Development and evaluation of a writing retreat program to build community and promote productivity in academic hospital medicine.

BACKGROUND: Scientific writing is a core component of academic hospital medicine, and yet finding time to engage in deeply focused writing is difficult in part due to the highly clinical, 24/7 nature of the specialty that can limit opportunities for writing-focused collaboration and mentorship. OBJECTIVE: Our objective was to develop and evaluate an academic writing retreat program. METHODS: We drafted a set of key retreat features to guide implementation of a 3-day, 2-night retreat program held within a 2 h radius of our hospital. Agendas included writing blocks ranging from 45 to 90 min interspersed with breaks and opportunities for feedback, exercise, and preparing meals together. After each retreat, we distributed an evaluation with multiple choice and free text response options to characterize retreat helpfulness and later gathered data on the status of each paper and grant worked on. RESULTS: We held 4 retreats between September 2022 and October 2023, engaging 18 faculty and fellows at a cost of $296 per attendee per retreat. In evaluations, nearly 80% reported that the retreat was extremely helpful, and comments praised the highly mentored environment, enriching community of colleagues, and release from commitments that get in the way of writing. Of the 24 papers attendees worked on, 12 have been accepted and 6 are under review. Of the 4 grant proposals, 2 are under review. CONCLUSIONS: We implemented a low-cost, productive writing retreat program that attendees reported was helpful in supporting deep work and represented a meaningful step toward building a community centered around academic writing.

Alarm burden and the nursing care environment: a 213-hospital cross-sectional study.

BACKGROUND: High rates of medical device alarms in hospitals are a well-documented threat to patient safety. Little is known about organisational features that may be associated with nurses' experience of alarm burden. AIMS: To evaluate the association between nurse-reported alarm burden, appraisals of patient safety, quality of care and hospital characteristics. METHODS: Secondary analysis of cross-sectional survey data from 3986 hospital-based direct-care registered nurses in 213 acute care hospitals in New York and Illinois, USA. We evaluated associations of alarm burden with appraisals of patient safety and quality of care and hospital characteristics (work environment, staffing adequacy, size, teaching status) using χ2 tests. RESULTS: The majority of respondents reported feeling overwhelmed by alarms (83%), delaying their response to alarms because they were unable to step away from another patient/task (76%), and experiencing situations where a patient needed urgent attention but no one responded to an alarm (55%). Nurses on medical-surgical units reported these experiences at higher rates than nurses working in intensive care units (p<0.001). Alarm burden items were significantly associated with poorer nurse-reported patient safety, quality of care, staffing and work environment. Findings were most pronounced for situations where a patient needed urgent attention but no one responded to the alarm, which was frequently/occasionally experienced by 72% of those who rated their hospital's safety as poor versus 38% good, p<0.001; 80% who rated overall quality of care poor/fair versus 46% good/excellent, p<0.001 and 65% from poor work environments versus 42% from good work environments, p<0.001. CONCLUSION: Most nurses reported feeling overwhelmed by medical device alarms, and our findings suggest that alarm burden may be more pronounced in hospitals with unfavourable working conditions and suboptimal quality and safety. Because this was a cross-sectional study, further research is needed to explore causal relationships and the role of modifiable systems factors in reducing alarm burden.

Observing sources of system resilience using in situ alarm simulations.

Alarm fatigue (and resultant alarm nonresponse) threatens the safety of hospitalized patients. Historically threats to patient safety, including alarm fatigue, have been evaluated using a Safety I perspective analyzing rare events such as failure to respond to patients' critical alarms. Safety II approaches call for learning from the everyday adaptations clinicians make to keep patients safe. To identify such sources of resilience in alarm systems, we conducted 59 in situ simulations of a critical hypoxemic-event alarm in medical/surgical and intensive care units at a tertiary care pediatric hospital between December 2019 and May 2022. Response timing, observations of the environment, and postsimulation debrief interviews were captured. Four primary means of successful alarm responses were mapped to domains of Systems Engineering Initiative for Patient Safety framework to inform alarm system design and improvement.

Clinician Perspectives on Specifications for Metrics to Inform Pediatric Alarm Management.

Background: Ongoing management of monitor alarms is important for reducing alarm fatigue among clinicians (e.g., nurses, physicians). Strategies to enhance clinician engagement in active alarm management in pediatric acute care have not been well explored. Access to alarm summary metrics may enhance clinician engagement. Objective: To lay the foundation for intervention development, we sought to identify functional specifications for formulating, packaging, and delivering alarm metrics to clinicians. Methods: Our team of clinician scientists and human factors engineers conducted focus groups with clinicians from medical-surgical inpatient units in a children's hospital. We inductively coded transcripts, developed codes into themes, and grouped themes into "current state" and "future state." Results: We conducted five focus groups with 13 clinicians (eight registered nurses and five doctors of medicine). In the current state, information exchanged among team members about alarm burden is initiated by nurses on an ad hoc basis. For a future state, clinicians identified ways in which alarm metrics could help them manage alarms and described specific information, such as alarm trends, benchmarks, and contextual data, that would support decision-making. Conclusion: We developed four recommendations for future strategies to enhance clinicians' active management of patient alarms: (1) formulate alarm metrics for clinicians by categorizing alarm rates by type and summarizing alarm trends over time, (2) package alarm metrics with contextual patient data to facilitate clinicians' sensemaking, (3) deliver alarm metrics in a forum that facilitates interprofessional discussion, and (4) provide clinician education to establish a shared mental model about alarm fatigue and evidence-based alarm-reduction strategies.

Evaluating the Accuracy of Pulse Oximetry in Children According to Race.

This cross-sectional study investigates the association between race and pulse oximeter accuracy in children in the US.

Developing a Nursing Dashboard to Align Nursing Care Delivery With Patient and Family Needs.

Clinical units and their nursing staffs are heterogeneous. Advances in data and analytics provide opportunities to better match patient needs with nurse competencies. Building upon a previous publication on a unit profile dashboard, team members now describe development of a nursing dashboard aggregating characteristics of staff on each clinical unit of the hospital. This article describes methods, challenges, and future directions for nurse leaders to use the dashboards to optimize care delivery and patient and nurse outcomes.

Pediatric Characteristics Associated With Higher Rates of Monitor Alarms.

Background: Continuous physiologic monitoring commonly is used in pediatric medical-surgical (med-surg) units and is associated with high alarm burden for clinicians. Characteristics of pediatric patients generating high rates of alarms on med-surg units are not known. Objective: To describe the demographic and clinical characteristics of pediatric med-surg patients associated with high rates of clinical alarms. Methods: We conducted a cross-sectional, single-site, retrospective study using existing clinical and alarm data from a children's hospital. Continuously monitored patients from med-surg units who had available alarm data were included. Negative binomial regression models were used to test the association between patient characteristics and the rate of clinical alarms per continuously monitored hour. Results: Our final sample consisted of 1,569 patients with a total of 38,501 continuously monitored hours generating 265,432 clinical alarms. Peripheral oxygen saturation (SpO2) low alarms accounted for 57.5% of alarms. Patients with medical complexity averaged 11% fewer alarms per hour than those without medical complexity (P < 0.01). Patients older than 5 years had up to 30% fewer alarms per hour than those who were younger than 5 years (P < 0.01). Patients using supplemental oxygen averaged 39% more alarms per hour compared with patients who had no supplemental oxygen use (P < 0.01). Patients at high risk for deterioration averaged 19% more alarms per hour than patients who were not high risk (P = 0.01). Conclusion: SpO2 alarms were the most common type of alarm in this study. The results highlight patient populations in pediatric medical-surgical units that may be high yield for interventions to reduce alarms. Most physiologic monitor alarms in pediatric medical-surgical (med-surg) units are not informative and likely could be safely eliminated to reduce noise and alarm fatigue.1-3 However, identifying and sustaining successful alarm-reduction strategies is a challenge. Research shows that 25% of patients in pediatric med-surg units produce almost three-quarters of all alarms.4 These patients are a potential high-yield target for alarm-reduction strategies; however, we are not aware of studies describing characteristics of pediatric patients generating high rates of alarms. The patient populations seen on pediatric med-surg units are diverse. Children of all ages are cared for on these units, with diagnoses ranging from acute respiratory infections, to management of chronic conditions, and to psychiatric conditions. Not all patients on pediatric med-surg units have physiologic parameters continuously monitored,4 but among those who do, understanding patient characteristics associated with high rates of alarms may help clinicians, healthcare technology management (HTM) professionals, and others working on alarm management strategies to develop targeted interventions. We conducted an exploratory retrospective study to describe patient characteristics associated with high rates of alarms in pediatric med-surg units.

Sustainable deimplementation of continuous pulse oximetry monitoring in children hospitalized with bronchiolitis: study protocol for the Eliminating Monitor Overuse (EMO) type III effectiveness-deimplementation cluster-randomized trial.

BACKGROUND: Methods of sustaining the deimplementation of overused medical practices (i.e., practices not supported by evidence) are understudied. In pediatric hospital medicine, continuous pulse oximetry monitoring of children with the common viral respiratory illness bronchiolitis is recommended only under specific circumstances. Three national guidelines discourage its use for children who are not receiving supplemental oxygen, but guideline-discordant practice (i.e., overuse) remains prevalent. A 6-hospital pilot of educational outreach with audit and feedback resulted in immediate reductions in overuse; however, the best strategies to optimize sustainment of deimplementation success are unknown. METHODS: The Eliminating Monitor Overuse (EMO) trial will compare two deimplementation strategies in a hybrid type III effectiveness-deimplementation trial. This longitudinal cluster-randomized design will be conducted in Pediatric Research in Inpatient Settings (PRIS) Network hospitals and will include baseline measurement, active deimplementation, and sustainment phases. After a baseline measurement period, 16-19 hospitals will be randomized to a deimplementation strategy that targets unlearning (educational outreach with audit and feedback), and the other 16-19 will be randomized to a strategy that targets unlearning and substitution (adding an EHR-integrated clinical pathway decision support tool). The primary outcome is the sustainment of deimplementation in bronchiolitis patients who are not receiving any supplemental oxygen, analyzed as a longitudinal difference-in-differences comparison of overuse rates across study arms. Secondary outcomes include equity of deimplementation and the fidelity to, and cost of, each deimplementation strategy. To understand how the deimplementation strategies work, we will test hypothesized mechanisms of routinization (clinicians developing new routines supporting practice change) and institutionalization (embedding of practice change into existing organizational systems). DISCUSSION: The EMO trial will advance the science of deimplementation by providing new insights into the processes, mechanisms, costs, and likelihood of sustained practice change using rigorously designed deimplementation strategies. The trial will also advance care for a high-incidence, costly pediatric lung disease. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05132322 . Registered on November 10, 2021.

Developing a Unit Profile Dashboard to Inform Nursing Care Delivery Based on Unique Needs of Patients.

Nurse leaders need real-time, accurate data to design care delivery models and make decisions that reflect the patient populations they serve. To support nurse leader practice and optimize patient care, we developed a unit profile dashboard to describe the unique characteristics of patient populations cared for on each clinical unit at our hospital. In this article, we describe dashboard development, challenges, use cases, and plans for data analytics to further advance nursing practice.

Parental Insights into Improving Home Pulse Oximetry Monitoring in Infants.

Home pulse oximeters prescribed for infants with cardiorespiratory conditions generate many false alarms, which create caregiver stress and sleep disturbance and can lead to unsafe practices. Additionally, relationships among oximeters, alarms, and everyday living demands are not well understood. Therefore, we aimed to gather parent perspectives on home pulse oximetry monitoring during the problem analysis phase of a quality improvement (QI) initiative. Methods: We purposively sampled and interviewed parents of infants prescribed home pulse oximeters and receiving local home care company services. We based questions on systems engineering frameworks previously used in healthcare. Data were coded iteratively and analyzed deductively (theoretical frameworks) and inductively (emerging themes). Results: Generally, themes aligned with theoretical frameworks. Parents expressed dissatisfaction with the number of false alarms home pulse oximeters generate, which parents primarily attributed to poor probe adhesiveness and the inability of oximeters to account for infant movement. Interviews highlighted the burden associated with poor device tones and portability. Device-related issues had negative repercussions for the entire family related to sleep quality, mobility, and social interactions. Universally, parents developed workarounds, including cessation of monitoring. Conclusions: Parents of infants monitored at home using pulse oximetry face many challenges, resulting in compromises in safety. Continuing to instruct parents to comply with prescribed monitoring recommendations may be unrealistic. Instead, we suggest re-engineering the home monitoring system with the needs and goals of children and their families at the center. Our description of adapting qualitative research and systems engineering methods may benefit others developing QI work.

Development and Validation of an Obstetric Comorbidity Risk Score for Clinical Use.

Background: A comorbidity summary score may support early and systematic identification of women at high risk for adverse obstetric outcomes. The objective of this study was to conduct the initial development and validation of an obstetrics comorbidity risk score for automated implementation in the electronic health record (EHR) for clinical use. Methods: The score was developed and validated using EHR data for a retrospective cohort of pregnancies with delivery between 2010 and 2018 at Kaiser Permanente Northern California, an integrated health care system. The outcome used for model development consisted of adverse obstetric events from delivery hospitalization (e.g., eclampsia, hemorrhage, death). Candidate predictors included maternal age, parity, multiple gestation, and any maternal diagnoses assigned in health care encounters in the 12 months before admission for delivery. We used penalized regression for variable selection, logistic regression to fit the model, and internal validation for model evaluation. We also evaluated prenatal model performance at 18 weeks of pregnancy. Results: The development cohort (n = 227,405 pregnancies) had an outcome rate of 3.8% and the validation cohort (n = 41,683) had an outcome rate of 2.9%. Of 276 candidate predictors, 37 were included in the final model. The final model had a validation c-statistic of 0.72 (95% confidence interval [CI] 0.70-0.73). When evaluated at 18 weeks of pregnancy, discrimination was modestly diminished (c-statistic 0.68 [95% CI 0.67-0.70]). Conclusions: The obstetric comorbidity score demonstrated good discrimination for adverse obstetric outcomes. After additional appropriate validation, the score can be automated in the EHR to support early identification of high-risk women and assist efforts to ensure risk-appropriate maternal care.

EHR-Integrated Monitor Data to Measure Pulse Oximetry Use in Bronchiolitis.

BACKGROUND AND OBJECTIVES: Continuous pulse oximetry (oxygen saturation [Spo2]) monitoring in hospitalized children with bronchiolitis not requiring supplemental oxygen is discouraged by national guidelines, but determining monitoring status accurately requires in-person observation. Our objective was to determine if electronic health record (EHR) data can accurately estimate the extent of actual Spo2 monitoring use in bronchiolitis. METHODS: This repeated cross-sectional study included infants aged 8 weeks through 23 months hospitalized with bronchiolitis. In the validation phase at 3 children's hospitals, we calculated the test characteristics of the Spo2 monitor data streamed into the EHR each minute when monitoring was active compared with in-person observation of Spo2 monitoring use. In the application phase at 1 children's hospital, we identified periods when supplemental oxygen was administered using EHR flowsheet documentation and calculated the duration of Spo2 monitoring that occurred in the absence of supplemental oxygen. RESULTS: Among 668 infants at 3 hospitals (validation phase), EHR-integrated Spo2 data from the same minute as in-person observation had a sensitivity of 90%, specificity of 98%, positive predictive value of 88%, and negative predictive value of 98% for actual Spo2 monitoring use. Using EHR-integrated data in a sample of 317 infants at 1 hospital (application phase), infants were monitored in the absence of oxygen supplementation for a median 4.1 hours (interquartile range 1.4-9.4 hours). Those who received supplemental oxygen experienced a median 5.6 hours (interquartile range 3.0-10.6 hours) of monitoring after oxygen was stopped. CONCLUSIONS: EHR-integrated monitor data are a valid measure of actual Spo2 monitoring use that may help hospitals more efficiently identify opportunities to deimplement guideline-inconsistent use.

Physiologic Monitor Alarm Burden and Nurses' Subjective Workload in a Children's Hospital.

BACKGROUND AND OBJECTIVES: Physiologic monitor alarms occur at high rates in children's hospitals; ≤1% are actionable. The burden of alarms has implications for patient safety and is challenging to measure directly. Nurse workload, measured by using a version of the National Aeronautics and Space Administration Task Load Index (NASA-TLX) validated among nurses, is a useful indicator of work burden that has been associated with patient outcomes. A recent study revealed that 5-point increases in the NASA-TLX score were associated with a 22% increased risk in missed nursing care. Our objective was to measure the relationship between alarm count and nurse workload by using the NASA-TLX. METHODS: We conducted a repeated cross-sectional study of pediatric nurses in a tertiary care children's hospital to measure the association between NASA-TLX workload evaluations (using the nurse-validated scale) and alarm count in the 2 hours preceding NASA-TLX administration. Using a multivariable mixed-effects regression accounting for nurse-level clustering, we modeled the adjusted association of alarm count with workload. RESULTS: The NASA-TLX score was assessed in 26 nurses during 394 nursing shifts over a 2-month period. In adjusted regression models, experiencing >40 alarms in the preceding 2 hours was associated with a 5.5 point increase (95% confidence interval 5.2 to 5.7; P < .001) in subjective workload. CONCLUSION: Alarm count in the preceding 2 hours is associated with a significant increase in subjective nurse workload that exceeds the threshold associated with increased risk of missed nursing care and potential patient harm.

Monitor-Watcher Use, Nurses' Knowledge of Electrocardiographic Monitoring, and Arrhythmia Detection.

BACKGROUND: Electrocardiographic telemetry monitors are ubiquitous in hospitals. Dedicated monitor watchers, either on the unit or in a centralized location, are often responsible for observing telemetry monitors and responding to their alarms. The impact of use of monitor watchers is not known. OBJECTIVES: To evaluate the association of monitor-watcher use with (1) nurses' knowledge of electrocardiographic (ECG) monitoring and (2) accuracy of arrhythmia detection. METHODS: Baseline data from 37 non-intensive care unit cardiac patient care areas in 17 hospitals in the Practical Use of the Latest Standards for Electrocardiography trial were analyzed. Nurses' knowledge (n = 1136 nurses) was measured using a validated, 20-item online test. Accuracy of arrhythmia detection (n = 1189 patients) was assessed for 5 consecutive days by comparing arrhythmias stored in the monitor with nurses' documentation. Multiple regression was used to evaluate the association of use of monitor watchers with scores on the ECG-monitoring knowledge test. The association of monitor-watcher use with accuracy of arrhythmia detection was examined by χ2 analysis. RESULTS: Of the 37 units, 13 (35%) had monitor watchers. Use of monitor watchers was not independently associated with ECG-monitoring knowledge (P = .08). The presence of monitor watchers also was not significantly associated with the accuracy of arrhythmia detection (P = .94). CONCLUSION: Although the use of monitor watchers was not associated with diminished nurses' knowledge of ECG monitoring, it also was not associated with more accurate arrhythmia detection. If implementing a monitor-watcher program, critical safety points, such as ensuring closed-loop communication, must be considered.

Validation of Postpartum Hemorrhage Admission Risk Factor Stratification in a Large Obstetrics Population.

OBJECTIVE: This study aimed to evaluate the performance of the California Maternal Quality Care Collaborative (CMQCC) admission risk criteria for stratifying postpartum hemorrhage risk in a large obstetrics population. STUDY DESIGN: Using detailed electronic health record data, we classified 261,964 delivery hospitalizations from Kaiser Permanente Northern California hospitals between 2010 and 2017 into high-, medium-, and low-risk groups based on CMQCC criteria. We used logistic regression to assess associations between CMQCC risk groups and postpartum hemorrhage using two different postpartum hemorrhage definitions, standard postpartum hemorrhage (blood loss ≥1,000 mL) and severe postpartum hemorrhage (based on transfusion, laboratory, and blood loss data). Among the low-risk group, we also evaluated associations between additional present-on-admission factors and severe postpartum hemorrhage. RESULTS: Using the standard definition, postpartum hemorrhage occurred in approximately 5% of hospitalizations (n = 13,479), with a rate of 3.2, 10.5, and 10.2% in the low-, medium-, and high-risk groups. Severe postpartum hemorrhage occurred in 824 hospitalizations (0.3%), with a rate of 0.2, 0.5, and 1.3% in the low-, medium-, and high-risk groups. For either definition, the odds of postpartum hemorrhage were significantly higher in medium- and high-risk groups compared with the low-risk group. Over 40% of postpartum hemorrhages occurred in hospitalizations that were classified as low risk. Among the low-risk group, risk factors including hypertension and diabetes were associated with higher odds of severe postpartum hemorrhage. CONCLUSION: We found that the CMQCC admission risk assessment criteria stratified women by increasing rates of severe postpartum hemorrhage in our sample, which enables early preparation for many postpartum hemorrhages. However, the CMQCC risk factors missed a substantial proportion of postpartum hemorrhages. Efforts to improve postpartum hemorrhage risk assessment using present-on-admission risk factors should consider inclusion of other nonobstetrical factors.

Analysis: Protocol for a New Method to Measure Physiologic Monitor Alarm Responsiveness.

Evaluating the clinical impacts of healthcare alarm management systems plays a critical role in assessing newly implemented monitoring technology, exposing latent threats to patient safety, and identifying opportunities for system improvement. We describe a novel, accurate, rapidly implementable, and readily reproducible in situ simulation approach to measure alarm response times and rates without the challenges and expense of video analysis. An interprofessional team consisting of biomedical engineers, human factors engineers, information technology specialists, nurses, physicians, facilitators from the hospital's simulation center, clinical informaticians, and hospital administrative leadership worked with three units at a pediatric hospital to design and conduct the simulations. Existing hospital technology was used to transmit a simulated, unambiguously critical alarm that appeared to originate from an actual patient to the nurse's mobile device, and discreet observers measured responses. Simulation observational data can be used to design and evaluate quality improvement efforts to address alarm responsiveness and to benchmark performance of different alarm communication systems.