A subgroup analysis of the four pediatric studies did show significant decrease in hospital mortality (RR, 0.79; 95% CI, 0.63-0.98), but significant heterogeneity was observed. Without a control group in most studies, it is difficult to draw conclusions about causality. This is especially true for the overall hospital mortality rate, which Solomon et al. note has been falling since 2000. This trend may confound the results of studies that observed decreases in hospital mortality rate following RRT implementation. Indeed, Chen et al., in a 2016 study assessing the impact of RRT implementation across New South Wales, Australia, found that overall hospital mortality rates and cardiac arrest rates had decreased in the 2 years prior to RRT implementation. 31 There were no significant changes in these trends once an RRT had been implemented. However, there was a significant decrease in mortality among patients with low mortality risk. This decreased mortality rate was attributed to RRT prevention of cardiac arrests, suggesting that the low-risk population is where future RRT implementation may have the most impact. Successful implementation of an RRT requires adoption by both monitoring and response teams, whichmay be influenced by cost, team composition, and staff perception. The benefits from RRT implementation may become apparent only after the RRT has been in place for some time. Moriarty et al. saw significant findings beginning in the second year following response team implementation. 32 However, these changes coincided with the institution’s efforts to educate nursing staff as well as to increase positive perception of the RRT, suggesting that educational efforts, rather than time, drive lasting culture and process changes. Cultural barriers and traditional hierarchical models of patient monitoring and rapid response may prevent successful implementation of RRTs. For example, Moriarty et al. suggest that the monitoring team may hesitate to activate the response team in fear of the call being viewed “as an acknowledgment of inadequacy on their part.” Just as a culture of clear communication and teamwork can help to facilitate successful RRT implementation, one that discourages speaking up and instead supports a hierarchical structure can impede both perceptions and use of an RRT. The RRT is dependent on the monitoring team’s engagement, perception, and activation of the RRT. While all included studies detail criteria for activation of the RRT, the actual mechanism of the activation process is often left undefined, without clear descriptions of who participates, what the process involves, or whether activation is mandatory versus voluntary. One study found that changing the activation mechanism from a voluntary to a mandatory call based on physiologic criteria resulted in a statistically significant decrease in cardiopulmonary arrest rates. This suggests that voluntary activation may present a barrier to successful RRT use, while mandatory activation may act as a facilitator. Further research on this topic is needed.
Conclusions The PSPs reviewed in this chapter aim to reduce FTR by addressing two of its core components: failure to identify and failure to respond to hospital patients who are at risk for rapid clinical deterioration. Thisreview finds that implementation of continuous patient monitoring may decrease rescue events and hospital length of stay but not mortality, while IM shows a moderate but inconsistent effect on mortality. It remains unclear whether RRT reduces mortality or ICU transfer rates. Together, these findings suggest that both the afferent and efferent arms of the rapid response system decrease in-hospital adverse events but not overall mortality. Many studies were observational and had an increased risk for bias, indicating a need for more rigorous, high-quality studies. Findings in both PSPs suggest that an RRS is most successful when there is effective and efficient communication. The electronic monitoring system, bedside staff, and rapid response staff are all susceptible to communication breakdown, and all points along the RRS pathway warrant careful consideration when deciding to implement an RRS. This requires not only education and training but also technical care so as not to create alert fatigue, as well as a cultural shift to support rather than discourage speaking up. Finally, very few studies comment on RRT activation, which is an important bridge connecting the RRS’s identification of deterioration and the response to prevent harm. A better understanding of the mechanism and components of this process may elucidate further interventions for minimizing FTR. Alarm fatigue Alarm fatigue occurs when clinicians experience high exposure to medical device alarms, causing alarm desensitization and leading to missed alarms or delayed response. As the frequency of alarms used in healthcare rises, alarm fatigue has been increasingly recognized as an important patient safety issue. Although the problem of alarm fatigue has been well documented, alarm-related events are often underreported, and there is still limited research examining interventions to address the issue. This section reviews two system-level patient safety practices that aim to address alarm fatigue: safety culture and risk assessment. Addressing alarm fatigue through improving safety culture involves system-wide interventions, such as leadership ensuring that there are clear processes in place for safe alarm management and establishing practices to share information about alarm-related incidents and prevention strategies. The literature provides moderate evidence for reduction in total alarms and noise level following the implementation of features of safety culture. Surveys assessing nurses’ perceptions of alarm fatigue and behavior changes regarding alarm management showed mixed results; however, two studies reported perceived reduction in alarm fatigue. More high-quality studies are needed to test the effects of safety culture elements on process and outcome measures related to alarm fatigue.
Performing baseline alarm risk assessments is an important step in order to understand current needs and conditions contributing to alarm fatigue. Conducting an alarm risk assessment can include evaluating medical devices and computer systems, analyzing data from clinical event reporting systems,and assessing patient satisfaction and the physical environment. There is currently limited research studying the impact of conducting alarm risk assessments on reducing alarm fatigue. Studies have generally examined alarm risk assessments as a component of larger quality improvement (QI) projects or system-wide initiatives and they provide moderately strong evidence supporting the use of multidisciplinary teams to conduct these Healthcare continues to become increasingly computerized, and clinicians use an assortment of equipment and technology to monitor patient conditions. Most healthcare devices provide auditory or visual warnings intended to alert clinicians when a patient’s condition deviates from a predetermined normal range. Many device alarms emit different sounds, tones, and/or pitches depending on the level of severity (i.e., advisory vs. warning vs. crisis alarms) to help clinicians determine how to respond. System status or non-clinical alarms can also occur and are caused by mechanical or electrical problems, such as a device needing new batteries. Device alarms can be an important tool to assist in clinical decision making; however, alarms can become hazardous to patient safety if excessive alarm frequency coupled with high prevalence of false alarms leads to alarm fatigue. assessments. Background Alarm fatigue occurs when clinicians, especially nurses, become desensitized to safety alarms due to the sheer number of alarm signals, which in turn can lead to missed alarms or delayed response. Alarm desensitization is compounded by the fact that false or nonactionable alarms occur frequently. False alarms are those that occur in the absence of an intended valid event, and nonactionable alarms occur when an alarm system works as designed but signifies an event that is not clinically significant and/or requires no additional intervention. The high volume of these nuisance alarms is not only disruptive, but also creates a situation where staff doubt the reliability of alarms and as a result turn down the volume, ignore, or deactivate the alarms. This adversely affects patient safety because clinicians are not only ignoring the nuisance alarms, but also ignoring or missing many clinically significant and actionable alarms. Alarm fatigue is increasingly recognized as a critical safety issue, and alarm management has become a priority for improvement in hospitals. From 2005 to 2008, the U.S. Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) reporting system received 566 reports of patient deaths related to monitoring device alarms. 33
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