Nurse Responses to Physiologic Monitor Alarms on a General Pediatric Unit

We characterized responses to physiologic monitor alarms by a group of nurses with a range of experience levels. We found that most nurse responses to alarms in continuously monitored general pediatric patients involved no intervention, and further assessment was often not conducted for alarms that occurred outside of the room if the nurse noted otherwise reassuring clinical context. Observed responses occurred for 36% of alarms during the study period when compared with bedside monitor-alarm generated data. Overall, only 14 clinical interventions were noted among the observed responses. Nurses noted that they felt the monitors were necessary for 82.9% of monitored patients because of the clinical context or because of unit policy.

Our study findings highlight some potential contradictions in the current widespread use of CPMs in general pediatric units and how clinicians respond to them in practice.² First, while nurses reported that monitors were necessary for most of their patients, participating nurses deemed few alarms clinically actionable and often chose not to further assess when they noted alarms outside of the room. This is in line with findings from prior studies suggesting that clinicians overvalue the contribution of monitoring systems to patient safety.^16,17 Second, while this finding occurred in a minority of the observations, the presence of family members at the patient’s bedside was cited by nurses as a rationale for whether they responded to alarms. While family members are capable of identifying safety issues,¹⁸ formal systems to engage them in patient safety and physiologic monitoring are lacking. Finally, clinical interventions or responses to the alerts of deteriorating patients, which best represented the original intent of CPMs, were rare and accounted for just 7% of the responses. Further work elucidating why physicians and nurses choose to use CPMs may be helpful to identify interventions to reduce inappropriate monitor use and highlight gaps in frontline staff knowledge about the benefits and risks of CPM use.

Our findings provide a novel understanding of previously observed phenomena, such as long response times or nonresponses in settings with high alarm rates.^4,10 Similar to that in a prior study conducted in the pediatric setting,¹¹ alarms with an observed response constituted a minority of the total alarms that occurred in our study. This finding has previously been attributed to mental fatigue, caregiver apathy, and desensitization.⁸ However, even though a minority of observed responses in our study included an intervention, the nurse had a rationale for why the alarm did or did not need a response. This behavior and the verbalized rationale indicate that in his/her opinion, not responding to the alarm was clinically appropriate. Study participants also reflected on the difficulties of responding to alarms given the monitor system setup, in which they may not always be capable of hearing alarms for their patients. Without data from nurses regarding the alarms that had no observed response, we can only speculate; however, based on our findings, each of these factors could contribute to nonresponse. Finally, while high numbers of false alarms have been posited as an underlying cause of alarm fatigue, we noted that a majority of nonresponse was reported to be related to other clinical factors. This relationship suggests that from the nurse’s perspective, a more applicable framework for understanding alarms would be based on clinical actionability⁴ over physiologic accuracy.

In total, our findings suggest that a multifaceted approach will be necessary to improve alarm response rates. These interventions should include adjusting parameters such that alarms are highly likely to indicate a need for intervention coupled with educational interventions addressing clinician knowledge of the alarm system and bias about the actionability of alarms may improve response rates. Changes in the monitoring system setup such that nurses can easily be notified when alarms occur may also be indicated, in addition to formally engaging patients and families around response to alarms. Although secondary notification systems (eg, alarms transmitted to individual clinician’s devices) are one solution, the utilization of these systems needs to be balanced with the risks of contributing to existing alarm fatigue and the need to appropriately tailor monitoring thresholds and strategies to patients.

Our study has several limitations. First, nurses may have responded in a way they perceive to be socially desirable, and studies using in-person observers are also prone to a Hawthorne-like effect,^19-21 where the nurse may have tried to respond more frequently to alarms than usual during observations. However, given that the majority of bedside alarms did not receive a response and a substantial number of responses involved no action, these effects were likely weak. Second, we were unable to assess which alarms were accurately reflecting the patient’s physiologic status and which were not; we were also unable to link observed alarm response to monitor-recorded alarms. Third, despite the use of silent observers and an actual, rather than a simulated, clinical setting, by virtue of the data collection method we likely captured a more deliberate thought process (so-called System 2 thinking)²² rather than the subconscious processes that may predominate when nurses respond to alarms in the course of clinical care (System 1 thinking).²² Despite this limitation, our study findings, which reflect a nurse’s in-the-moment thinking, remain relevant to guiding the improvement of monitoring systems, and the development of nurse-facing interventions and education. Finally, we studied a small, purposive sample of nurses at a single hospital. Our study sample impacts the generalizability of our results and precluded a detailed analysis of the effect of nurse- and patient-level variables.