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Safety analysis of proposed data-driven physiologic alarm parameters for hospitalized children
Veena V Goel1,2, Sarah F Poole3, Christopher A Longhurst4,5
1Division of Pediatric Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.
Insights
New heart rate and respiratory rate percentiles for hospitalized children reduce out-of-range vital sign measurements, potentially mitigating alarm fatigue. Data-driven limits are as safe as current standards.
Area of Science:
- Pediatric critical care medicine
- Clinical informatics
- Biostatistics
Background:
- Alarm fatigue is a significant issue in hospitals, often stemming from non-specific vital sign alarm limits.
- Current vital sign reference ranges may not accurately reflect the physiological norms of hospitalized children, leading to frequent, non-actionable alarms.
Purpose of the Study:
- To develop and validate age-stratified 5th and 95th percentile heart rate (HR) and respiratory rate (RR) values for hospitalized children.
- To analyze the safety and efficacy of replacing current vital sign reference ranges with these new data-driven limits.
Main Methods:
- Retrospective cross-sectional study using nurse-charted HR and RR data from 7202 children for training and 2287 for validation.
- Comparison of data-driven percentile limits against current reference ranges using data from 148 rapid response team (RRT) and cardiorespiratory arrest (CRA) events.
Main Results:
- Data-driven vital sign limits resulted in 55.6% fewer out-of-range measurements compared to current limits.
- While most RRT/CRA events had abnormal HR/RR by either limit, chart reviews indicated clinical status changes were often identified by other means.
Conclusions:
- A substantial proportion of hospitalized children exhibit vital signs outside current reference ranges.
- Data-driven vital sign limits appear as safe as current standards and may help reduce alarm fatigue when implemented in physiologic monitors.
Introduction:
Modification of alarm limits is one approach to mitigating alarm fatigue. We aimed to create and validate heart rate (HR) and respiratory rate (RR) percentiles for hospitalized children, and analyze the safety of replacing current vital sign reference ranges with proposed data-driven, age-stratified 5th and 95th percentile values.
Methods:
In this retrospective cross-sectional study, nurse-charted HR and RR data from a training set of 7202 hospitalized children were used to develop percentile tables. We compared 5th and 95th percentile values with currently accepted reference ranges in a validation set of 2287 patients. We analyzed 148 rapid response team (RRT) and cardiorespiratory arrest (CRA) events over a 12-month period, using HR and RR values in the 12 hours prior to the event, to determine the proportion of patients with out-of-range vitals based upon reference versus data-driven limits.
Results:
There were 24,045 (55.6%) fewer out-of-range measurements using data-driven vital sign limits. Overall, 144/148 RRT and CRA patients had out-of-range HR or RR values preceding the event using current limits, and 138/148 were abnormal using data-driven limits. Chart review of RRT and CRA patients with abnormal HR and RR per current limits considered normal by data-driven limits revealed that clinical status change was identified by other vital sign abnormalities or clinical context.
Conclusions:
A large proportion of vital signs in hospitalized children are outside presently used norms. Safety evaluation of data-driven limits suggests they are as safe as those currently used. Implementation of these parameters in physiologic monitors may mitigate alarm fatigue. Journal of Hospital Medicine 2015;11:817-823. © 2015 Society of Hospital Medicine.
