BACKGROUND AND OBJECTIVES: Consumer home monitors (CHM), which measure vital signs, are popular products marketed to detect airway obstruction and arrhythmia. Yet, they lack evidence of infant death prevention, demonstrate suboptimal accuracy, and may result in false alarms that prompt unnecessary acute care visits. To better understand the hospital utilization and costs of CHM, we characterized emergency department (ED) and hospital encounters associated with CHM use at a children's hospital.

METHODS: We used structured query language to search the free text of all ED and admission notes between January 2013 and December 2019 to identify clinical documentation discussing CHM use. Two physicians independently reviewed the presence of CHM use and categorized encounter characteristics.

RESULTS: Evidence of CHM use contributed to the presentation of 36 encounters in a sample of over 300 000 encounters, with nearly half occurring in 2019. The leading discharge diagnoses were viral infection (13, 36%), gastroesophageal reflux (8, 22%) and false positive alarm (6, 17%). Median encounter duration was 20 hours (interquartile range: 3 hours to 2 days; max 10.5 days) and median cost of encounters was $2188 (interquartile range: $255 to $7632; max $84 928).

CONCLUSIONS: Although the annual rate of CHM-related encounters was low and did not indicate a major public health burden, for individual families who present to the ED or hospital for concerns related to CHMs, there may be important adverse financial and emotional consequences.

<p>Guidelines discourage continuous pulse oximetry monitoring of hospitalized infants with bronchiolitis who are not receiving supplemental oxygen. Excess monitoring is theorized to contribute to increased alarm burden, but this burden has not been quantified. We evaluated admissions of 201 children (aged 0-24 months) with bronchiolitis. We categorized time ≥60 minutes following discontinuation of supplemental oxygen as "continuously monitored (guideline-discordant)," "intermittently measured (guideline-concordant)," or "unable to classify." Across 4402 classifiable hours, 77% (11,101) of alarms occurred during periods of guideline-discordant monitoring. Patients experienced a median of 35 alarms (interquartile range [IQR], 10-81) during guideline-discordant, continuously monitored time, representing a rate of 6.7 alarms per hour (IQR, 2.1-12.3). In comparison, the median hourly alarm rate during periods of guideline-concordant intermittent measurement was 0.5 alarms per hour (IQR, 0.1-0.8). Reducing guideline-discordant monitoring in bronchiolitis patients would reduce nurse alarm burden.</p>

<p><strong>BACKGROUND AND OBJECTIVES: </strong>Continuous pulse oximetry (oxygen saturation [Spo]) 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 Spo monitoring use in bronchiolitis.</p>

<p><strong>METHODS: </strong>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 Spo monitor data streamed into the EHR each minute when monitoring was active compared with in-person observation of Spo 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 Spo monitoring that occurred in the absence of supplemental oxygen.</p>

<p><strong>RESULTS: </strong>Among 668 infants at 3 hospitals (validation phase), EHR-integrated Spo 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 Spo 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.</p>

<p><strong>CONCLUSIONS: </strong>EHR-integrated monitor data are a valid measure of actual Spo monitoring use that may help hospitals more efficiently identify opportunities to deimplement guideline-inconsistent use.</p>

<p><strong>BACKGROUND AND OBJECTIVES: </strong>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.</p>

<p><strong>METHODS: </strong>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.</p>

<p><strong>RESULTS: </strong>The NASA-TLX score was assessed in 26 nurses during 394 nursing shifts over a 2-month period. In adjusted regression models, experiencing &gt;40 alarms in the preceding 2 hours was associated with a 5.5 point increase (95% confidence interval 5.2 to 5.7; &lt; .001) in subjective workload.</p>

<p><strong>CONCLUSION: </strong>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.</p>

<p>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.</p>