WHAT'S KNOWN ON THIS SUBJECT: Accurately identifying ill hospitalized children with vital signs concerning for clinical deterioration is fundamental to inpatient pediatrics. Normal vital sign ranges for healthy children are useful for outpatient practice but have limited application to detecting deterioration in the hospital setting.WHAT THIS STUDY ADDS: Percentile curves for heart and respiratory rate in hospitalized children were developed and validated. The distributions differed from existing reference ranges and early warning scores. They may be useful to identify vital signs deviating from ranges expected among hospitalized children.abstract OBJECTIVE: To develop and validate heart and respiratory rate percentile curves for hospitalized children and compare their vital sign distributions to textbook reference ranges and pediatric early warning score (EWS) parameters. METHODS:For this cross-sectional study, we used 6 months of nursedocumented heart and respiratory rates from the electronic records of 14 014 children on general medical and surgical wards at 2 tertiary-care children' s hospitals. We developed percentile curves using generalized additive models for location, scale, and shape with 67% of the patients and validated the curves with the remaining 33%. We then determined the proportion of observations that deviated from textbook reference ranges and EWS parameters. RESULTS:We used 116 383 heart rate and 116 383 respiratory rate values to develop and validate the percentile curves. Up to 54% of heart rate observations and up to 40% of respiratory rate observations in our sample were outside textbook reference ranges. Up to 38% of heart rate observations and up to 30% of respiratory rate observations in our sample would have resulted in increased EWSs. CONCLUSIONS:A high proportion of vital signs among hospitalized children would be considered out of range according to existing reference ranges and pediatric EWSs. The percentiles we derived may serve as useful references for clinicians and could be used to inform the development of evidence-based vital sign parameters for physiologic monitor alarms, inpatient electronic health record vital sign alerts, medical emergency team calling criteria, and EWSs.

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 non-actionable physiologic monitor alarms respond more slowly to subsequent alarms that could represent life-threatening conditions. Design Observational study using video. Setting Freestanding children's hospital. Patients (1) Pediatric intensive care unit (PICU) patients requiring inotropic support and/or mechanical ventilation, and (2) 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 patient's room. We evaluated the association between the number of non-actionable 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 non-actionable. Kaplan-Meier plots showed incremental increases in response time as the number of non-actionable alarms in the preceding 120 minutes increased (log-rank test stratified by nurse P<.001 in PICU, P=.009 on ward). Conclusions Most alarms were non-actionable, 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.

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, CINAHL, 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. While 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.

Rapid response system implementation reversed an increasing trend of critical deterioration. Cardiac arrest and death were extremely rare at baseline, and their reductions were not statistically significant despite using nearly 5 years of data. Hospitals seeking to measure rapid response system performance may consider using valid proximate outcomes like critical deterioration in addition to rare, catastrophic outcomes.