Physiologic Monitor Alarm Rates at 5 Children’s Hospitals

Alarm fatigue is a patient safety hazard in hospitals¹ that occurs when exposure to high rates of alarms leads clinicians to ignore or delay their responses to the alarms.^2,3 To date, most studies of physiologic monitor alarms in hospitalized children have used data from single institutions and often only a few units within each institution.⁴ These limited studies have found that alarms in pediatric units are rarely actionable.² They have also shown that physiologic monitor alarms occur frequently in children’s hospitals and that alarm rates can vary widely within a single institution,⁵ but the extent of variation between children’s hospitals is unknown. In this study, we aimed to describe and compare physiologic monitor alarm characteristics and the proportion of patients monitored in the inpatient units of 5 children’s hospitals.

We performed a cross-sectional study using a point-prevalence design of physiologic monitor alarms and monitoring during a 24-hour period at 5 large, freestanding tertiary-care children’s hospitals. At the time of the study, each hospital had an alarm management committee in place and was working to address alarm fatigue. Each hospital’s institutional review board reviewed and approved the study.

We collected 24 consecutive hours of data from the inpatient units of each hospital between March 24, 2015, and May 1, 2015. Each hospital selected the data collection date within that window based on the availability of staff to perform data collection.⁶ We excluded emergency departments, procedural areas, and inpatient psychiatry and rehabilitation units. By using existing central alarm-collection software that interfaced with bedside physiologic monitors, we collected data on audible alarms generated for apnea, arrhythmia, low and high oxygen saturation, heart rate, respiratory rate, blood pressure, and exhaled carbon dioxide. Bedside alarm systems and alarm collection software differed between centers; therefore, alarm types that were not consistently collected at every institution (eg, alarms for electrode and device malfunction, ventilators, intracranial and central venous pressure monitors, and temperatures probes) were excluded. To estimate alarm rates and to account for fluctuations in hospital census throughout the day,⁷ we collected census (to calculate the number of alarms per patient day) and the number of monitored patients (to calculate the number of alarms per monitored-patient day, including only monitored patients in the denominator) on each unit at 3 time points, 8 hours apart. Patients were considered continuously monitored if they had presence of a waveform and data for pulse oximetry, respiratory rate, and/or heart rate at the time of data collection. We then determined the rate of alarms by unit type—medical-surgical unit (MSU), neonatal intensive care unit (NICU), or pediatric intensive care unit (PICU)—and the alarm types. Based on prior literature demonstrating up to 95% of alarms contributed by a minority of patients on a single unit,⁸ we also calculated the percentage of alarms contributed by beds in the highest quartile of alarms. We also assessed the percentage of patients monitored by unit type. The Supplementary Appendix shows the alarm parameter thresholds in use at the time of the study.