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Improving Alarm Management Practices: Wireless Bed Exit Alerts on Medical-Surgical Units

Author: Amy Clodfelter, MSIT (2023)

Primary advisor: Angela Ross, DNP

Committee members: Amy Franklin, PhD and Kelly Aldrich, DNP

DHI Translational Project, McWilliams School of Biomedical Informatics at UTHealth Houston


In 2013, The Joint Commission published a Sentinel Event Alert due to patient deaths and injuries related to alarm-related issues. Some of the contributing factors were alarm fatigue, limited customized settings, lack of staff training, inadequate staffing resources to respond, and dearth of integrated devices (Advisory Board, 2013). The integration of smartphone technology with the patient call-bell system provides the opportunity to enhance patient safety by supporting nurses’ ability to communicate and prioritize care delivery directly. These challenges, however, are associated with achieving a balance between alarm support and alarm fatigue, which include distracting nurses from patient care or desensitizing the nurse to other alarms and calls (Burkoski et al., 2019).

Hospitals have quantitative and anecdotal reports of seriously high volumes of wireless alerts on the nurses’ smartphones. Nurses have complained that the phones are generating too much noise to consume or timely prioritize. In a single 12-hour shift, one 32-bed medical-surgical unit received over 500 patient calls, with only 15 signals having a response on the smartphone. Preliminary alarm inventory revealed the bed exit wireless alert as a leading contributor of signal volume across many units and hospitals. There is no metric to determine the appropriate volume of signals to avoid burden; it reflects volume perception and alert value to the end-user (Hayhurst, 2020).

The company has fully implemented integrated technologies to improve communication and collaboration between staff and patients using smartphones and call light systems. Lack of standard policies and workflow improvement processes has led to increased nuisance alarms that make these Health Information Technologies less useful and safe. Using system data, workflow observations, and nursing interviews, Singh and Sittig’s (2016) HIT Safety Framework was applied to identify and prioritize sociotechnical factors that impact the end-to-end bed exit alarm workflow. Interventions were piloted on 3 medical-surgical units with like hardware and software wireless integrations. This study reviewed the application of sociotechnical models and frameworks to reduce wireless calls without introducing risk and impacting patient care. Workflow changes, policy revisions, and system data were used to demonstrate meaningful improvement without unintended consequences.