce alarm related issues.

Stage 3: Pilot alarm management programs

Level 3 organizations have completed the pilot project and can show an improvement in alarm management control using objective data. The organization has begun to move from an ad hoc approach to combat alarm problems to one that is more proactive.

Once the organization can demonstrate measurable improvements and an ability to collect and analyze performance metrics at a local/pilot level, the organization is set to move on to stage 4, improving performance throughout the institution.

Stage 4: Operationalize best practices

Capitalizing on the success and learnings of stage 3, stage 4 organizations demonstrate an ability to manage alarms at an institutional level. Stage 4 organizations can demonstrate consistent objective metrics indicating lasting improvements in alarm performance.

Stage 5: Shoot for the moon

Stage 5 is largely aspirational. The ultimate goal: That no patient should be harmed as the result of inappropriate alarm management, and the entire organization is proactively engaged in managing alarm system vulnerabilities, while continuously looking ahead to improve methodologies and technologies.

Information technology service management philosophically emphasizes the importance of using standardized best-practice processes to ensure the successful management of IT operations. The Joint Commission, a not-for-profit hospital accreditation and certification organization, has established a National Patient Safety Goal focused on improving alarm management. Although The Joint Commission uses it as part of its accreditation review, it does not specify the processes by which hospitals should improve alarm management. Standardizing the development, implementation and adoption of alarm management practices is essential for patient care and safety as well as the resilience of nurses and physicians. CIOs modernizing hospital communication must take into account the fragmented nature of multiple systems and find a way to connect, triage and send the right information to the right people at the right time. Ultimately, an effective alarm management program will benefit both patients and care teams.


  1. Biomedical Instrumentation & Technology, May/June 2016, Welch, Rayo, Kanter et al