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

ABSTRACT: Alarm fatigue is reported to be a major threat to patient safety, yet little empirical data support its existence in the hospital.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.Observational study using video.Freestanding children's hospital.Pediatric intensive care unit (PICU) patients requiring inotropic support and/or mechanical ventilation, and medical ward patients.None.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 patient's 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.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?

SUBMITTER: Bonafide CP

PROVIDER: S-EPMC4456276 | biostudies-literature | 2015 Jun

REPOSITORIES: biostudies-literature

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

Bonafide Christopher P CP Lin Richard R Zander Miriam M Graham Christian Sarkis CS Paine Christine W CW Rock Whitney W Rich Andrew A Roberts Kathryn E KE Fortino Margaret M Nadkarni Vinay M VM Localio A Russell AR Keren Ron R

Journal of hospital medicine 20150415 6

<h4>Background</h4>Alarm fatigue is reported to be a major threat to patient safety, yet little empirical data support its existence in the hospital.<h4>Objective</h4>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.<h4>Design</h4>Observational study using video.<h4>Setting</h4>Freestanding children's hospital.<h4>Patients</h4>Pediatric intensive care unit (PICU) pati ...[more]

PMID: 25873486

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Project description:Importance:Bedside monitor alarms alert nurses to life-threatening physiologic changes among patients, but the response times of nurses are slow. Objective:To identify factors associated with physiologic monitor alarm response time. Design, Setting, and Participants:This prospective cohort study used 551 hours of video-recorded care administered by 38 nurses to 100 children in a children's hospital medical unit between July 22, 2014, and November 11, 2015. Exposures:Patient, nurse, and alarm-level factors hypothesized to predict response time. Main Outcomes and Measures:We used multivariable accelerated failure-time models stratified by each nurse and adjusted for clustering within patients to evaluate associations between exposures and response time to alarms that occurred while the nurse was outside the room. Results:The study participants included 38 nurses, 100% (n?=?38) of whom were white and 92% (n?=?35) of whom were female, and 100 children, 51% (n?=?51) of whom were male. The race/ethnicity of the child participants was 45% (n?=?45) black or African American, 33% (n?=?33) white, 4% (n?=?4) Asian, and 18% (n?=?18) other. Of 11?745 alarms among 100 children, 50 (0.5%) were actionable. The adjusted median response time among nurses was 10.4 minutes (95% CI, 5.0-15.8) and varied based on the following variables: if the patient was on complex care service (5.3 minutes [95% CI, 1.4-9.3] vs 11.1 minutes [95% CI, 5.6-16.6] among general pediatrics patients), whether family members were absent from the patient's bedside (6.3 minutes [95% CI, 2.2-10.4] vs 11.7 minutes [95% CI, 5.9-17.4] when family present), whether a nurse had less than 1 year of experience (4.4 minutes [95% CI, 3.4-5.5] vs 8.8 minutes [95% CI, 7.2-10.5] for nurses with 1 or more years of experience), if there was a 1 to 1 nursing assignment (3.5 minutes [95% CI, 1.3-5.7] vs 10.6 minutes [95% CI, 5.3-16.0] for nurses caring for 2 or more patients), if there were prior alarms requiring intervention (5.5 minutes [95% CI, 1.5-9.5] vs 10.7 minutes [5.2-16.2] for patients without intervention), and if there was a lethal arrhythmia alarm (1.2 minutes [95% CI, -0.6 to 2.9] vs 10.4 minutes [95% CI, 5.1-15.8] for alarms for other conditions). Each hour that elapsed during a nurse's shift was associated with a 15% longer response time (6.1 minutes [95% CI, 2.8-9.3] in hour 2 vs 14.1 minutes [95% CI, 6.4-21.7] in hour 8). The number of nonactionable alarms to which the nurse was exposed in the preceding 120 minutes was not associated with response time. Conclusions and Relevance:Response time was associated with factors that likely represent the heuristics nurses use to assess whether an alarm represents a life-threatening condition. The nurse to patient ratio and physical and mental fatigue (measured by the number of hours into a shift) represent modifiable factors associated with response time. Chronic alarm fatigue resulting from long-term exposure to nonactionable alarms may be a more important determinant of response time than short-term exposure.

Project description:BackgroundClinicians in intensive care units experience alarm fatigue related to frequent false and non-actionable alarms produced by physiologic monitors. To reduce non-actionable alarms, alarm settings may need to be customized for individual patients; however, nurses may not customize alarms because of competing demands and alarm fatigue.ObjectiveTo examine the effectiveness and acceptance of physiologic monitor software to support customization of alarms.MethodsThis pre/post intervention study was conducted in a 56-bed medical intensive care unit. IntelliVue® Alarm Advisor customization support software for alarm limit violations was installed on all monitors and education on its use provided. For 2 months before and after implementation of the software, data were collected on patient characteristics from the electronic health record, alarm counts and duration from the monitoring system, and nurses' experience of alarms from a survey.ResultsMedium-priority heart rate, respiratory rate, and arterial pressure alarms were significantly reduced after software implementation (9.3%, 11.8%, and 15.9% reduction respectively; p<0.001 for all). The duration of these alarms was also significantly shorter (7.8%, 13.3%, and 9.3% reduction respectively; p<0.05 for all). The number and duration of SpO2 alarms did not decrease (p>0.05 for both). Patients post-intervention had worse Glasgow Coma Scale scores (p = 0.014), but otherwise were comparable to those pre-intervention. Nurses reported less time spent on non-actionable alarms post-intervention than pre-intervention (p = 0.026). Also lower post-intervention were the proportions of nurses who reported that alarms disturbed their workflow (p = 0.027) and who encountered a situation where an important alarm was ignored (p = 0.043). The majority (>50%) agreed that the software supported setting appropriate alarm limits and was easy to use.ConclusionAlarm customization software was associated with a reduction in alarms. Use of software to support nurses' recognition of trends in patients' alarms and facilitate changes to alarm settings may add value to alarm reduction initiatives.

Project description:Clinical deterioration of hospitalized patients is common and can lead to critical illness and death. Rapid response teams (RRTs) assess and treat high-risk patients with signs of clinical deterioration to prevent further worsening and subsequent adverse outcomes. Whether activation of the RRT early in the course of clinical deterioration impacts outcomes, however, remains unclear. We sought to characterize the relationship between increasing time to RRT activation after physiologic deterioration and short-term patient outcomes.DesignRetrospective multicenter cohort study.SettingThree academic hospitals in Pennsylvania.PatientsWe included the RRT activation of a hospitalization for non-ICU inpatients greater than or equal to 18 years old.InterventionsNone.Measurements and main resultsThe primary exposure was time to RRT activation after physiologic deterioration. We selected four Cardiac Arrest Risk Triage (CART) score thresholds a priori from which to measure time to RRT activation (CART score ≥ 12, ≥ 16, ≥ 20, and ≥ 24). The primary outcome was 7-day mortality-death or discharge to hospice care within 7 days of RRT activation. For each CART threshold, we modeled the association of time to RRT activation duration with 7-day mortality using multivariable fractional polynomial regression. Increased time from clinical decompensation to RRT activation was associated with higher risk of 7-day mortality. This relationship was nonlinear, with odds of mortality increasing rapidly as time to RRT activation increased from 0 to 4 hours and then plateauing. This pattern was observed across several thresholds of physiologic derangement.ConclusionsIncreasing time to RRT activation was associated in a nonlinear fashion with increased 7-day mortality. This relationship appeared most marked when using a CART score greater than 20 threshold from which to measure time to RRT activation. We suggest that these empirical findings could be used to inform RRT delay definitions in further studies to determine the clinical impact of interventions focused on timely RRT activation.

Project description:ImportanceAlthough children's hospitals (CH) provide a substantial proportion of highly specialized pediatric care in the United States, the value of CH compared with non-children's hospitals (NCH) for routine surgical procedures is unknown.ObjectiveTo examine the value of CH for routine surgical procedures by assessing clinical outcomes and payment data.Design, setting, and participantsThis retrospective cohort study examined pediatric patients undergoing 1 of 13 commonly performed surgical procedures between 2010 and 2015 with 90-day follow-up using administrative data from the Health Care Cost Institute. Data analysis was conducted from July 2019 to December 2021.ExposuresThe primary exposure was tier of CH status, defined using self-reported pediatric services, affiliation with pediatric focused programs, and validated based on proportion of pediatric admissions.Main outcomes and measuresPayments for common surgical procedures from private insurers and overall complication and readmission rates at 30, 60, and 90 days.ResultsThere were 368 220 pediatric patients who underwent one of the surgical procedures of interest; 220 899 (60.0%) of the patients were male; 118 977 (32.3%) had their procedure at freestanding CH (CH-A), 75 256 (20.4%) at CH attached to an adult hospital (CH-B), and 173 987 (47.3%) at NCH. The mean (SD) payment for all procedures at CH-A was $6533.56 ($6399.97), $5847.50 ($4947.47) at CH-B, and $5034.25 ($4787.07) at NCH. The mean (SD) overall complication rate was 0.004 (0.06) at CH-A, 0.01 (0.07) at CH-B, and 0.003 (0.06) at NCH. Readmission rates at 30, 60, and 90 days were similar across all hospital types. After adjusting for zip code, year, surgery, surgery setting, and observable patient, hospital, and county characteristics, the estimated payments for inpatient common procedures were 39% higher at CH-A than at NCH. Payments for outpatient common procedures were 34% higher at CH-A than at NCH.Conclusions and relevanceIn this cohort study, children who underwent common surgical procedures had equivalent clinical outcomes at CH and NCH but the procedures were associated with higher payments and, thus, overall lower value care. To ensure delivery of optimal value to patients and payers, more research is needed to evaluate mechanisms to ensure access, decrease costs, and improve value at both CH and NCH.

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

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

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