Christine Weirich Paine

Association between exposure to nonactionable physiologic monitor alarms and response time in a children's hospital

BACKGROUND Alarm fatigue is reported to be a major threat to patient safety, yet little empirical data support its existence in the hospital. OBJECTIVE To determine if nurses exposed to high rates of nonactionable physiologic monitor alarms respond more slowly to subsequent alarms that could represent life-threatening conditions. DESIGN Observational study using video. SETTING Freestanding childrens hospital. PATIENTS Pediatric intensive care unit (PICU) patients requiring inotropic support and/or mechanical ventilation, and medical ward patients. INTERVENTION None. MEASUREMENTS Actionable alarms were defined as correctly identifying physiologic status and warranting clinical intervention or consultation. We measured response time to alarms occurring while there were no clinicians in the patients room. We evaluated the association between the number of nonactionable alarms the patient had in the preceding 120 minutes (categorized as 0-29, 30-79, or 80+ alarms) and response time to subsequent alarms in the same patient using a log-rank test that accounts for within-nurse clustering. RESULTS We observed 36 nurses for 210 hours with 5070 alarms; 87.1% of PICU and 99.0% of ward clinical alarms were nonactionable. Kaplan-Meier plots showed incremental increases in response time as the number of nonactionable alarms in the preceding 120 minutes increased (log-rank test stratified by nurse P < 0.001 in PICU, P = 0.009 in the ward). CONCLUSIONS Most alarms were nonactionable, and response time increased as nonactionable alarm exposure increased. Alarm fatigue could explain these findings. Future studies should evaluate the simultaneous influence of workload and other factors that can impact response time.

Systematic Review of Physiologic Monitor Alarm Characteristics and Pragmatic Interventions to Reduce Alarm Frequency

BACKGROUND Alarm fatigue from frequent nonactionable physiologic monitor alarms is frequently named as a threat to patient safety. PURPOSE To critically examine the available literature relevant to alarm fatigue. DATA SOURCES Articles published in English, Spanish, or French between January 1980 and April 2015 indexed in PubMed, Cumulative Index to Nursing and Allied Health Literature, Scopus, Cochrane Library, Google Scholar, and ClinicalTrials.gov. STUDY SELECTION Articles focused on hospital physiologic monitor alarms addressing any of the following: (1) the proportion of alarms that are actionable, (2) the relationship between alarm exposure and nurse response time, and (3) the effectiveness of interventions in reducing alarm frequency. DATA EXTRACTION We extracted data on setting, collection methods, proportion of alarms determined to be actionable, nurse response time, and associations between interventions and alarm rates. DATA SYNTHESIS Our search produced 24 observational studies focused on alarm characteristics and response time and 8 studies evaluating interventions. Actionable alarm proportion ranged from <1% to 36% across a range of hospital settings. Two studies showed relationships between high alarm exposure and longer nurse response time. Most intervention studies included multiple components implemented simultaneously. Although studies varied widely, and many had high risk of bias, promising but still unproven interventions include widening alarm parameters, instituting alarm delays, and using disposable electrocardiographic wires or frequently changed electrocardiographic electrodes. CONCLUSIONS Physiologic monitor alarms are commonly nonactionable, and evidence supporting the concept of alarm fatigue is emerging. Several interventions have the potential to reduce alarms safely, but more rigorously designed studies with attention to possible unintended consequences are needed.

Cost-Benefit Analysis of a Medical Emergency Team in a Children’s Hospital

OBJECTIVES: Medical emergency teams (METs) can reduce adverse events in hospitalized children. We aimed to model the financial costs and benefits of operating an MET and determine the annual reduction in critical deterioration (CD) events required to offset MET costs. METHODS: We performed a single-center cohort study between July 1, 2007 and March 31, 2012 to determine the cost of CD events (unplanned transfers to the ICU with mechanical ventilation or vasopressors in the 12 hours after transfer) as compared with transfers to the ICU without CD. We then performed a cost-benefit analysis evaluating varying MET compositions and staffing models (freestanding or concurrent responsibilities) on the annual reduction in CD events needed to offset MET costs. RESULTS: Patients who had CD cost

Barriers to Calling for Urgent Assistance Despite a Comprehensive Pediatric Rapid Response System

99 773 (95% confidence interval,

Transitioning Adolescents and Young Adults With Sickle Cell Disease From Pediatric to Adult Health Care: Provider Perspectives.

69 431 to

Development of Guidelines for Skeletal Survey in Young Children With Intracranial Hemorrhage

130 116; P < .001) more during their post-event hospital stay than transfers to the ICU that did not meet CD criteria. Annual MET operating costs ranged from

Skeletal surveys in young, injured children: A systematic review

287 145 for a nurse and respiratory therapist team with concurrent responsibilities to

Barriers and facilitators to successful transition from pediatric to adult inflammatory bowel disease care from the perspectives of providers.

2 358 112 for a nurse, respiratory therapist, and ICU attending physician freestanding team. In base-case analysis, a nurse, respiratory therapist, and ICU fellow team with concurrent responsibilities cost

Video Methods for Evaluating Physiologic Monitor Alarms And Alarm Responses

350 698 per year, equivalent to a reduction of 3.5 CD events. CONCLUSIONS: CD is expensive. The costs of operating a MET can plausibly be recouped with a modest reduction in CD events. Hospitals reimbursed with bundled payments could achieve real financial savings by reducing CD with an MET.

Physician Attitudes Toward Family-Activated Medical Emergency Teams for Hospitalized Children

BACKGROUND Rapid response systems (RRSs) aim to identify and rescue hospitalized patients whose condition is deteriorating before respiratory or cardiac arrest occurs. Previous studies of RRS implementation have shown variable effectiveness, which may be attributable in part to barriers preventing staff from activating the system. OBJECTIVE To proactively identify barriers to calling for urgent assistance that exist despite recent implementation of a comprehensive RRS in a childrens hospital. METHODS Qualitative study using open-ended, semistructured interviews of 27 nurses and 30 physicians caring for patients in general medical and surgical care areas. RESULTS The following themes emerged: (1) Self-efficacy in recognizing deteriorating conditions and activating the medical emergency team (MET) were considered strong determinants of whether care would be appropriately escalated for children in a deteriorating condition. (2) Intraprofessional and interprofessional hierarchies were sometimes challenging to navigate and led to delays in care for patients whose condition was deteriorating. (3) Expectations of adverse interpersonal or clinical outcomes from MET activations and intensive care unit transfers could strongly shape escalation-of-care behavior (eg, reluctance among subspecialty attending physicians to transfer patients to the intensive care unit for fear of inappropriate management). CONCLUSIONS The results of this study provide an in-depth description of the barriers that may limit RRS effectiveness. By recognizing and addressing these barriers, hospital leaders may be able to improve the RRS safety culture and thus enhance the impact of the RRS on rates of cardiac arrest, respiratory arrest, and mortality outside the intensive care unit.