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There are good reasons why many hospitals dream of smarter, silent ICUs. One, they contribute to better patient outcomes. Two, they make for better, more efficient working environments for busy caregivers. That’s why Ascom is currently part of two high-level projects co-funded by the EU—projects devoted to bringing smarter, silent ICUs closer to reality. Learn more from Paolo Burchietti of Ascom’s Global Solutions team.
Paolo Burchietti, part of Ascom’s Global Solutions team, with 20-plus years’ experience in clinical workflows, he is leading Ascom’s contribution in two innovative, high-tech international healthcare projects. He took the time to explain the projects, and how they could address some pressing challenges in modern Intensive Care Units (ICUs).
But first, some context. Most of us have a mental picture of an ICU: an open ward with five to ten or more beds, each one surrounded by banks of medical devices, and a ceaseless cacophony of loud, disruptive alarms.
Burchietti nods in agreement at the mention of ICU noise levels. “Most people,” he says, “simply don’t realize how loud it can get in an ICU.” In fact, peaks as high as 127.9 dBA have been recorded, and almost all ICUs regularly exceed—and by a wide margin—the 35 dB ICU bedside noise ceiling recommended by the World Health Organization (WHO).
Most people also have no idea of the risks noise poses to ICU patients. The truth, however, is that prolonged exposure to loud noise puts them at an increased risk of developing a condition called ICU delirium. “This serious phenomenon,” says Burchietti, “often results in longer ICU stays, and has a negative impact on readmission rates, long-term cognitive impairment and mortality. Much remains to be learned about ICU delirium, but this we do know: a quiet environment is one of the best preventive and remedial measures at our disposal.”
Unfortunately, many hospitals now face a major obstacle to the creation of quiet ICUs; to the kind of calm settings so important to combatting ICU delirium. Ironically, it is an obstacle that arose as a result of a well-meaning measure to curb the spread of hospital-borne infections: the adaptation of single-patient rooms in ICUs. Having ICU patients in single-rooms does indeed reduce the spread of such infections (also known as healthcare-associated or nosocomial infections). But as Burchietti points out, “the patient is alone with a bunch of medical devices making noise in a confined space reserved only for him or her. And it is even worse once the door closes.”
Noise isn’t the only issue facing single-patient room ICUs. In traditional open-plan ICUs, nurses not only hear all the alarms generated by medical devices, they also have direct visual contact with their assigned patients. Placing ICU patients in their own rooms, however, removes these two information sources. “Yes, the patient is better protected from infection and has better privacy,” says Burchietti. “But now we face two tough challenges: how can we reliably get alarm notifications to caregivers outside that room, and how can we do so in a way that is silent in the room and not overwhelming for the nurse?”
The answer, obviously, is with advanced alarm management systems. Again, a little context is helpful. Traditionally, a hospital would use a Distributed Information System (DIS) to transmit alarm notifications from patients and bedside medical devices such as infusion pumps, ventilators and monitors. A DIS, however, does not guarantee delivery—there is no certainty that the correct caregiver actually saw or heard the alert.
“The next step up from a DIS,” says Burchietti, “is a DAS, a Distributed Alarm System. This has the advantage of guaranteeing delivery of alarm notifications, but lacks confirmation that they have been responded to or acted upon.” For that level of functionality, a CDAS (Distributed Alarm System with Operator Confirmation) is needed. “Put simply, a CDAS requires the nurse receiving the alarm to confirm she or he has received the alert, and either accept it for action, or reject it. If rejected or not answered, the alert then passes automatically to the next nurse designated for action.”
Burchietti’s two projects are concerned with evolving CDAS to enable truly silent and smart ICU clinical alarm management—particularly in the context of the single-patient room layout now becoming the norm in ICUs around the world.
“Both projects,” says Burchietti, “are part of a group of four research initiatives called Smart and Silent ICU (SASICU), that are jointly funded by the private sector and the EU via the Innovative Health Initiative (IHI) which brings together the financial resources of the EU and healthcare industry associations.”
In broad terms, all the SASICU projects deal with Service-oriented Device Connectivity (SDC) standard (ISO/IEEE 11073 SDC), which facilitates the interoperability of different medical devices and IT systems in ICUs and other high-acuity environments. The projects explore how alarm-system architectures based on the SDC standard can help reduce noise pollution in ICUs, and improve patient care with meaningful identification of actionable alarms.
Most people simply don’t realize how loud it can get in an ICU. In fact, peaks as high as 127.9 dBA have been recorded, and almost all ICUs regularly exceed by a wide margin the 35 dB ICU bedside noise ceiling recommended by the World Health Organization.
“In our first project,” says Burchietti, “we partnered with leading medical device manufacturers Dräger and B. Braun to conduct a clinical study at the Erasmus University Medical Center in Rotterdam, the Netherlands.” The project, which began in September 2023 and runs until September 2026, has three key phases:
“It might seem like a straightforward ‘before-and-after’ study,” says Burchietti, “but it’s actually quite complex, involving three multinational companies, collaboration with numerous teams at a major teaching hospital, and more than 100 ICU patients.” The scale of the undertaking can be gauged by the fact that for 12 months the study records all alarms originating from patient monitors, ventilators and infusion pumps, as well as noise levels in all eight rooms.
The second project is a simulation study of ‘Smart Alarms’, where SDC is used to enable the safe suppression of clinically non-actionable alarms in order to reduce the cognitive load on busy caregivers.
As Burchietti explains, the vast majority of ICU alarms are actually not necessary. “Between 85% to 95% of them do not require immediate action from caregivers,” he says. “So this project, which is in collaboration with the University Medical Center Utrecht, is focused on developing new, more efficient ways of filtering out these unnecessary alerts. In addition, we are also exploring ways of identifying patient deterioration in advance before an alarm is actually generated.”
Such alarm filtering already exists, but is what Burchietti calls “fairly rudimentary—relying mainly on time limits and other simple parameters to reduce alarm frequency.” What, however, is needed is an alarm-suppression model that considers the patient’s overall clinical situation and its evolution.
“Imagine,” says Burchietti, “an ICU patient who is receiving life-sustaining medication from an infusion pump; the kind of medication without which the patient may die after a few minutes. Now, should a fault occur in the pump, we want an alarm to go out immediately. But what if the patient is receiving antibiotics, where several hours can safely go by before staff need to intervene. From the infusion pumps both of them are communicated as red alarms, but they are radically different. The latter could be communicated just as a task to the nurse. We obviously can’t try these scenarios with real ICU patients, but we can safely simulate them in a lab setting.”
Like the Silent ICU study, the Smart Alarm project at UMC Utrecht is due to conclude in September 2026. “It is,” says Burchietti, “by its nature a more forward-looking study, but it will yield valuable insights into how we can make alarm systems much more nuanced. For example, by assessing the patient’s total clinical picture, tomorrow’s systems will be predictive—will be able to ‘consider’ a mass of clinically relevant data in order to issue pre-emptive alarms.”
With less than a year to go for both projects, Burchietti is finally seeing light at the end of the tunnel. “It has,” he admits, “been an incredibly busy—but also incredibly rewarding—experience. I’m sure I speak for all my Ascom colleagues when I say we have learned so much from working with two great hospitals, and collaborating with our industry partners.”
He is however keen to correct some misconceptions about the development of silent and smart ICUs. “Some think that in the near-future hospitals can simply replace their existing ICUs with silent and smart versions, as if the new ICUs are ‘modules’ that can just be dropped in place.”
The reality for silent and smart ICUs is, Burchietti stresses, like most progress in healthcare, going to be evolutionary. “It will be paced, with hospitals gradually adding silent ICU-compatible devices and software to legacy systems. The value of the solutions we are developing lies in the support they offer hospitals as they make this transition at their own pace. When it is time for hospitals to upgrade their ICUs, they will be certain of having solutions supporting the next level, and that have been rigorously tested and verified for maximum safety and reliability.”
Acknowledgement
This project is supported by the Innovative Health Initiative Joint Undertaking (IHI JU) under grant agreement No. 101132808. The JU receives support from the European Union’s Horizon Europe research and innovation programme and COCIR, EFPIA, Vaccines Europe, EuropaBio, and MedTech Europe.
Disclaimer: Funded by the European Union, private members, and contributing partners of the IHI JU. Views and opinions expressed are those of the author(s) only and do not necessarily reflect those of the aforementioned parties. None of the aforementioned parties can be held responsible for them.
