Video methods for evaluating physiologic monitor alarms and alarm responses.

False physiologic monitor alarms are extremely common in the hospital environment. High false alarm rates have the potential to lead to alarm fatigue, leading nurses to delay their responses to alarms, ignore alarms, or disable them entirely. Recent evidence from the U.S. Food and Drug Administration (FDA) and The Joint Commission has demonstrated a link between alarm fatigue and patient deaths. Yet, very little scientific effort has focused on the rigorous quantitative measurement of alarms and responses in the hospital setting. We developed a system using multiple temporarily mounted, minimally obtrusive video cameras in hospitalized patients' rooms to characterize physiologic monitor alarms and nurse responses as a proxy for alarm fatigue. This allowed us to efficiently categorize each alarm's cause, technical validity, actionable characteristics, and determine the nurse's response time. We describe and illustrate the methods we used to acquire the video, synchronize and process the video, manage the large digital files, integrate the video with data from the physiologic monitor alarm network, archive the video to secure servers, and perform expert review and annotation using alarm "bookmarks." We discuss the technical and logistical challenges we encountered, including the root causes of hardware failures as well as issues with consent, confidentiality, protection of the video from litigation, and Hawthorne-like effects. The description of this video method may be useful to multidisciplinary teams interested in evaluating physiologic monitor alarms and alarm responses to better characterize alarm fatigue and other patient safety issues in clinical settings.

Development of a Multidisciplinary Professional Advancement Framework.

The creation of professional advancement programs is an important goal to support development of nurses and other team members. Maintaining consistency among programs within one institution poses a challenge. The development of an overarching framework has provided this structure. Our framework is composed of core components, key elements, and best practices that can be applied to ensure consistency among all programs. This framework can be applied to existing programs or guide new eight programs.

Experience of burnout among pediatric inpatient nurse preceptors.

BACKGROUND: There is a paucity of research describing burnout among nurses who work in the role of a preceptor, in the inpatient setting. In 2017, precepting nurses at an academic children's hospital were surveyed using the Oldenburg Burnout Inventory (OBI). Results of the survey inspired leadership to further explore this phenomenon using key informant interviews. METHODS: Prospective qualitative description with individual interviews analyzed using conventional content analysis. RESULTS: In regard to burnout, five themes illustrated the experiences of precepting nurses. "Feeling the Responsibility" reflected the cognitive stain of precepting. "An Obligation to the Role," reflected the dimensions of the OBI that addressed distancing and decreased interest in the work. However, preceptors described positive experiences "It Challenges Me Every Day," awareness of resources "Nursing Response," and insights for improving the preceptor program, "Future Strategies." CONCLUSIONS: While elements of the OBI were salient in the data, three inductive themes highlighted the balance of positive challenges and learning opportunities that inspire preceptors.

The Association of the Nurse Work Environment and Patient Safety in Pediatric Acute Care.

OBJECTIVES: Eighteen years ago, the Institute of Medicine estimated that medical errors in hospital were a major cause of mortality. Since that time, reducing patient harm and improving the culture of patient safety have been national health care priorities. The study objectives were to describe the current state of patient safety in pediatric acute care settings and to assess whether modifiable features of organizations are associated with better safety culture. METHODS: An observational cross-sectional study used 2015-2016 survey data on 177 hospitals in four U.S. states, including pediatric care in general hospitals and freestanding children's hospitals. Pediatric registered nurses providing direct patient care assessed hospital safety and the clinical work environment. Safety was measured by items from the Agency for Healthcare Research and Quality's Culture of Patient Safety survey. Hospital clinical work environment was measured by the National Quality Forum-endorsed Practice Environment Scale. RESULTS: A total of 1875 pediatric nurses provided an assessment of safety in their hospitals. Sixty percent of pediatric nurses gave their hospitals less than an excellent grade on patient safety; significant variation across hospitals was observed. In the average hospital, 46% of nurses report that mistakes are held against them and 28% do not feel safe questioning authority regarding unsafe practices. Hospitals with better clinical work environments received better patient safety grades. CONCLUSIONS: The culture of patient safety varies across U.S. hospital pediatric settings. In better clinical work environments, nurses report more positive safety culture and higher safety grades.

Safety and Quality of Pediatric Care in Freestanding Children's and General Hospitals.

OBJECTIVES: The purpose of this study was to evaluate quality and safety of care in acute pediatric settings from the perspectives of nurses working at the bedside and to investigate hospital-level factors associated with more favorable quality and safety. METHODS: Using data from a large survey of registered nurses in 330 acute care hospitals, we described nurses' assessments of safety and quality of care in inpatient pediatric settings, including freestanding children's hospitals (FCHs) (n = 21) and general hospitals with pediatric units (n = 309). Multivariate logistic regression models were used to estimate the effects of being a FCH on favorable reports on safety and quality before and after adjusting for hospital-level and nurse characteristics and Magnet status. RESULTS: Nurses in FCHs were more likely to report favorably on quality and safety after we accounted for hospital-level and individual nurse characteristics; however, adjusting for a hospital's Magnet status rendered associations between FCHs and quality and safety insignificant. Nurses in Magnet hospitals were more likely to report favorably on quality and safety. CONCLUSIONS: Quality and safety of pediatric care remain uneven; however, the organizational attributes of Magnet hospitals explain, in large part, more favorable quality and safety in FCHs compared with pediatric units in general acute care hospitals. Modifiable features of the nurse work environment common to Magnet hospitals hold promise for improving quality and safety of care. Transforming nurse work environments to keep patients safe, as recommended by the National Academy of Medicine 20 years ago, remains an unfinished agenda in pediatric inpatient settings.

Video Analysis of Factors Associated With Response Time to Physiologic Monitor Alarms in a Children's Hospital.

Importance: Bedside monitor alarms alert nurses to life-threatening physiologic changes among patients, but the response times of nurses are slow. Objective: To identify factors associated with physiologic monitor alarm response time. Design, Setting, and Participants: This prospective cohort study used 551 hours of video-recorded care administered by 38 nurses to 100 children in a children's hospital medical unit between July 22, 2014, and November 11, 2015. Exposures: Patient, nurse, and alarm-level factors hypothesized to predict response time. Main Outcomes and Measures: We used multivariable accelerated failure-time models stratified by each nurse and adjusted for clustering within patients to evaluate associations between exposures and response time to alarms that occurred while the nurse was outside the room. Results: The study participants included 38 nurses, 100% (n = 38) of whom were white and 92% (n = 35) of whom were female, and 100 children, 51% (n = 51) of whom were male. The race/ethnicity of the child participants was 45% (n = 45) black or African American, 33% (n = 33) white, 4% (n = 4) Asian, and 18% (n = 18) other. Of 11 745 alarms among 100 children, 50 (0.5%) were actionable. The adjusted median response time among nurses was 10.4 minutes (95% CI, 5.0-15.8) and varied based on the following variables: if the patient was on complex care service (5.3 minutes [95% CI, 1.4-9.3] vs 11.1 minutes [95% CI, 5.6-16.6] among general pediatrics patients), whether family members were absent from the patient's bedside (6.3 minutes [95% CI, 2.2-10.4] vs 11.7 minutes [95% CI, 5.9-17.4] when family present), whether a nurse had less than 1 year of experience (4.4 minutes [95% CI, 3.4-5.5] vs 8.8 minutes [95% CI, 7.2-10.5] for nurses with 1 or more years of experience), if there was a 1 to 1 nursing assignment (3.5 minutes [95% CI, 1.3-5.7] vs 10.6 minutes [95% CI, 5.3-16.0] for nurses caring for 2 or more patients), if there were prior alarms requiring intervention (5.5 minutes [95% CI, 1.5-9.5] vs 10.7 minutes [5.2-16.2] for patients without intervention), and if there was a lethal arrhythmia alarm (1.2 minutes [95% CI, -0.6 to 2.9] vs 10.4 minutes [95% CI, 5.1-15.8] for alarms for other conditions). Each hour that elapsed during a nurse's shift was associated with a 15% longer response time (6.1 minutes [95% CI, 2.8-9.3] in hour 2 vs 14.1 minutes [95% CI, 6.4-21.7] in hour 8). The number of nonactionable alarms to which the nurse was exposed in the preceding 120 minutes was not associated with response time. Conclusions and Relevance: Response time was associated with factors that likely represent the heuristics nurses use to assess whether an alarm represents a life-threatening condition. The nurse to patient ratio and physical and mental fatigue (measured by the number of hours into a shift) represent modifiable factors associated with response time. Chronic alarm fatigue resulting from long-term exposure to nonactionable alarms may be a more important determinant of response time than short-term exposure.

Missed Nursing Care in Pediatrics.

OBJECTIVES: A growing literature suggests that missed nursing care is common in hospitals and may contribute to poor patient outcomes. There has been scant empirical evidence in pediatric populations. Our objectives were to describe the frequency and patterns of missed nursing care in inpatient pediatric settings and to determine whether missed nursing care is associated with unfavorable work environments and high nurse workloads. METHODS: A cross-sectional study using registered nurse survey data from 2006 to 2008 was conducted. Data from 2187 NICU, PICU, and general pediatric nurses in 223 hospitals in 4 US states were analyzed. For 12 nursing activities, nurses reported about necessary activities that were not done on their last shift because of time constraints. Nurses reported their patient assignment and rated their work environment. RESULTS: More than half of pediatric nurses had missed care on their previous shift. On average, pediatric nurses missed 1.5 necessary care activities. Missed care was more common in poor versus better work environments (1.9 vs 1.2; P < .01). For 9 of 12 nursing activities, the prevalence of missed care was significantly higher in the poor environments (P < .05). In regression models that controlled for nurse, nursing unit, and hospital characteristics, the odds that a nurse missed care were 40% lower in better environments and increased by 70% for each additional patient. CONCLUSIONS: Nurses in inpatient pediatric care settings that care for fewer patients each and practice in a professionally supportive work environment miss care less often, increasing quality of patient care.

Pediatric fluid and electrolyte balance: critical care case studies.

The care of the critically ill infant or child often is complicated further by disruptions in fluid or electrolyte balance. Prompt recognition of these disruptions is essential to the care of these patients. This article provides an overview of the principles of fluid and electrolyte balance in the critically ill infant and child. Imbalances in fluid homeostasis and imbalances in sodium, potassium, and calcium homeostasis are presented in a case study format.

Association between exposure to nonactionable physiologic monitor alarms and response time in a children's hospital.

BACKGROUND: Alarm fatigue is reported to be a major threat to patient safety, yet little empirical data support its existence in the hospital. OBJECTIVE: To determine if nurses exposed to high rates of nonactionable physiologic monitor alarms respond more slowly to subsequent alarms that could represent life-threatening conditions. DESIGN: Observational study using video. SETTING: Freestanding children's hospital. PATIENTS: Pediatric intensive care unit (PICU) patients requiring inotropic support and/or mechanical ventilation, and medical ward patients. INTERVENTION: None. MEASUREMENTS: Actionable alarms were defined as correctly identifying physiologic status and warranting clinical intervention or consultation. We measured response time to alarms occurring while there were no clinicians in the patient's room. We evaluated the association between the number of nonactionable alarms the patient had in the preceding 120 minutes (categorized as 0-29, 30-79, or 80+ alarms) and response time to subsequent alarms in the same patient using a log-rank test that accounts for within-nurse clustering. RESULTS: We observed 36 nurses for 210 hours with 5070 alarms; 87.1% of PICU and 99.0% of ward clinical alarms were nonactionable. Kaplan-Meier plots showed incremental increases in response time as the number of nonactionable alarms in the preceding 120 minutes increased (log-rank test stratified by nurse P < 0.001 in PICU, P = 0.009 in the ward). CONCLUSIONS: Most alarms were nonactionable, and response time increased as nonactionable alarm exposure increased. Alarm fatigue could explain these findings. Future studies should evaluate the simultaneous influence of workload and other factors that can impact response time.

The pragmatics of feeding the pediatric patient with acute respiratory distress syndrome.

Acute respiratory distress syndrome (ARDS) represents the ultimate pulmonary response to a wide range of injuries, from septicemia to trauma. Optimal nutrition is vital to enhancing oxygen delivery, supporting adequate cardiac contractility and respiratory musculature, eliminating fluid and electrolyte imbalances, and supporting the proinflammatory response. Research is providing a better understanding of nutrients that specifically address the complex physiologic changes in ARDS. This article highlights the pathophysiology of ARDS as it relates to nutrition, relevant nutritional assessment, and important enteral and parenteral considerations for the pediatric patient who has ARDS.

Barriers to calling for urgent assistance despite a comprehensive pediatric rapid response system.

BACKGROUND: Rapid response systems (RRSs) aim to identify and rescue hospitalized patients whose condition is deteriorating before respiratory or cardiac arrest occurs. Previous studies of RRS implementation have shown variable effectiveness, which may be attributable in part to barriers preventing staff from activating the system. OBJECTIVE: To proactively identify barriers to calling for urgent assistance that exist despite recent implementation of a comprehensive RRS in a children's hospital. METHODS: Qualitative study using open-ended, semistructured interviews of 27 nurses and 30 physicians caring for patients in general medical and surgical care areas. RESULTS: The following themes emerged: (1) Self-efficacy in recognizing deteriorating conditions and activating the medical emergency team (MET) were considered strong determinants of whether care would be appropriately escalated for children in a deteriorating condition. (2) Intraprofessional and interprofessional hierarchies were sometimes challenging to navigate and led to delays in care for patients whose condition was deteriorating. (3) Expectations of adverse interpersonal or clinical outcomes from MET activations and intensive care unit transfers could strongly shape escalation-of-care behavior (eg, reluctance among subspecialty attending physicians to transfer patients to the intensive care unit for fear of inappropriate management). CONCLUSIONS: The results of this study provide an in-depth description of the barriers that may limit RRS effectiveness. By recognizing and addressing these barriers, hospital leaders may be able to improve the RRS safety culture and thus enhance the impact of the RRS on rates of cardiac arrest, respiratory arrest, and mortality outside the intensive care unit.

Impact of rapid response system implementation on critical deterioration events in children.

IMPORTANCE: Rapid response systems aim to identify and rescue deteriorating hospitalized patients. Previous pediatric rapid response system implementation studies have shown variable effectiveness in preventing rare, catastrophic outcomes such as cardiac arrest and death. OBJECTIVE: To evaluate the impact of pediatric rapid response system implementation inclusive of a medical emergency team and an early warning score on critical deterioration, a proximate outcome defined as unplanned transfer to the intensive care unit with noninvasive or invasive mechanical ventilation or vasopressor infusion in the 12 hours after transfer. DESIGN, SETTING, AND PARTICIPANTS: Quasi-experimental study with interrupted time series analysis using piecewise regression. At an urban, tertiary care children's hospital in the United States, we evaluated 1810 unplanned transfers from the general medical and surgical wards to the pediatric and neonatal intensive care units that occurred during 370,504 non-intensive care patient-days between July 1, 2007, and May 31, 2012. INTERVENTIONS: Implementation of a hospital-wide rapid response system inclusive of a medical emergency team and an early warning score in February 2010. MAIN OUTCOMES AND MEASURES: Rate of critical deterioration events, adjusted for season, ward, and case mix. RESULTS: Rapid response system implementation was associated with a significant downward change in the preintervention trajectory of critical deterioration and a 62% net decrease relative to the preintervention trend (adjusted incidence rate ratio = 0.38; 95% CI, 0.20-0.75). We observed absolute reductions in ward cardiac arrests (from 0.03 to 0.01 per 1000 non-intensive care patient-days) and deaths during ward emergencies (from 0.01 to 0.00 per 1000 non-intensive care patient-days), but these were not statistically significant (P = .21 and P = .99, respectively). Among all unplanned transfers, critical deterioration was associated with a 4.97-fold increased risk of death (95% CI, 3.33-7.40; P < .001). CONCLUSIONS AND RELEVANCE: Rapid response system implementation reversed an increasing trend of critical deterioration. Cardiac arrest and death were extremely rare at baseline, and their reductions were not statistically significant despite using nearly 5 years of data. Hospitals seeking to measure rapid response system performance may consider using valid proximate outcomes like critical deterioration in addition to rare, catastrophic outcomes.

Cost-benefit analysis of a medical emergency team in a children's hospital.

OBJECTIVES: Medical emergency teams (METs) can reduce adverse events in hospitalized children. We aimed to model the financial costs and benefits of operating an MET and determine the annual reduction in critical deterioration (CD) events required to offset MET costs. METHODS: We performed a single-center cohort study between July 1, 2007 and March 31, 2012 to determine the cost of CD events (unplanned transfers to the ICU with mechanical ventilation or vasopressors in the 12 hours after transfer) as compared with transfers to the ICU without CD. We then performed a cost-benefit analysis evaluating varying MET compositions and staffing models (freestanding or concurrent responsibilities) on the annual reduction in CD events needed to offset MET costs. RESULTS: Patients who had CD cost $99,773 (95% confidence interval, $69,431 to $130,116; P < .001) more during their post-event hospital stay than transfers to the ICU that did not meet CD criteria. Annual MET operating costs ranged from $287,145 for a nurse and respiratory therapist team with concurrent responsibilities to $2,358,112 for a nurse, respiratory therapist, and ICU attending physician freestanding team. In base-case analysis, a nurse, respiratory therapist, and ICU fellow team with concurrent responsibilities cost $350,698 per year, equivalent to a reduction of 3.5 CD events. CONCLUSIONS: CD is expensive. The costs of operating a MET can plausibly be recouped with a modest reduction in CD events. Hospitals reimbursed with bundled payments could achieve real financial savings by reducing CD with an MET.

Beyond statistical prediction: qualitative evaluation of the mechanisms by which pediatric early warning scores impact patient safety.

BACKGROUND: Early warning scores (EWSs) assign points to clinical observations and generate scores to help clinicians identify deteriorating patients. Despite marginal predictive accuracy in retrospective datasets and a paucity of studies prospectively evaluating their clinical effectiveness, pediatric EWSs are commonly used. OBJECTIVE: To identify mechanisms beyond their statistical ability to predict deterioration by which physicians and nurses use EWSs to support their decision making. DESIGN: Qualitative study. SETTING: A children's hospital with a rapid response system. PARTICIPANTS: Physicians and nurses who recently cared for patients with false-positive and false-negative EWSs (score failures). INTERVENTION: Semistructured interviews. MEASUREMENTS: Themes identified through grounded theory analysis. RESULTS: Four themes emerged among the 57 subjects interviewed: (1) The EWS facilitates safety by alerting physicians and nurses to concerning changes and prompting them to think critically about deterioration. (2) The EWS provides less-experienced nurses with vital sign reference ranges. (3) The EWS serves as evidence that empowers nurses to overcome barriers to escalating care. (4) In stable patients, those with baseline abnormal physiology, and those experiencing neurologic deterioration, the EWS may not be helpful. CONCLUSIONS: Although pediatric EWSs have marginal performance when applied to datasets, clinicians who recently experienced score failures still considered them valuable to identify deterioration and transcend hierarchical barriers. Combining an EWS with a clinician's judgment may result in a system better equipped to respond to deterioration than retrospective data analyses alone would suggest. Future research should seek to evaluate the clinical effectiveness of EWSs in real-world settings.

Development of a pragmatic measure for evaluating and optimizing rapid response systems.

OBJECTIVES: Standard metrics for evaluating rapid response systems (RRSs) include cardiac and respiratory arrest rates. These events are rare in children; therefore, years of data are needed to evaluate the impact of RRSs with sufficient statistical power. We aimed to develop a valid, pragmatic measure for evaluating and optimizing RRSs over shorter periods of time. METHODS: We reviewed 724 medical emergency team and 56 code-blue team activations in a children's hospital between February 2010 and February 2011. We defined events resulting in ICU transfer and noninvasive ventilation, intubation, or vasopressor infusion within 12 hours as "critical deterioration." By using in-hospital mortality as the gold standard, we evaluated the test characteristics and validity of this proximate outcome metric compared with a national benchmark for cardiac and respiratory arrest rates, the Child Health Corporation of America Codes Outside the ICU Whole System Measure. RESULTS: Critical deterioration (1.52 per 1000 non-ICU patient-days) was more than eightfold more common than the Child Health Corporation of America measure of cardiac and respiratory arrests (0.18 per 1000 non-ICU patient-days) and was associated with >13-fold increased risk of in-hospital death. The critical deterioration metric demonstrated both criterion and construct validity. CONCLUSIONS: The critical deterioration rate is a valid, pragmatic proximate outcome associated with in-hospital mortality. It has great potential for complementing existing patient safety measures for evaluating RRS performance.