Cardiorespiratory and Pulse Oximetry Monitoring in Hospitalized Children: A Delphi Process.

OBJECTIVES: Cardiorespiratory and pulse oximetry monitoring in children who are hospitalized should balance benefits of detecting deterioration with potential harms of alarm fatigue. We developed recommendations for monitoring outside the ICU on the basis of available evidence and expert opinion. METHODS: We conducted a comprehensive literature search for studies addressing the utility of cardiorespiratory and pulse oximetry monitoring in common pediatric conditions and drafted candidate monitoring recommendations based on our findings. We convened a panel of nominees from national professional organizations with diverse expertise: nursing, medicine, respiratory therapy, biomedical engineering, and family advocacy. Using the RAND/University of California, Los Angeles Appropriateness Method, panelists rated recommendations for appropriateness and necessity in 3 sequential rating sessions and a moderated meeting. RESULTS: The panel evaluated 56 recommendations for intermittent and continuous monitoring for children hospitalized outside the ICU with 7 common conditions (eg, asthma, croup) and/or receiving common therapies (eg, supplemental oxygen, intravenous opioids). The panel reached agreement on the appropriateness of monitoring recommendations for 55 of 56 indications and on necessity of monitoring for 52. For mild or moderate asthma, croup, pneumonia, and bronchiolitis, the panel recommended intermittent vital sign or oximetry measurement only. The panel recommended continuous monitoring for severe disease in each respiratory condition as well as for a new or increased dose of intravenous opiate or benzodiazepine. CONCLUSIONS: Expert panel members agreed that intermittent vital sign assessment, rather than continuous monitoring, is appropriate management for a set of specific conditions of mild or moderate severity that require hospitalization.

Nurse Responses to Physiologic Monitor Alarms on a General Pediatric Unit.

BACKGROUND: Hospitalized children generate up to 152 alarms per patient per day outside of the intensive care unit. In that setting, as few as 1% of alarms are clinically important. How nurses make decisions about responding to alarms, given an alarm's low specificity for detecting clinical deterioration, remains unclear. OBJECTIVE: Our objective was to describe how bedside nurses think about and act upon monitor alarms for hospitalized children. DESIGN, SETTING, PARTICIPANTS: This was a qualitative study that involved the direct observation of nurses working on a general pediatric unit at a large children's hospital. MEASUREMENTS: We used a structured tool that included predetermined categories to assess nurse responses to monitor alarms. Data on alarm frequency and type were pulled from bedside monitors. RESULTS: We conducted 61.3 patient-hours of observation with nine nurses, in which we documented 207 nurse responses to patient alarms. For 67% of alarms heard outside of the room, the nurse decided not to respond without further assessment. Nurses most commonly cited reassuring clinical context (eg, medical team in room), as the rationale for alarm nonresponse. The nurse deemed clinical intervention necessary in only 14 (7%) of the observed responses. CONCLUSION: Nurses rely on clinical and contextual details to determine how to respond to alarms. Few of the alarm responses in our study resulted in a clinical intervention. These findings suggest that multiple system-level and educational interventions may be necessary to improve the efficacy and safety of continuous monitoring.

Factors Influencing Use of Continuous Physiologic Monitors for Hospitalized Pediatric Patients.

OBJECTIVES: Continuous physiologic monitors (CPMs) generate frequent alarms and are used for up to 50% of children who are hospitalized outside of the ICU. Our objective was to assess factors that influence the decision to use CPMs. METHODS: In this qualitative study, we used group-level assessment, a structured method designed to engage diverse stakeholder groups. We recruited clinicians and other staff who work on a 48-bed hospital medicine unit at a freestanding children's hospital. We developed a list of open-ended prompts used to address CPM use on inpatient units. Demographic data were collected from each participant. We conducted 6 sessions to permit maximum participation among all groups, and themes from all sessions were merged and distilled. RESULTS: Participants (n = 78) included nurses (37%), attending physicians (17%), pediatric residents (32%), and unit staff (eg, unit coordinator; 14%). Participants identified several themes. First, there are patient factors (eg, complexity and instability) for which CPMs are useful. Second, participants perceived that alarms have negative effects on families (eg, anxiety and sleep deprivation). Third, CPMs are often used as surrogates for clinical assessments. Fourth, CPM alarms cause anxiety and fatigue for frontline staff. Fifth, the decision to use CPMs should be, but is not often, a team decision. Sixth, and finally, there are issues related to the monitor system's setup that reduces its utility. CONCLUSIONS: Hospital medicine staff identified patient-, staff-, and system-level factors relevant to CPM use for children who were hospitalized. These data will inform the development of system-level interventions to improve CPM use and address high alarm rates.