A Framework for Reducing Alarm Fatigue on Pediatric Inpatient Units

Monitor Only the Patients at Significant Risk of Life-Threatening Events

According to American Heart Association guidelines, pediatric continuous electrocardiographic (ECG) monitoring, aimed primarily at detecting arrhythmias, is indicated for only a small fraction of patients who we care for on pediatric hospitalist-led teams outside the ICU.¹ For patients without known heart disease, they note that monitoring may be beneficial but is not essential in children with chest pain, blunt chest trauma, acute neurologic events, severe asthma exacerbation, Kawasaki disease, those administered drugs with potential for QT prolongation, those being evaluated for syncope (which we would extend to apparent life threatening events), and infants with prenatal exposure to cocaine (putting them at risk for coronary vasospasm).

Similar to ECG monitoring, 1 of the 5 recommendations on the Pediatric Hospital Medicine Choosing Wisely list is “Don’t use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen.”¹³ On the basis of the American Heart Association and Choosing Wisely recommendations, a first step that we can take now is to develop consensus guidelines at our institutions for initiating continuous ECG and pulse oximetry monitoring. One potential implementation strategy is to include the appropriate indications in a drop-down menu when monitoring is ordered in an electronic health record as a means of providing clinical decision support and reinforcing appropriate use.¹⁴

A second area in which we can improve care and reduce unnecessary monitoring is to develop standards on how best to discontinue monitoring in patients who no longer need it. One effective way to do this that is analogous to the way we order many medications is to include a duration in the monitoring order based on the patient’s initial condition and severity of illness. For example, an initial order for monitoring could include a duration of 24 hours, with a prompt for nurses to reassess the need and contact the physician once the order expires if they believe that discontinuing monitoring would be unsafe.¹⁴

Reduce Invalid (Artifact) Alarms

Invalid alarms from artifact are usually caused by poor contact between the sensor and the skin, which may be due to the sensor’s adhesive drying out or the patient moving. Among patients in whom monitoring is necessary while they are awake and active, interventions that have been successful in reducing these alarms include meticulous skin preparation and changing electrodes every 24 hours.¹⁵

Reduce Nuisance (Valid but Nonactionable) Alarms

Nuisance alarms occur mainly when the alarm thresholds used to trigger alarms are set to levels at which clinicians would not intervene or when the alarm thresholds are set at appropriate actionable thresholds but the amount of time the patient spends outside the threshold is brief and resolves spontaneously. First and foremost, alarms are designed to indicate emergencies and should summon staff to the bedside immediately. So the first step is to identify thresholds at which there is little ambiguity that a valid alarm beyond that threshold indicates an emergency: a condition for which an intervention is necessary.¹⁶ One reasonable starting point is to use published data from hospitalized children to choose age-based cut points for heart and respiratory rates¹⁷ (e.g., using the first and 99th percentiles for age, or even more extreme values) and an actionable threshold for pulse oximetry that represents an emergency (e.g., <80%).¹⁸

After thresholds are chosen, they can be adjusted further based on the patient’s physiology to minimize nonactionable alarms. Because nurses are primarily responsible for responding to the alarms themselves, they often have excellent insight into whether a patient’s parameters are effective based on their unique conditions and whether those parameters should be adjusted. Although policies may vary from institution to institution, it may be beneficial to expand the responsibilities of the nursing staff to allow nurses to change alarm parameters within a margin considered safe (e.g., ±10% from the originally ordered settings) without a physician order provided that physicians and the rest of the team caring for that patient are notified and the change is documented.

The next step is to consider instituting a delay in the interval of time between when a threshold is crossed and when the alarm fires. The aim of this intervention is to reduce frequent alarms for brief and self-limited breaches of the thresholds. One technology for implementing pulse oximetry alarm delays called SatSeconds (for Nellcor devices) takes into account both the depth of the desaturation and the duration, alarming immediately for major desaturations while delaying alarms for less significant drops.¹⁹

Improve Alarm Recognition and Notification for the Remaining Actionable Alarms

Once interventions have been implemented to improve the signal-to-noise ratio by reducing the noise (invalid and nuisance alarms), we can turn our attention to strengthening the signal (actionable alarms). Alarms cannot be useful if no one hears them or recognizes their acuity. As inpatient units expand to become more spacious and hospitals convert multipatient rooms into private rooms flanking long hallways, it gets harder and harder for staff to hear and recognize alarms. Two potential approaches to address this problem that can be considered include secondary notification systems and the employment of monitor watchers.

Secondary notification systems pass alarm information from the monitor system to the nurse’s pager or wireless telephone system using a network interface.²⁰ These systems allow the hospital to configure which alarms pass through to the mobile device and which alarm at the bedside only. They also allow for automatic escalation of the alarm message to the charge nurse or another clinician if the primary nurse does not acknowledge the alarm within a specified timeframe.¹⁹

An additional layer of support is to employ technicians who continuously view the waveforms and alarms of many patients from a central station. These “monitor watchers” have the potential to improve care but are expensive, and few studies have demonstrated tangible improvements in patient outcomes.^21,22