Halley Ruppel

Background: We established a Patient Safety Learning Lab (AHRQ R18HS029473) to examine the sociotechnical system that drives interprofessional communication in pediatric inpatient settings in the context of evolving communication technologies, and to co-create and evaluate solutions with clinician end users. Here, we describe the use of human-centered design and system engineering processes for the Problem Analysis phase of this project. Methods: We applied the “Empathize” and “Define” steps of the design thinking process to our Problem Analysis. The goal of the Empathize step is to generate a comprehensive understanding of a problem(s) as experienced by the end user. We conducted interviews and observations with interprofessional clinicians from pediatric inpatient units in a single children’s hospital. We used other operational and clinical data to triangulate findings (clinician secure messaging metadata, survey data, and policies/procedures). In the “Define” step, we iteratively developed user-centered problem statements. Results: Data synthesized for the problem analysis included: interviews with 28 clinicians, 32 hours of unit observations; metadata for 433,432 secure messages; 155 free-text clinician survey responses; and 40 communication-related policies/procedures. The Problem Analysis revealed communication challenges in the following domains for clinicians providing frontline care (i.e., bedside nurses, residents, frontline fellows): (1) efficiently locating and contacting other members of the care team; (2) communicating urgency level of information; and (3) managing high volume of minimally informative messages. Conclusions: Practical application of human-centered design and systems thinking contributed to a more holistic understanding of communication challenges, and their patient safety implications, from the perspective of multiple end-user groups.

Introduction: Prospective, real-world clinical studies of the association between skin color and pulse oximeter (SpO2) accuracy in children are needed to address the limitations of previous research. Such studies are essential for generating evidence for clinicians, regulators and industry. This is the protocol for a multisite study funded by the National Heart, Lung, and Blood Institute (R01HL171313; 1 January 2024–31 December 2028). Methods and analysis: In this pragmatic, observational study conducted in three large paediatric cardiac catheterisation centres in the USA, children undergoing cardiac catheterisation with directly measured arterial oxygen saturation will be prospectively enrolled. The outcome variable (SpO ₂ bias) is the difference between contemporaneous paired measurements of pulse oximetry (SpO ₂ ) and the standard reference comparator, arterial blood sample oxygen saturation (SaO ₂ ), obtained during the catheterisation procedure. The independent variable is an objective measure of skin colour obtained via spectrophotometry. Our primary analysis is a multivariable regression model testing the relationship between skin colour and SpO ₂ bias, after adjusting for covariates. We will also conduct a moderator analysis to identify factors that may affect the magnitude of the association. The target sample size is 584 participants. Ethics and dissemination: This study was approved by the University of Pennsylvania Institutional Review Board (#854895) under expedited review. Study risks are minimal. Parental permission, and child assent when applicable, are obtained prior to enrolment. In accordance with the NIH Public Access Policy, publications associated with the study will be made publicly available through PubMed Central. The analytic dataset will be contributed to a repository for future use. In collaboration with a children’s hospital-based research family advisory council, interpretation and dissemination of the results for lay, clinical and scientific audiences will be considered. Trial registration number: Although not a clinical trial, this observational study is registered on ClinicalTrials.gov (identifier: NCT06529575 ) for public awareness.

Nurse staffing decisions are often made without input from high-quality, reliable patient acuity measures, especially in medical-surgical settings. Staffing decisions not aligned with patient care needs can contribute to inadequate patient-to-nurse ratios and nurse burnout, potentially resulting in preventable patient harm and death. We conducted a proof-of-concept study to explore the feasibility of adapting an evidence-based patient acuity tool for use in the EHR. A retrospective cohort of pediatric medical-surgical inpatients was used to map electronic patient data variables. We developed an algorithm to calculate the score for one domain of the tool and validated it by comparing it with a score based on a manual chart review. Through multiple rounds of testing and refinement of the variables and algorithm, we achieved 100% concordance between scores generated by the algorithm and the manual chart review. Our proof-of-concept study demonstrates the feasibility and challenges of adapting an evidence-based patient acuity score for automation in the EHR. Further collaboration with data scientists is warranted to operationalize the tool in the EHR and achieve an automated acuity score that can improve staffing decisions, support nursing practice, and enhance team collaboration.

Continuous pulse oximetry (cSpO₂) monitoring use outside established guidelines is common in children hospitalized with bronchiolitis. We analyzed clinicians' real‐time rationale for continuous monitoring in stable children with bronchiolitis not requiring supplemental oxygen. Data for this study were collected as part a multicenter deimplementation trial for cSpO₂ in children hospitalized with bronchiolitis. We analyzed 371 clinician responses across 36 hospitals; 258 (70%) responses did not include a clinical reason for monitoring (“nonclinical”; e.g., respondent forgot to discontinue monitoring, did not know why the patient was monitored, or was following an order). The remaining 113 (30%) responses contained a clinical reason for monitoring (“clinical”; e.g., recently requiring oxygen, physical exam concerns, or concerns relating to patient condition or history). Strategies to reduce unnecessary monitoring should include changes in workflow to facilitate shared understanding of monitoring goals and timely discontinuation of monitoring.

Background: Scientific writing is a core component of academic hospital medicine, and yet finding time to engage in deeply focused writing is difficult in part due to the highly clinical, 24/7 nature of the specialty that can limit opportunities for writing‐focused collaboration and mentorship.Objective: Our objective was to develop and evaluate an academic writing retreat program.Methods: We drafted a set of key retreat features to guide implementation of a 3‐day, 2‐night retreat program held within a 2 h radius of our hospital. Agendas included writing blocks ranging from 45 to 90 min interspersed with breaks and opportunities for feedback, exercise, and preparing meals together. After each retreat, we distributed an evaluation with multiple choice and free text response options to characterize retreat helpfulness and later gathered data on the status of each paper and grant worked on.Results: We held 4 retreats between September 2022 and October 2023, engaging 18 faculty and fellows at a cost of $296 per attendee per retreat. In evaluations, nearly 80% reported that the retreat was extremely helpful, and comments praised the highly mentored environment, enriching community of colleagues, and release from commitments that get in the way of writing. Of the 24 papers attendees worked on, 12 have been accepted and 6 are under review. Of the 4 grant proposals, 2 are under review.Conclusions: We implemented a low‐cost, productive writing retreat program that attendees reported was helpful in supporting deep work and represented a meaningful step toward building a community centered around academic writing.

Background: High rates of medical device alarms in hospitals are a well-documented threat to patient safety. Little is known about organisational features that may be associated with nurses’ experience of alarm burden. Aims: To evaluate the association between nurse-reported alarm burden, appraisals of patient safety, quality of care and hospital characteristics. Methods: Secondary analysis of cross-sectional survey data from 3986 hospital-based direct-care registered nurses in 213 acute care hospitals in New York and Illinois, USA. We evaluated associations of alarm burden with appraisals of patient safety and quality of care and hospital characteristics (work environment, staffing adequacy, size, teaching status) using χ² tests. Results: The majority of respondents reported feeling overwhelmed by alarms (83%), delaying their response to alarms because they were unable to step away from another patient/task (76%), and experiencing situations where a patient needed urgent attention but no one responded to an alarm (55%). Nurses on medical-surgical units reported these experiences at higher rates than nurses working in intensive care units (p<0.001). Alarm burden items were significantly associated with poorer nurse-reported patient safety, quality of care, staffing and work environment. Findings were most pronounced for situations where a patient needed urgent attention but no one responded to the alarm, which was frequently/occasionally experienced by 72% of those who rated their hospital’s safety as poor versus 38% good, p<0.001; 80% who rated overall quality of care poor/fair versus 46% good/excellent, p<0.001 and 65% from poor work environments versus 42% from good work environments, p<0.001. Conclusion: Most nurses reported feeling overwhelmed by medical device alarms, and our findings suggest that alarm burden may be more pronounced in hospitals with unfavourable working conditions and suboptimal quality and safety. Because this was a cross-sectional study, further research is needed to explore causal relationships and the role of modifiable systems factors in reducing alarm burden.

Background: Continuous physiologic monitoring commonly is used in pediatric medical-surgical (med-surg) units and is associated with high alarm burden for clinicians. Characteristics of pediatric patients generating high rates of alarms on med-surg units are not known. Objective: To describe the demographic and clinical characteristics of pediatric med-surg patients associated with high rates of clinical alarms. Methods: We conducted a cross-sectional, single-site, retrospective study using existing clinical and alarm data from a children's hospital. Continuously monitored patients from med-surg units who had available alarm data were included. Negative binomial regression models were used to test the association between patient characteristics and the rate of clinical alarms per continuously monitored hour. Results: Our final sample consisted of 1,569 patients with a total of 38,501 continuously monitored hours generating 265,432 clinical alarms. Peripheral oxygen saturation (SpO₂) low alarms accounted for 57.5% of alarms. Patients with medical complexity averaged 11% fewer alarms per hour than those without medical complexity (P < 0.01). Patients older than 5 years had up to 30% fewer alarms per hour than those who were younger than 5 years (P < 0.01). Patients using supplemental oxygen averaged 39% more alarms per hour compared with patients who had no supplemental oxygen use (P < 0.01). Patients at high risk for deterioration averaged 19% more alarms per hour than patients who were not high risk (P = 0.01). Conclusion: SpO₂ alarms were the most common type of alarm in this study. The results highlight patient populations in pediatric medical-surgical units that may be high yield for interventions to reduce alarms. Most physiologic monitor alarms in pediatric medical-surgical (med-surg) units are not informative and likely could be safely eliminated to reduce noise and alarm fatigue.^1-3 However, identifying and sustaining successful alarm-reduction strategies is a challenge. Research shows that 25% of patients in pediatric med-surg units produce almost three-quarters of all alarms.⁴ These patients are a potential high-yield target for alarm-reduction strategies; however, we are not aware of studies describing characteristics of pediatric patients generating high rates of alarms. The patient populations seen on pediatric med-surg units are diverse. Children of all ages are cared for on these units, with diagnoses ranging from acute respiratory infections, to management of chronic conditions, and to psychiatric conditions. Not all patients on pediatric med-surg units have physiologic parameters continuously monitored,⁴ but among those who do, understanding patient characteristics associated with high rates of alarms may help clinicians, healthcare technology management (HTM) professionals, and others working on alarm management strategies to develop targeted interventions. We conducted an exploratory retrospective study to describe patient characteristics associated with high rates of alarms in pediatric med-surg units.

In Reply We thank Verma and Bailey for their interest in our study.¹ We agree that pulse oximeter accuracy is a uniquely pressing issue for children. Respiratory illness is a leading cause of pediatric hospitalization in the US,² and clinicians routinely make care decisions based on threshold pulse oximeter values in children.³ Given the use of pulse oximetry to drive care decisions in pediatrics, systematic bias in accuracy by race and skin color could threaten equity in care.