Objective To characterize the rate of monitoring alarms by alarm priority, signal type and developmental age in a Level-IIIB Neonatal Intensive Care Unit (NICU) population. Study Design Retrospective analysis of 2 294 687 alarm messages from Philips monitors in a convenience sample of 917 NICU patients, covering 12 001 patient-days. We stratified alarm rates by alarm priority, signal type, postmenstrual age (PMA), and birth weight (BW) and reviewed and adjudicated over 21 000 critical alarms. Results Of all alarms, 3.6% were critical alarms, 55.0% were advisory alarms, and 41.4% were device alerts. Over 60% of alarms related to oxygenation monitoring. The average alarm rate (±SEM) was 177.1±4.9 [median: 135.9; IQR: 89.2–213.3] alarms/patient-day; the medians varied significantly with PMA and BW (p<0.001) in U-shaped patterns, with higher rates at lower and higher PMA and BW. Based on waveform reviews, over 99% of critical arrhythmia alarms were deemed technically false. Conclusions The alarm burden in this NICU population is very significant; the average alarm rate significantly underrepresents alarm rates at low and high PMA and BW. Virtually all critical arrhythmia alarms were artifactual.

Up to 20% of newborn infants retro-transferred to a lower level of care require readmission to a higher-level facility. In this study, we developed and validated a prediction rule (The Rule for Elective Transfer between Units for Recovering Neonates) to identify clinical characteristics of infants at risk for failing retro-transfer. In the 1970s, regionalization of neonatal care was proposed in the United States as a strategy to improve neonatal outcomes. 1-6 Regionalization emphasizes the importance of matching patients with health care facilities that are able to provide an appropriate level of care. 1 The American Academy of Pediatrics (AAP) has defined levels of care for neonatal intensive care units (NICUs), ranging from Level I units (well newborn nurseries) to Level IV units (regional NICUs with pediatric surgical subspecialists). 7 Recent changes in the landscape of health care in the United States, such as the establishment of Accountable Care Organizations, have brought the importance of responsibility for care within regional networks to the forefront. 8 However, there has been a trend toward expansion of community hospital services to include care for sicker infants, effectively deregionalizing systems of neonatal care. 9-13 This shift further emphasizes the need for neonatal transfers to be both appropriate and well-planned.

This study was not externally funded. There are no conflicts of interest to declare.

Most neonatal ICU staff report experience with do-not-resuscitate orders; however, many, particularly nurses and respiratory therapists, report no training in this area. Variable beliefs with respect to withholding and withdrawing care for patients with do-not-resuscitate orders exist among staff. Because neonatal ICU patients with do-not-resuscitate orders may ultimately survive, withholding or withdrawing interventions may have long-lasting effects, which may or may not coincide with familial intentions.

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