<p><strong>Importance: </strong>Bedside monitor alarms alert nurses to life-threatening physiologic changes among patients, but the response times of nurses are slow.</p>

<p><strong>Objective: </strong>To identify factors associated with physiologic monitor alarm response time.</p>

<p><strong>Design, Setting, and Participants: </strong>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.</p>

<p><strong>Exposures: </strong>Patient, nurse, and alarm-level factors hypothesized to predict response time.</p>

<p><strong>Main Outcomes and Measures: </strong>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.</p>

<p><strong>Results: </strong>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.</p>

<p><strong>Conclusions and Relevance: </strong>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.</p>

<p><strong>BACKGROUND: </strong>Identification of the characteristics that put hospitalized children at high risk of deterioration may help to target patients whose physiologic status should be intensively monitored for signs of deterioration, and reduce unnecessary monitoring in patients at very low risk. Previous studies have evaluated vital sign-based early warning scores to detect deterioration that has already begun.</p>

<p><strong>OBJECTIVE: </strong>To develop a predictive score for deterioration using non-vital sign patient characteristics in order to risk-stratify hospitalized children before signs of deterioration are detectable.</p>

<p><strong>DESIGN: </strong>Case-control study.</p>

<p><strong>SETTING: </strong>A 460-bed children's hospital.</p>

<p><strong>PATIENTS: </strong>Cases (n = 141) were children who deteriorated while receiving care on non-intensive care unit (non-ICU) inpatient units. Controls (n = 423) were randomly selected.</p>

<p><strong>MEASUREMENTS: </strong>The exposures were complex chronic conditions, other patient characteristics, and laboratory studies. The outcome was clinical deterioration, defined as cardiopulmonary arrest, acute respiratory compromise, or urgent ICU transfer.</p>

<p><strong>RESULTS: </strong>The 7-item score included age &lt;1 year, epilepsy, congenital/genetic conditions, history of transplant, enteral tube, hemoglobin &lt;10 g/dL, and blood culture drawn in the preceding 72 hours. We grouped the patients into risk strata based on their scores. The very low-risk group's probability of deterioration was less than half of baseline risk. The high-risk group's probability of deterioration was more than 80-fold higher than the baseline risk.</p>

<p><strong>CONCLUSIONS: </strong>We identified a set of characteristics associated with clinical deterioration in children. Used in combination as a score, these characteristics may be useful in triaging the intensity of monitoring and surveillance for deterioration that children receive while hospitalized on non-ICU units.</p>

<p>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.</p>

<p><strong>BACKGROUND: </strong>The pediatric intensive care unit (PICU), with limited number of beds and resource-intensive services, is a key component of patient flow. Because the PICU is a crossroads for many patients, transfer or discharge delays can negatively impact a patient's clinical status and efficiency.</p>

<p><strong>OBJECTIVE: </strong>The objective of this study was to describe, using direct observation, PICU bed utilization.</p>

<p><strong>METHODS: </strong>We conducted a real-time, prospective observational study in a convenience sample of days in the PICU of an urban, tertiary-care children's hospital.</p>

<p><strong>RESULTS: </strong>Among 824 observed hours, 19,887 bed-hours were recorded, with 82% being for critical care services and 18% for non-critical care services. Fourteen activities accounted for 95% of bed-hours. Among 200 hours when the PICU was at full capacity, 75% of the time included at least 1 bed that was used for non-critical care services; 37% of the time at least 2 beds. The mean waiting time for a floor bed assignment was 9 hours (median, 5.5 hours) and accounted for 4.62% of all bed-hours observed.</p>

<p><strong>CONCLUSIONS: </strong>The PICU delivered critical care services most of the time, but periods of non-critical care services represented a significant amount of time. In particular, periods with no bed available for new patients were associated with at least 1 or more PICU beds being used for non-critical care activities. The method should be reproducible in other settings to learn more about the structure and processes of care and patient flow and to make improvements.</p>

<p><strong>BACKGROUND: </strong>Alarm fatigue is reported to be a major threat to patient safety, yet little empirical data support its existence in the hospital.</p>

<p><strong>OBJECTIVE: </strong>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.</p>

<p><strong>DESIGN: </strong>Observational study using video.</p>

<p><strong>SETTING: </strong>Freestanding children's hospital.</p>

<p><strong>PATIENTS: </strong>Pediatric intensive care unit (PICU) patients requiring inotropic support and/or mechanical ventilation, and medical ward patients.</p>

<p><strong>INTERVENTION: </strong>None.</p>

<p><strong>MEASUREMENTS: </strong>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.</p>

<p><strong>RESULTS: </strong>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 &lt; 0.001 in PICU, P = 0.009 in the ward).</p>

<p><strong>CONCLUSIONS: </strong>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.</p>