Context: Alarm fatigue is a threat to hospital patient safety. National surveys reveal that
high alarm rates interrupt patient care, reduce trust in alarms, and lead clinicians to
disable alarms entirely. Safety huddles offer an appropriate forum for reviewing alarm data
and identifying patients whose high alarm rates may necessitate safe tailoring of alarm
Objectives: To evaluate the impact of a focused physiologic monitor alarm reduction
intervention integrated into safety huddles that involves discussing safe monitor parameter
adjustments on the physiologic monitor alarm rates of individual patients with high alarm
rates who meet "low acuity" criteria.
Study Design: A prospective, quasi-experimental pilot study of the impact of the huddle
intervention on the alarm rates of low acuity high alarm rate individual patients discussed
in huddles in the PICU. The huddle intervention will consist of a script to facilitate the
discussion of the alarm data.
Setting/Participants: Participants will include all low acuity patients and their providers
in the PICU at The Children's Hospital of Philadelphia.
Study Interventions and Measures: The primary outcome is the rate of crisis and warning
alarms per patient day for intervention cases as compared with others in the high alarm /
low acuity cohort. Safety measures will include unexpected changes in patient acuity or code
blue events within one week of monitor change or discharge.
Eligible primary participants will be the physicians and nurse practitioners caring for
the PICU patients who are discussed as part of the huddle interventions. Eligible
secondary participants will include all low acuity patients in the PICU at The Children's
Hospital of Philadelphia.
Inclusion Criteria Primary Subjects: Any physician or nurse practioner caring for an
intervention patient or control patient in the PICU at CHOP
- Low acuity patients as determined by Optilink Guidelines
- High alarm patients (top 10-20%)
- Admission to the PICU
Exclusion Criteria Primary Subjects: None
Secondary Subjects: Patients who are medically ready for transfer out of ICU or discharge
home (status continuously tracked by charge nurse). Patients who are medically ready for
transfer out have an accepting service in place and a bed ready on the floor.