Nurse Responses to Physiologic Monitor Alarms on a General Pediatric Unit
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. 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.
© 2019 Society of Hospital Medicine
Alarms from bedside continuous physiologic monitors (CPMs) occur frequently in children’s hospitals and can lead to harm. Recent studies conducted in children’s hospitals have identified alarm rates of up to 152 alarms per patient per day outside of the intensive care unit,1-3 with as few as 1% of alarms being considered clinically important.4 Excessive alarms have been linked to alarm fatigue, when providers become desensitized to and may miss alarms indicating impending patient deterioration. Alarm fatigue has been identified by national patient safety organizations as a patient safety concern given the risk of patient harm.5-7 Despite these concerns, CPMs are routinely used: up to 48% of pediatric patients in nonintensive care units at children’s hospitals are monitored.2
Although the low number of alarms that receive responses has been well-described,8,9 the reasons why clinicians do or do not respond to alarms are unclear. A study conducted in an adult perioperative unit noted prolonged nurse response times for patients with high alarm rates.10 A second study conducted in the pediatric inpatient setting demonstrated a dose-response effect and noted progressively prolonged nurse response times with increased rates of nonactionable alarms.4,11 Findings from another study suggested that underlying factors are highly complex and may be a result of excessive alarms, clinician characteristics, and working conditions (eg, workload and unit noise level).12 Evidence also suggests that humans have difficulty distinguishing the importance of alarms in situations where multiple alarm tones are used, a common scenario in hospitals.
An enhanced understanding of why nurses respond to alarms in daily practice will inform intervention development and improvement work. In the long term, this information could help improve systems for monitoring pediatric inpatients that are less prone to issues with alarm fatigue. The objective of this qualitative study, which employed structured observation, was to describe how bedside nurses think about and act upon bedside monitor alarms in a general pediatric inpatient unit.
METHODS
Study Design and Setting
This prospective observational study took place on a 48-bed hospital medicine unit at a large, freestanding children’s hospital with >650 beds and >19,000 annual admissions. General Electric (Little Chalfont, United Kingdom) physiologic monitors (models Dash 3000, 4000, and 5000) were used at the time of the study, and nurses could be notified of monitor alarms in four ways: First, an in-room auditory alarm sounds. Second, a light positioned above the door outside of each patient room blinks for alarms that are at a “warning” or “critical level” (eg ventricular tachycardia or low oxygen saturation). Third, audible alarms occur at the unit’s central monitoring station. Lastly, another staff member can notify the patient’s nurse via in-person conversion or secure smart phone communication. On the study unit, CPMs are initiated and discontinued through a physician order.
