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Crying Wolf: An Evaluation of One Year of Bedside Alarms at a Children’s Hospital

July 16, 2024

Start with a simple question: in one year, at one children’s hospital, for every patient across all units, what is the total number of times that patient monitors alarm? A mere seven million, nine hundred thirty-four thousand, nine hundred and ninety-seven, according to a study published by Clark et al. in the August edition of Hospital Pediatrics, a study which offers an excellent introduction to the science of alarm burden (10.1542/hpeds.2023-007604).

The team retrospectively collected all alarm data in the year 2019 from their tertiary care, free-standing children’s hospital. The nearly 8,000,000 alarms were then categorized based on unit type, monitor source (i.e. pulse oximetry, arterial line) and alarm cause (i.e. high heart rate, apnea). Their overall results make intuitive sense—the NICU and PICU had significantly higher incidences of alarms when compared to the Med-Surg units, for example—but it is in the granular data on alarm burden and alarm cause that surprising results emerge.

Let’s first explore alarm burden. While the total of 7,934,997 alarms is an eye-catching number in isolation, the implications for daily workflow are staggering. Each patient across all units in their hospital generated 94.4 alarms per patient-day (appd), with the average Med-Surg patient generating 81.33 appd. For my fellow hospitalists, if we presume our nursing colleagues have four patients on monitoring (a bold assumption, perhaps, given the post-COVID decline in available RN workforce) 1, this equates to an alarm every four minutes and twenty-four seconds. With data suggesting that up to 99% of all alarms on the pediatric wards are clinically non-actionable2, attending to this barrage of alarms becomes even less appealing. Even more dishearteningly, Clark et al.’s results on the cause of these alarms compound the issue.

Unsurprisingly, the most common cause of alarms in this study was low oxygen saturation. The second most common? “Technical,” an umbrella term that encompasses alarms like “motion artifact” or “poor waveform,” alarms that add to cognitive burden without identifying physiologic change. On Med-Surg floors, more than 25% of all alarms fell under this “technical” cause, significantly more than any intensive care setting. Let’s return to our theoretical nurse on the pediatric wards with four patients on monitoring: every four-and-a-half minutes, this RN has their attention pulled to a monitor that has a 1% chance of providing clinically actionable information and a one-in-four chance that the alarm’s cause is a wiggly toddler who will simply not keep their pulse oximeter on. Sobering, to say the least.

To conclude, Clark et al.’s thorough efforts in contextualizing their work in the landscape of patient safety and monitoring literature make this study a fantastic jumping-off point for anyone interested in exploring alarm fatigue and alarm burden in pediatric hospitals; personally, I finished the paper motivated to explore my own hospital’s use (or overuse) of bedside monitoring for possible QI work. With bronchiolitis season approaching, I look forward to challenging my team to keep unnecessary monitors off our patients and unnecessary alarm burden out of our nurses’ workflow.

References

1. Auerbach DI, Buerhaus PI, Donelan K, Staiger DO. Projecting the Future Registered Nurse Workforce After the COVID-19 Pandemic. JAMA Health Forum. 2024 Feb 2;5(2):e235389. doi: 10.1001/jamahealthforum.2023.5389. PMID: 38363560; PMCID: PMC10873770.

2. Bonafide CP, Lin R, Zander M, Sarkis Graham C, Paine CW, Rock W, Rich A, Roberts KE, Fortino M, Nadkarni VM, Localio AR, Keren R. Association between exposure to non-actionable physiologic monitor alarms and response time in a children’s hospital. J Hosp Med. 2015;10(6): 345–351.

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