Skip to main content
Log in

The Influence of Audible Alarm Loudness and Type on Clinical Multitasking

  • Clinical Systems
  • Published:
Journal of Medical Systems Aims and scope Submit manuscript

Abstract

In high-consequence industries such as health care, auditory alarms are an important aspect of an informatics system that monitors patients and alerts providers attending to multiple concurrent tasks. Alarms levels are unnecessarily high and alarm signals are uninformative. In a laboratory-based task setting, we studied 25 anesthesiology residents’ responses to auditory alarms in a multitasking paradigm comprised of three tasks: patient monitoring, speech perception/intelligibility, and visual vigilance. These tasks were in the presence of background noise plus/minus music, which served as an attention-diverting stimulus. Alarms signified clinical decompensation and were either conventional alarms or a novel informative auditory icon alarm. Both alarms were presented at four different levels. Task performance (accuracy and response times) were analyzed using logistic and linear mixed-effects regression. Salient findings were 1), the icon alarm had similar performance to the conventional alarm at a +2 dB signal-to-noise-ratio (SNR) (accuracy: OR 1.21 (95% CI 0.88, 1.67), response time: 0.04 s at 2 dB (95% CI: –0.16, 0.24), which is a much lower level than current clinical environments; 2) the icon alarm was associated with 27% greater odds (95% CI: 18%, 37%) of correctly addressing the vigilance task, regardless of alarm SNR, suggesting crossmodal/multisensory multitasking benefits; and 3) compared to the conventional alarm, the icon alarm was associated with an absolute improvement in speech perception of 4% in the presence of an attention-diverting auditory stimulus (p = 0.031). These findings suggest that auditory icons can provide multitasking benefits in cognitively demanding clinical environments.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
$34.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

Availability of data and material

Per IRB regulations we have retained the data for a minimum of five years and are happy to turn over all raw data to the Journal of Medical Systems per request.

Code availability

We are happy to supply all the code views of analysis upon request.

References

  1. Wickens, C. D., Mountford, S. J., & Schreiner, W. (1981, Apr). Multiple resources, task-hemispheric integrity, and individual differences in time-sharing. Hum Factors, 23(2), 211–229. https://doi.org/10.1177/001872088102300209

  2. Edworthy, J. (2013, May 1). Medical audible alarms: a review. J Am Med Inform Assoc, 20(3), 584–589. https://doi.org/10.1136/amiajnl-2012-001061

  3. Wickens, C. D. (2008, Jun). Multiple resources and mental workload. Hum Factors, 50(3), 449–455. https://doi.org/10.1518/001872008X288394

  4. Verma, R., Mohan, B., Attri, J. P., Chatrath, V., Bala, A., & Singh, M. (2015, Sep-Dec). Anesthesiologist: The silent force behind the scene. Anesth Essays Res, 9(3), 293–297. https://doi.org/10.4103/0259-1162.159775

  5. Shambo, L., Umadhay, T., & Pedoto, A. (2015, Feb). Music in the operating room: is it a safety hazard? AANA J, 83(1), 43–48. https://www.ncbi.nlm.nih.gov/pubmed/25842633

  6. Darbyshire, J. L., Muller-Trapet, M., Cheer, J., Fazi, F. M., & Young, J. D. (2019, Aug). Mapping sources of noise in an intensive care unit. Anaesthesia, 74(8), 1018–1025. https://doi.org/10.1111/anae.14690

  7. Katz, J. D. (2014, Oct). Noise in the operating room. Anesthesiology, 121(4), 894–898. https://doi.org/10.1097/ALN.0000000000000319

  8. Rokho, K., & Martin, B. (2010). Night Noise Guidelines for Europe. Noise Health, 12, 63–84.

    Google Scholar 

  9. Busch-Vishniac, I. J., West, J. E., Barnhill, C., Hunter, T., Orellana, D., & Chivukula, R. (2005, Dec). Noise levels in Johns Hopkins Hospital. J Acoust Soc Am, 118(6), 3629–3645. https://doi.org/10.1121/1.2118327

  10. Tegnestedt, C., Gunther, A., Reichard, A., Bjurstrom, R., Alvarsson, J., Martling, C. R., & Sackey, P. (2013, Sep). Levels and sources of sound in the intensive care unit - an observational study of three room types. Acta Anaesthesiol Scand, 57(8), 1041–1050. https://doi.org/10.1111/aas.12138

  11. Ayoub, C. M., Rizk, L. B., Yaacoub, C. I., Gaal, D., & Kain, Z. N. (2005, May). Music and ambient operating room noise in patients undergoing spinal anesthesia. Anesth Analg, 100(5), 1316–1319, table of contents. https://doi.org/10.1213/01.ANE.0000153014.46893.9B

  12. Ullmann, Y., Fodor, L., Schwarzberg, I., Carmi, N., Ullmann, A., & Ramon, Y. (2008, May). The sounds of music in the operating room. Injury, 39(5), 592–597. https://doi.org/10.1016/j.injury.2006.06.021

  13. Xie, H., Kang, J., & Mills, G. H. (2009). Clinical review: The impact of noise on patients' sleep and the effectiveness of noise reduction strategies in intensive care units. Crit Care, 13(2), 208. https://doi.org/10.1186/cc7154

    Article  PubMed  PubMed Central  Google Scholar 

  14. Momtahan, K., Hetu, R., & Tansley, B. (1993, Oct). Audibility and identification of auditory alarms in the operating room and intensive care unit. Ergonomics, 36(10), 1159–1176. https://doi.org/10.1080/00140139308967986

  15. Schlesinger, J. J., Baum Miller, S. H., Nash, K., Bruce, M., Ashmead, D., Shotwell, M. S., Edworthy, J. R., Wallace, M. T., & Weinger, M. B. (2018, Jun). Acoustic features of auditory medical alarms-An experimental study of alarm volume. J Acoust Soc Am, 143(6), 3688. https://doi.org/10.1121/1.5043396

  16. Lacherez, P., Seah, E. L., & Sanderson, P. (2007, Aug). Overlapping melodic alarms are almost indiscriminable. Hum Factors, 49(4), 637–645. https://doi.org/10.1518/001872007X215719

  17. Sanderson, P. M., Wee, A., & Lacherez, P. (2006, Feb). Learnability and discriminability of melodic medical equipment alarms. Anaesthesia, 61(2), 142–147. https://www.ncbi.nlm.nih.gov/pubmed/16430567

  18. Wee, A. N., & Sanderson, P. M. (2008, Feb). Are melodic medical equipment alarms easily learned? Anesth Analg, 106(2), 501–508, table of contents. https://doi.org/10.1213/01.ane.0000286148.58823.6c

  19. Belz, S. M., Robinson, G. S., & Casali, J. G. (1999, Dec). A new class of auditory warning signals for complex systems: auditory icons. Hum Factors, 41(4), 608–618. https://doi.org/10.1518/001872099779656734

  20. Edworthy, J., Page, R., Hibbard, A., Kyle, S., Ratnage, P., & Claydon, S. (2014, Sep). Learning three sets of alarms for the same medical functions: a perspective on the difficulty of learning alarms specified in an international standard. Appl Ergon, 45(5), 1291–1296. https://doi.org/10.1016/j.apergo.2013.10.003

  21. Graham, R. (1999, Sep). Use of auditory icons as emergency warnings: evaluation within a vehicle collision avoidance application. Ergonomics, 42(9), 1233–1248. https://doi.org/10.1080/001401399185108

  22. Keller, P., & Stevens, C. (2004, Mar). Meaning from environmental sounds: types of signal-referent relations and their effect on recognizing auditory icons. J Exp Psychol Appl, 10(1), 3–12. https://doi.org/10.1037/1076-898X.10.1.3

  23. Perry, N. C., Stevens, C. J., Wiggins, M. W., & Howell, C. E. (2007, Dec). Cough once for danger: icons versus abstract warnings as informative alerts in civil aviation. Hum Factors, 49(6), 1061–1071. https://doi.org/10.1518/001872007X249929

  24. Stephan, K. L., Smith, S. E., Martin, R. L., Parker, S. P., & McAnally, K. I. (2006, Summer). Learning and retention of associations between auditory icons and denotative referents: implications for the design of auditory warnings. Hum Factors, 48(2), 288–299. https://doi.org/10.1518/001872006777724426

  25. IEC. (2020). Medical Electrical Equipment—Part 1–8: General Requirements for Basic Safety and Essential Performance—Collateral Standard: General Requirements, Tests and Guidance for Alarm Systems in Medical Electrical Equipment and Medical Electrical Systems. https://webstore.iec.ch/publication/2599

  26. Bennett, C., Dudaryk, R., Crenshaw, N., Edworthy, J., & McNeer, R. (2019, Aug). Recommendation of New Medical Alarms Based on Audibility, Identifiability, and Detectability in a Randomized, Simulation-Based Study. Crit Care Med, 47(8), 1050–1057. https://doi.org/10.1097/CCM.0000000000003802

  27. Edworthy, J., Reid, S., McDougall, S., Edworthy, J., Hall, S., Bennett, D., Khan, J., & Pye, E. (2017, Nov). The Recognizability and Localizability of Auditory Alarms: Setting Global Medical Device Standards. Hum Factors, 59(7), 1108–1127. https://doi.org/10.1177/0018720817712004

  28. Edworthy, J. R., McNeer, R. R., Bennett, C. L., Dudaryk, R., McDougall, S. J. P., Schlesinger, J. J., … Osborn, D. . (2018). Getting Better Hospital Alarm Sounds Into a Global Standard. Ergonomics in Design, 26(4), 4–13. https://doi.org/10.1177/1064804618763268

  29. McNeer, R. R., Horn, D. B., Bennett, C. L., Edworthy, J. R., & Dudaryk, R. (2018, Jul). Auditory Icon Alarms Are More Accurately and Quickly Identified than Current Standard Melodic Alarms in a Simulated Clinical Setting. Anesthesiology, 129(1), 58–66. https://doi.org/10.1097/ALN.0000000000002234

  30. Konkani, A., Oakley, B., & Bauld, T. J. (2012, Nov-Dec). Reducing hospital noise: a review of medical device alarm management. Biomed Instrum Technol, 46(6), 478–487. https://doi.org/10.2345/0899-8205-46.6.478

  31. Harrell, F. E., Jr. (2015). Regression modeling strategies with application to linear models, logistics, and ordinal regression and survival analysis. Journal of Statistical Software, 70(2).

  32. Althouse, A. D. (2016, May). Adjust for Multiple Comparisons? It's Not That Simple. Ann Thorac Surg, 101(5), 1644–1645. https://doi.org/10.1016/j.athoracsur.2015.11.024

  33. Feise, R. J. (2002, Jun 17). Do multiple outcome measures require p-value adjustment? BMC Med Res Methodol, 2, 8. https://doi.org/10.1186/1471-2288-2-8

  34. Brungart, D. S., & Scott, K. R. (2001, Jul). The effects of production and presentation level on the auditory distance perception of speech. J Acoust Soc Am, 110(1), 425–440. https://www.ncbi.nlm.nih.gov/pubmed/11508968

  35. Brungart, D. S., & Simpson, B. D. (2007, Sep). Effect of target-masker similarity on across-ear interference in a dichotic cocktail-party listening task. J Acoust Soc Am, 122(3), 1724. https://doi.org/10.1121/1.2756797

  36. AAMI. (2015). Clinical Alarm Management Compendium. AAMI Foundation. https://www.aami.org/docs/default-source/foundation/alarms/alarm-compendium-2015.pdf?sfvrsn=2d2b53bd_2

  37. Fleischman, W., Ciliberto, B., Rozanski, N., Parwani, V., & Bernstein, S. L. (2020, Jun). Emergency department monitor alarms rarely change clinical management: An observational study. Am J Emerg Med, 38(6), 1072–1076. https://doi.org/10.1016/j.ajem.2019.158370

  38. Hravnak, M., Pellathy, T., Chen, L., Dubrawski, A., Wertz, A., Clermont, G., & Pinsky, M. R. (2018, Nov - Dec). A call to alarms: Current state and future directions in the battle against alarm fatigue. J Electrocardiol, 51(6S), S44-S48. https://doi.org/10.1016/j.jelectrocard.2018.07.024

  39. Koomen, E., Webster, C. S., Konrad, D., van der Hoeven, J. G., Best, T., Kesecioglu, J., Gommers, D. A., de Vries, W. B., & Kappen, T. H. (2021, Jan). Reducing medical device alarms by an order of magnitude: A human factors approach. Anaesth Intensive Care, 49(1), 52–61. https://doi.org/10.1177/0310057X20968840

  40. Welch, J. (2011, Spring). An evidence-based approach to reduce nuisance alarms and alarm fatigue. Biomed Instrum Technol, Suppl, 46–52. https://doi.org/10.2345/0899-8205-45.s1.46

  41. Cooke, M., Barker, J., Cunningham, S., & Shao, X. (2006, Nov). An audio-visual corpus for speech perception and automatic speech recognition. J Acoust Soc Am, 120(5 Pt 1), 2421–2424. https://doi.org/10.1121/1.2229005

  42. Greenwood, D. D. (1961). Critical Bandwidth and the Frequency Coordinates of the Basilar Membrane. Journal of the Acoustical Society of America, 33(10), 1344–1356. https://doi.org/10.1121/1.1908437

  43. Huang, N., & Elhilali, M. (2017, Mar). Auditory salience using natural soundscapes. J Acoust Soc Am, 141(3), 2163. https://doi.org/10.1121/1.4979055

  44. Kayser, C., Petkov, C. I., Lippert, M., & Logothetis, N. K. (2005, Nov 8). Mechanisms for allocating auditory attention: an auditory saliency map. Curr Biol, 15(21), 1943–1947. https://doi.org/10.1016/j.cub.2005.09.040

  45. Pires, L. D., Vieira, M. N., & Yehia, H. C. (2017, Mar). Automatic loudness control in short-form content for broadcasting. J Acoust Soc Am, 141(3), EL287. https://doi.org/10.1121/1.4978023

  46. Cvach, M. (2012, Jul-Aug). Monitor alarm fatigue: an integrative review. Biomed Instrum Technol, 46(4), 268–277. https://doi.org/10.2345/0899-8205-46.4.268

  47. Deb, S., & Claudio, D. (2014). Alarm fatigue and its influence on staff performance. IIE Transactions on Healthcare Systems Engineering, 5(3), 183–196. https://doi.org/10.1080/19488300.2015.1062065

    Article  Google Scholar 

  48. Drew, B. J., Harris, P., Zegre-Hemsey, J. K., Mammone, T., Schindler, D., Salas-Boni, R., Bai, Y., Tinoco, A., Ding, Q., & Hu, X. (2014). Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational study of consecutive intensive care unit patients. PLoS One, 9(10), e110274. https://doi.org/10.1371/journal.pone.0110274

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  49. Kristensen, M. S., Edworthy, J., & Özcan, E. (2016). Alarm fatigue in the ward: An acoustical problem? SoundEffects-An Interdisciplinary Journal of Sound and Sound Experience, 6, 88-104.

    Article  Google Scholar 

  50. Sendelbach, S., & Funk, M. (2013, Oct-Dec). Alarm fatigue: a patient safety concern. AACN Adv Crit Care, 24(4), 378–386; quiz 387–378. https://doi.org/10.1097/NCI.0b013e3182a903f9

  51. Brown, Z., Edworthy, J., Sneyd, J. R., & Schlesinger, J. (2015, Nov). A comparison of linear and logarithmic auditory tones in pulse oximeters. Appl Ergon, 51, 350–357. https://doi.org/10.1016/j.apergo.2015.06.006

    Article  PubMed  Google Scholar 

  52. Tsien, C. L., & Fackler, J. C. (1997, Apr). Poor prognosis for existing monitors in the intensive care unit. Crit Care Med, 25(4), 614–619. https://doi.org/10.1097/00003246-199704000-00010

  53. Popplewell, A. (2010, Oct). Sound advice demands a receptive audience. Health Estate, 64(9), 75–77. https://www.ncbi.nlm.nih.gov/pubmed/21058626

  54. Carlyon, R. P., Plack, C. J., Fantini, D. A., & Cusack, R. (2003). Cross-modal and non-sensory influences on auditory streaming. Perception, 32(11), 1393–1402. https://doi.org/10.1068/p5035

    Article  PubMed  Google Scholar 

  55. Mulligan, N. W., Duke, M., & Cooper, A. W. (2007, Sep). The effects of divided attention on auditory priming. Mem Cognit, 35(6), 1245–1254. https://doi.org/10.3758/bf03193598

  56. Finomore, V. S., Jr., Shaw, T. H., Warm, J. S., Matthews, G., & Boles, D. B. (2013, Dec). Viewing the workload of vigilance through the lenses of the NASA-TLX and the MRQ. Hum Factors, 55(6), 1044–1063. https://doi.org/10.1177/0018720813484498

  57. Funke, G. J., Warm, J. S., Baldwin, C. L., Garcia, A., Funke, M. E., Dillard, M. B., Finomore, V. S., Jr., Matthews, G., & Greenlee, E. T. (2016, Sep). The Independence and Interdependence of Coacting Observers in Regard to Performance Efficiency, Workload, and Stress in a Vigilance Task. Hum Factors, 58(6), 915–926. https://doi.org/10.1177/0018720816646657

  58. Paine, C. W., Goel, V. V., Ely, E., Stave, C. D., Stemler, S., Zander, M., & Bonafide, C. P. (2016, Feb). Systematic Review of Physiologic Monitor Alarm Characteristics and Pragmatic Interventions to Reduce Alarm Frequency. J Hosp Med, 11(2), 136–144. https://doi.org/10.1002/jhm.2520

  59. Stevenson, R. A., Wilson, M. M., Powers, A. R., & Wallace, M. T. (2013, Apr). The effects of visual training on multisensory temporal processing. Exp Brain Res, 225(4), 479–489. https://doi.org/10.1007/s00221-012-3387-y

  60. Dingley, C., Daugherty, K., Derieg, M. K., & Peersing, R. (2008). Improving Patient Safety Through Provider Communication Strategy Enhancements. Advances in Patient Safety: New Directions and Alternative Approaches, 3(1), 1–18.

    Google Scholar 

  61. Wahr, J. A., Prager, R. L., Abernathy, J. H., 3rd, Martinez, E. A., Salas, E., Seifert, P. C., Groom, R. C., Spiess, B. D., Searles, B. E., Sundt, T. M., 3rd, Sanchez, J. A., Shappell, S. A., Culig, M. H., Lazzara, E. H., Fitzgerald, D. C., Thourani, V. H., Eghtesady, P., Ikonomidis, J. S., England, M. R., Sellke, F. W., Nussmeier, N. A., American Heart Association Council on Cardiovascular, S., Anesthesia, C. o. C., Stroke, N., Council on Quality of, C., & Outcomes, R. (2013, Sep 3). Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association. Circulation, 128(10), 1139–1169. https://doi.org/10.1161/CIR.0b013e3182a38efa

Download references

Funding

The authors did not receive support from any organization for submitted work.

Author information

Authors and Affiliations

Authors

Contributions

Alexandra Bruder: This author acquired all data from the anechoic chamber for the study. She also wrote the original manuscript and was involved in all the revisions and writing of the manuscript; Clayton Rothwell: This author was involved in all the revisions and writing of the manuscript and provided assistance with the figures and verification of results and statistical analyses; Laura Fuhr: This author helped with the IRB approval and participated in writing the original manuscript; Matthew Shotwell: This author performed all the statistical analysis and contributed to the creation for the outline of the figures and tables. This author also helped with revisions and the writing of the manuscript; Judy Edworthy: This author developed the auditory stimuli used in the experiment, contributed to the writing of the manuscript and all the revisions; Joseph Schlesinger: This author oversaw the entire project. This author also contributed to writing the manuscript and overseeing and contributing to all the revisions and interpretation and application of data.

Corresponding author

Correspondence to Alexandra L. Bruder.

Ethics declarations

Ethics approval

Approval for this study was obtained from Vanderbilt Institutional Review Board, IRB Number 170118.

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Consent for publication

Our submission abides by the Journal of Medical Systems preview and bylaws for consent to publication.

Conflicts of interest/competing interests

The authors have no conflicts of interest or competing interests to declare.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Clinical Systems

Supplementary information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 15 KB)

Supplementary file2 (DOCX 14 KB)

Supplementary file3 (DOCX 19 KB)

Supplementary file4 (DOCX 1628 KB)

Supplementary file5 (DOCX 13 KB)

Supplementary file6 (MP4 100 KB)

Supplementary file7 (MP4 95 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bruder, A.L., Rothwell, C.D., Fuhr, L.I. et al. The Influence of Audible Alarm Loudness and Type on Clinical Multitasking. J Med Syst 46, 5 (2022). https://doi.org/10.1007/s10916-021-01794-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s10916-021-01794-9

Keywords

Navigation