In the Journals

Nurse response time to alarms varies based on intuition

Responses to physiologic monitor alarms in children’s hospitals are affected by multiple factors, including the length of time spent working, the severity of the condition, nurse-to-patient ratio, and physical and mental fatigue, according to research published in JAMA Pediatrics.

“For alarms to be effective, they should activate only for serious physiologic changes and be considered important by staff members. Unfortunately, most current physiologic monitors generate high rates of alarms that are rarely actionable,” Christopher P. Bonafide, MD, MSCE, academic hospitalist in the division of general pediatrics at The Children’s Hospital of Philadelphia, and colleagues wrote. “Perhaps as a result, the response times of nurses to alarms were slow. A delayed response to a patient whose alarm represents impending cardiac arrest could be catastrophic.”

Christopher Bonafide
Christopher P. Bonafide

To recognize the factors linked to alarm response times, the researchers conducted a prospective cohort study in which they analyzed recorded video footage of nurse-administered care within a children’s medical unit. Analyzed care was provided between July 22, 2014, and Nov. 11, 2015.

The researchers then used multivariable accelerated failure-time models, which were categorized for 38 individual nurses. Clustering within patients was accounted for to assess the connection between alarm exposures and response times to alarms that occurred while the nurse was not in the room.

All nurses involved in this study where white, and 92% were female. Of the 100 patients included in the analysis, 45% were black, 33% were white, 4% were Asian and 18% identified as another race. The machines attached to these children generated 11,745 alarms, with 50 of them classified as actionable. The adjusted median response time was 10.4 minutes and was affected by many variables. These included whether the patient was on complex care service (5.3 vs. 11.1 minutes if not), presence of family in room (6.3 vs. 11.7 with family present) and years of nursing experience (4.4 minutes for less than 1 year vs. 8.8 for 1 year or more).

Other factors related to nurse response time were nurse-to-patient ratio (3.5 minutes for 1-to-1 nursing assignments vs. 10.6 for those caring for more than two patients), number of prior alarms needing intervention (5.5 vs. 10.7 minutes for those not requiring intervention), and if it was a lethal arrhythmia alarm (1.2 vs. 10.4 minutes for alarms for other conditions. Nonactionable alarm exposure in the previous 2 hours did not affect response time.

“It is well established that nurses use intuition and heuristics in clinical decision making,” Bonafide and colleagues wrote. “We theorize that the decision whether to respond immediately to an alarm is based on heuristics, to which many of the factors described earlier contribute. These heuristics are used to make intuitive judgments about the probability that the alarm represents a life-threatening condition that warrants an immediate response to prevent patient harm.” — by Katherine Bortz

Disclosure: Dr. Keren is an Associate Editor of JAMA Pediatrics but was not involved in the editorial review or the decision to accept the article for publication.

Responses to physiologic monitor alarms in children’s hospitals are affected by multiple factors, including the length of time spent working, the severity of the condition, nurse-to-patient ratio, and physical and mental fatigue, according to research published in JAMA Pediatrics.

“For alarms to be effective, they should activate only for serious physiologic changes and be considered important by staff members. Unfortunately, most current physiologic monitors generate high rates of alarms that are rarely actionable,” Christopher P. Bonafide, MD, MSCE, academic hospitalist in the division of general pediatrics at The Children’s Hospital of Philadelphia, and colleagues wrote. “Perhaps as a result, the response times of nurses to alarms were slow. A delayed response to a patient whose alarm represents impending cardiac arrest could be catastrophic.”

Christopher Bonafide
Christopher P. Bonafide

To recognize the factors linked to alarm response times, the researchers conducted a prospective cohort study in which they analyzed recorded video footage of nurse-administered care within a children’s medical unit. Analyzed care was provided between July 22, 2014, and Nov. 11, 2015.

The researchers then used multivariable accelerated failure-time models, which were categorized for 38 individual nurses. Clustering within patients was accounted for to assess the connection between alarm exposures and response times to alarms that occurred while the nurse was not in the room.

All nurses involved in this study where white, and 92% were female. Of the 100 patients included in the analysis, 45% were black, 33% were white, 4% were Asian and 18% identified as another race. The machines attached to these children generated 11,745 alarms, with 50 of them classified as actionable. The adjusted median response time was 10.4 minutes and was affected by many variables. These included whether the patient was on complex care service (5.3 vs. 11.1 minutes if not), presence of family in room (6.3 vs. 11.7 with family present) and years of nursing experience (4.4 minutes for less than 1 year vs. 8.8 for 1 year or more).

Other factors related to nurse response time were nurse-to-patient ratio (3.5 minutes for 1-to-1 nursing assignments vs. 10.6 for those caring for more than two patients), number of prior alarms needing intervention (5.5 vs. 10.7 minutes for those not requiring intervention), and if it was a lethal arrhythmia alarm (1.2 vs. 10.4 minutes for alarms for other conditions. Nonactionable alarm exposure in the previous 2 hours did not affect response time.

“It is well established that nurses use intuition and heuristics in clinical decision making,” Bonafide and colleagues wrote. “We theorize that the decision whether to respond immediately to an alarm is based on heuristics, to which many of the factors described earlier contribute. These heuristics are used to make intuitive judgments about the probability that the alarm represents a life-threatening condition that warrants an immediate response to prevent patient harm.” — by Katherine Bortz

Disclosure: Dr. Keren is an Associate Editor of JAMA Pediatrics but was not involved in the editorial review or the decision to accept the article for publication.