Impact of a Safety Huddle–Based Intervention on Monitor Alarm Rates in Low-Acuity Pediatric Intensive Care Unit Patients

BACKGROUND

Physiologic monitors are intended to prevent cardiac and respiratory arrest by generating alarms to alert clinicians to signs of instability. To minimize the probability that monitors will miss signs of deterioration, alarm algorithms and default parameters are often set to maximize sensitivity while sacrificing specificity.¹ As a result, monitors generate large numbers of nonactionable alarms—alarms that are either invalid and do not accurately represent the physiologic status of the patient or are valid but do not warrant clinical intervention.² Prior research has demonstrated that the pediatric intensive care unit (PICU) is responsible for a higher proportion of alarms than pediatric wards³ and a large proportion of these alarms, 87% - 97%, are nonactionable.^4-8 In national surveys of healthcare staff, respondents report that high alarm rates interrupt patient care and can lead clinicians to disable alarms entirely.⁹ Recent research has supported this, demonstrating that nurses who are exposed to higher numbers of alarms have slower response times to alarms.^4,10 In an attempt to mitigate safety risks, the Joint Commission in 2012 issued recommendations for hospitals to (a) establish guidelines for tailoring alarm settings and limits for individual patients and (b) identify situations in which alarms are not clinically necessary.¹¹

In order to address these recommendations within our PICU, we sought to evaluate the impact of a focused physiologic monitor alarm reduction intervention integrated into safety huddles. Safety huddles are brief, structured discussions among physicians, nurses, and other staff aiming to identify safety concerns.¹² Huddles offer an appropriate forum for reviewing alarm data and identifying patients whose high alarm rates may necessitate safe tailoring of alarm limits. Pilot data demonstrating high alarm rates among low-acuity PICU patients led us to hypothesize that low-acuity, high-alarm PICU patients would be a safe and effective target for an alarm huddle-based intervention.

In this study, we aimed to measure the impact of a structured safety huddle review of low-acuity PICU patients with high rates of priority alarms who were randomized to intervention compared with other low-acuity, high-alarm, concurrent, and historical control patients in the PICU.

Study Definitions

Priority alarm activation rate. We conceptualized priority alarms as any alarm for a clinical condition that requires a timely response to determine if intervention is necessary to save a patient’s life,⁴ yet little empirical data support its existence in the hospital. We operationally defined these alarms on the General Electric Solar physiologic monitoring devices as any potentially life-threatening events including lethal arrhythmias (asystole, ventricular tachycardia, and ventricular fibrillation) and alarms for vital signs (heart rate, respiratory rate, and oxygen saturation) outside of the set parameter limits. These alarms produced audible tones in the patient room and automatically sent text messages to the nurse’s phone and had the potential to contribute to alarm fatigue regardless of the nurse’s location.

High-alarm patients. High-alarm patients were those who had more than 40 priority alarms in the preceding 4 hours, representing the top 20% of alarm rates in the PICU according to prior quality improvement projects completed in our PICU.

Low-acuity patients. Prior to and during this study, patient acuity was determined using the OptiLink Patient Classification System (OptiLink Healthcare Management Systems, Inc.; Tigard, OR; www.optilinkhealthcare.com; see Appendix 1) for the PICU twice daily. Low-acuity patients comprised on average 16% of the PICU patients.

Setting and Subjects

This study was performed in the PICU at The Children’s Hospital of Philadelphia.

The PICU is made up of 3 separate wings: east, south, and west. Bed availability was the only factor determining patient placement on the east, south, or west wing; the physical bed location was not preferentially assigned based on diagnosis or disease severity. The east wing was the intervention unit where the huddles occurred.

The PICU is composed of 3 different geographical teams. Two of the teams are composed of 4 to 5 pediatric or emergency medicine residents, 1 fellow, and 1 attending covering the south and west wings. The third team, located on the east wing, is composed of 1 to 2 pediatric residents, 2 to 3 nurse practitioners, 1 fellow, and 1 attending. Bedside family-centered rounds are held at each patient room, with the bedside nurse participating by reading a nursing rounding script that includes vital signs, vascular access, continuous medications, and additional questions or concerns.

Control subjects were any monitored patients on any of the 3 wings of the PICU between April 1, 2015, and October 31, 2015. The control patients were in 2 categories: historical controls from April 1, 2015, to May 31, 2015, and concurrent controls from June 1, 2015, to October 31, 2015, who were located anywhere in the PICU. On each nonholiday weekday beginning June 1, 2015, we randomly selected up to 2 patients to receive the intervention. These were high-alarm, low-acuity patients on the east wing to be discussed in the daily morning huddle. If more than 2 high-alarm, low-acuity patients were eligible for intervention, they were randomly selected by using the RAND function in Microsoft Excel. The other low-acuity, high-alarm patients in the PICU were included as control patients. Patients were eligible for the study if they were present for the 4 hours prior to huddle and present past noon on the day of huddle. If patients met criteria as high-alarm, low-acuity patients on multiple days, they could be enrolled as intervention or control patients multiple times. Patients’ alarm rates were calculated by dividing the number of alarms by their length of stay to the minute. There was no adjustment made for patients enrolled more than once.