Nurse Responses to Physiologic Monitor Alarms on a General Pediatric Unit

Abstract

BACKGROUND Hospitalized children generate up to 152 alarms per patient per day outside of the intensive care unit. In that setting, as few as 1% of alarms are clinically important. How nurses make decisions about responding to alarms, given an alarm's low specificity for detecting clinical deterioration, remains unclear. OBJECTIVE Our objective was to describe how bedside nurses think about and act upon monitor alarms for hospitalized children. DESIGN, SETTING, PARTICIPANTS This was a qualitative study that involved the direct observation of nurses working on a general pediatric unit at a large children's hospital. MEASUREMENTS We used a structured tool that included predetermined categories to assess nurse responses to monitor alarms. Data on alarm frequency and type were pulled from bedside monitors. RESULTS We conducted 61.3 patient‐hours of observation with nine nurses, in which we documented 207 nurse responses to patient alarms. For 67% of alarms heard outside of the room, the nurse decided not to respond without further assessment. Nurses most commonly cited reassuring clinical context (eg, medical team in room), as the rationale for alarm nonresponse. The nurse deemed clinical intervention necessary in only 14 (7%) of the observed responses. CONCLUSION Nurses rely on clinical and contextual details to determine how to respond to alarms. Few of the alarm responses in our study resulted in a clinical intervention. These findings suggest that multiple system‐level and educational interventions may be necessary to improve the efficacy and safety of continuous monitoring.

Accuracy and Monitoring of Pediatric Early Warning Score (PEWS) Scores Prior to Emergent Pediatric Intensive Care Unit (ICU) Transfer: Retrospective Analysis

“…Additionally, those without a continuous monitoring order had higher recorded PEWS scores prior to transfer than those with continuous monitoring, indicating that clinicians may be missing important changes in the underlying physiology when relying on intermittent vital sign assessment alone. Continuous monitoring in children can be challenging to implement because it can be difficult to keep continuous monitoring leads and probes on mobile children, and previous estimates have demonstrated as few as 1% of alarms in children are clinically meaningful [ 29 ]. We speculate that there can be clinical benefit to shifting the clinical monitoring paradigm away from its use only as a means of responding to critical physiological alarms and towards a means for early detection of clinical deterioration using continuous predictive analytics monitoring so clinicians can initiate proactive clinical actions [ 28 , 30 , 31 ].…”

Accuracy and Monitoring of Pediatric Early Warning Score (PEWS) Scores Prior to Emergent Pediatric Intensive Care Unit (ICU) Transfer: Retrospective Analysis (Preprint)

“…Additionally, those without a continuous monitoring order had higher recorded PEWS scores prior to transfer than those with continuous monitoring, indicating that clinicians may be missing important changes in the underlying physiology when relying on intermittent vital sign assessment alone. Continuous monitoring in children can be challenging to implement because it can be difficult to keep continuous monitoring leads and probes on mobile children, and previous estimates have demonstrated as few as 1% of alarms in children are clinically meaningful [29]. We speculate that there can be clinical benefit to shifting the clinical monitoring paradigm away from its use only as a means of responding to critical physiological alarms and towards a means for early detection of clinical deterioration using continuous predictive analytics monitoring so clinicians can initiate proactive clinical actions [28,30,31].…”

Nursing and precision predictive analytics monitoring in the acute and intensive care setting: An emerging role for responding to COVID-19 and beyond

“…In the ICU, the bedside cardiorespiratory monitor alone generates, on average, 187 audible alarms per day averaging 1 per every 7.7 minutes with upwards of 90 percent of them being non-actionable. 49 , 50 , 51 , 52 , 53 Clinicians become accustomed to ignoring non-actionable or false alarms and in doing so may overlook alarms in a true emergent situation, otherwise known as ‘alarm fatigue’. 54 , 55 Precision predictive analytics monitoring that rely on alert strategies must be designed to assess and account for alarm fatigue within the design and implementation in order to offset unintended consequences.…”