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Safety Huddle Intervention for Reducing Physiologic Monitor Alarms: A Hybrid Effectiveness-Implementation Cluster
Christopher P Bonafide1,2,3,4, A Russell Localio5, Shannon Sternler6,3,7
1Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA. bonafide@email.chop.edu.
Insights
Safety huddles reduced individual patient monitor alarms but did not impact unit-level alarm rates. This intervention was effective for specific children, though overall unit rates remained unchanged due to low intervention dose.
Area of Science:
- Pediatric patient safety
- Clinical workflow optimization
- Healthcare quality improvement
Background:
- Frequent monitor alarms in hospitals rarely require clinical intervention.
- Reducing unnecessary alarms is crucial for patient safety and efficient care.
- Existing alarm management strategies need further evaluation.
Purpose of the Study:
- To assess if safety huddles decrease unit-level and individual patient alarm rates.
- To evaluate the implementation outcomes of a safety huddle intervention.
- To determine the effectiveness of alarm data review in a pediatric setting.
Main Methods:
- A unit-level, cluster randomized, hybrid trial was conducted in a children's hospital.
- Intervention units held structured safety huddles to discuss high-alarm patients.
- Patient-level analysis compared alarm rates before and after huddle discussions.
Main Results:
- Safety huddles did not significantly reduce unit-level alarm rates (P = .50).
- Discussed patients experienced a significant reduction in alarms post-huddle (97 fewer alarms/patient-day, P < .001).
- Low intervention dose (0.85 patients/unit/day) was observed.
Conclusions:
- Safety huddles effectively reduced alarms for individual pediatric patients.
- The intervention's impact on unit-level alarm rates was limited by a low intervention dose.
- Targeted huddle discussions show promise for personalized alarm management.
Background:
Monitor alarms occur frequently but rarely warrant intervention.
Objective:
This study aimed to determine if a safety huddle-based intervention reduces unit-level alarm rates or alarm rates of individual patients whose alarms are discussed, as well as evaluate implementation outcomes.
Design:
Unit-level, cluster randomized, hybrid effectiveness-implementation trial with a secondary patient-level analysis.
Setting:
Children's hospital.
Patients:
Unit-level: all patients hospitalized on 4 control (n = 4177) and 4 intervention (n = 7131) units between June 15, 2015 and May 8, 2016. Patient-level: 425 patients on randomly selected dates postimplementation.
Intervention:
Structured safety huddle review of alarm data from the patients on each unit with the most alarms, with a discussion of ways to reduce alarms.
Measurements:
Unit-level: change in unit-level alarm rates between baseline and postimplementation periods in intervention versus control units. Patient-level: change in individual patients' alarm rates between the 24 hours leading up to huddles and the 24 hours after huddles in patients who were discussed versus not discussed in huddles.
Results:
Alarm data informed 580 huddle discussions. In unit-level analysis, intervention units had 2 fewer alarms/patient-day (95% CI: 7 fewer to 6 more, P = .50) compared with control units. In patient-level analysis, patients discussed in huddles had 97 fewer alarms/patientday (95% CI: 52-138 fewer, P < .001) in the posthuddle period compared with patients not discussed in huddles. Implementation outcome analysis revealed a low intervention dose of 0.85 patients/unit/day.
Conclusions:
Safety huddle-based alarm discussions did not influence unit-level alarm rates due to low intervention dose but were effective in reducing alarms for individual children.
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