Andrew S Kern-Goldberger, MD

Since 2012, when the Centers for Medicare & Medicaid Services (CMS) began linking financial penalties to hospitals with excessive readmissions for adult patients, researchers have questioned the extent to which pediatric readmissions can be used as a reliable quality measure. Compared with readmissions among adult patients, readmissions among pediatric patients are relatively uncommon. Furthermore, few (approximately 2%) qualify as potentially preventable, and pediatric readmission rates remain largely unchanged despite targeted attempts to prevent reutilization.^1,2 Nonetheless, state Medicaid agencies have continued to reduce reimbursement for hospitals based on available readmissions metrics, most commonly the Potentially Preventable Readmissions (PPR) algorithm.¹

In this issue of the Journal of Hospital Medicine, Auger et al³ performed a retrospective study to explore four existing metrics of pediatric hospital readmissions for their ability to identify preventable and unplanned readmissions. Investigators examined 30-day readmissions (n = 1,125) from 2014-2016 across multiple subspecialties, and classified readmissions by their preventability and unplanned status with use of a validated chart abstraction tool. Using the results of chart abstraction as the gold standard, investigators calculated the sensitivity and specificity, as well as estimated the positive and negative predictive values, of each readmissions metric. Auger and colleagues found that none of the four readmissions metrics could reliably assess preventability, and that only one metric reliably predicted unplanned hospital readmissions. Specifically, the commonly used PPR algorithm was estimated to have a positive predictive value of 13.0%-35.5% across a prevalence range of 10%-30%. This means that in a hospital where 10% of readmissions are truly preventable, the PPR will be wrong approximately 87% of the time. Tying payments to this metric is difficult to justify.

The authors highlighted the policy implications of the PPR falling short in its ability to identify preventable and unplanned pediatric readmissions. A good quality measure should be consistently reliable, and neither the PPR nor other measures studied meets this benchmark. Yet the findings lead to a broader conclusion: if most pediatric readmissions are not preventable, if there is no reliable way of measuring preventability, and if we have not demonstrated the ability to change patient trajectories away from reutilization, then perhaps the sun has set on using readmissions as a comprehensive quality measure for hospital-based care.

So how, then, should the hospital-to-home transition be evaluated? The paradigm of pediatric value of care is shifting to incorporate family-centered perspectives into consideration of quality measures.² There has to be a balance between healthcare costs and outcomes that affect families; measures should take into account issues such as patient and caregiver anxiety and time away from work.² Moreover, because social determinants of health and medical complexity strongly influence readmission rates,^4,5 focus should be placed on redirecting resources toward patients and families with significant medical, social, and financial needs as they transition home from the hospital. While measures of healthcare equity are currently lacking, the overall quality and equity of pediatric care transitions could be enhanced by looking beyond the narrow lens of readmission rates to incorporate actual needs assessments of families.

In summary, Auger and colleagues identified deficits in existing readmission metrics—but creating a solution that is meaningful to all stakeholders will be more complex than simply identifying a better metric. Family-centered quality metrics show promise in creating value in pediatric care within an equitable health system, but long-term evaluation of these metrics is necessary.

The authors have nothing to disclose.

Since 2012, when the Centers for Medicare & Medicaid Services (CMS) began linking financial penalties to hospitals with excessive readmissions for adult patients, researchers have questioned the extent to which pediatric readmissions can be used as a reliable quality measure. Compared with readmissions among adult patients, readmissions among pediatric patients are relatively uncommon. Furthermore, few (approximately 2%) qualify as potentially preventable, and pediatric readmission rates remain largely unchanged despite targeted attempts to prevent reutilization.^1,2 Nonetheless, state Medicaid agencies have continued to reduce reimbursement for hospitals based on available readmissions metrics, most commonly the Potentially Preventable Readmissions (PPR) algorithm.¹

In this issue of the Journal of Hospital Medicine, Auger et al³ performed a retrospective study to explore four existing metrics of pediatric hospital readmissions for their ability to identify preventable and unplanned readmissions. Investigators examined 30-day readmissions (n = 1,125) from 2014-2016 across multiple subspecialties, and classified readmissions by their preventability and unplanned status with use of a validated chart abstraction tool. Using the results of chart abstraction as the gold standard, investigators calculated the sensitivity and specificity, as well as estimated the positive and negative predictive values, of each readmissions metric. Auger and colleagues found that none of the four readmissions metrics could reliably assess preventability, and that only one metric reliably predicted unplanned hospital readmissions. Specifically, the commonly used PPR algorithm was estimated to have a positive predictive value of 13.0%-35.5% across a prevalence range of 10%-30%. This means that in a hospital where 10% of readmissions are truly preventable, the PPR will be wrong approximately 87% of the time. Tying payments to this metric is difficult to justify.

The authors highlighted the policy implications of the PPR falling short in its ability to identify preventable and unplanned pediatric readmissions. A good quality measure should be consistently reliable, and neither the PPR nor other measures studied meets this benchmark. Yet the findings lead to a broader conclusion: if most pediatric readmissions are not preventable, if there is no reliable way of measuring preventability, and if we have not demonstrated the ability to change patient trajectories away from reutilization, then perhaps the sun has set on using readmissions as a comprehensive quality measure for hospital-based care.

So how, then, should the hospital-to-home transition be evaluated? The paradigm of pediatric value of care is shifting to incorporate family-centered perspectives into consideration of quality measures.² There has to be a balance between healthcare costs and outcomes that affect families; measures should take into account issues such as patient and caregiver anxiety and time away from work.² Moreover, because social determinants of health and medical complexity strongly influence readmission rates,^4,5 focus should be placed on redirecting resources toward patients and families with significant medical, social, and financial needs as they transition home from the hospital. While measures of healthcare equity are currently lacking, the overall quality and equity of pediatric care transitions could be enhanced by looking beyond the narrow lens of readmission rates to incorporate actual needs assessments of families.

In summary, Auger and colleagues identified deficits in existing readmission metrics—but creating a solution that is meaningful to all stakeholders will be more complex than simply identifying a better metric. Family-centered quality metrics show promise in creating value in pediatric care within an equitable health system, but long-term evaluation of these metrics is necessary.

The authors have nothing to disclose.

Since 2012, when the Centers for Medicare & Medicaid Services (CMS) began linking financial penalties to hospitals with excessive readmissions for adult patients, researchers have questioned the extent to which pediatric readmissions can be used as a reliable quality measure. Compared with readmissions among adult patients, readmissions among pediatric patients are relatively uncommon. Furthermore, few (approximately 2%) qualify as potentially preventable, and pediatric readmission rates remain largely unchanged despite targeted attempts to prevent reutilization.^1,2 Nonetheless, state Medicaid agencies have continued to reduce reimbursement for hospitals based on available readmissions metrics, most commonly the Potentially Preventable Readmissions (PPR) algorithm.¹

In this issue of the Journal of Hospital Medicine, Auger et al³ performed a retrospective study to explore four existing metrics of pediatric hospital readmissions for their ability to identify preventable and unplanned readmissions. Investigators examined 30-day readmissions (n = 1,125) from 2014-2016 across multiple subspecialties, and classified readmissions by their preventability and unplanned status with use of a validated chart abstraction tool. Using the results of chart abstraction as the gold standard, investigators calculated the sensitivity and specificity, as well as estimated the positive and negative predictive values, of each readmissions metric. Auger and colleagues found that none of the four readmissions metrics could reliably assess preventability, and that only one metric reliably predicted unplanned hospital readmissions. Specifically, the commonly used PPR algorithm was estimated to have a positive predictive value of 13.0%-35.5% across a prevalence range of 10%-30%. This means that in a hospital where 10% of readmissions are truly preventable, the PPR will be wrong approximately 87% of the time. Tying payments to this metric is difficult to justify.

The authors highlighted the policy implications of the PPR falling short in its ability to identify preventable and unplanned pediatric readmissions. A good quality measure should be consistently reliable, and neither the PPR nor other measures studied meets this benchmark. Yet the findings lead to a broader conclusion: if most pediatric readmissions are not preventable, if there is no reliable way of measuring preventability, and if we have not demonstrated the ability to change patient trajectories away from reutilization, then perhaps the sun has set on using readmissions as a comprehensive quality measure for hospital-based care.

So how, then, should the hospital-to-home transition be evaluated? The paradigm of pediatric value of care is shifting to incorporate family-centered perspectives into consideration of quality measures.² There has to be a balance between healthcare costs and outcomes that affect families; measures should take into account issues such as patient and caregiver anxiety and time away from work.² Moreover, because social determinants of health and medical complexity strongly influence readmission rates,^4,5 focus should be placed on redirecting resources toward patients and families with significant medical, social, and financial needs as they transition home from the hospital. While measures of healthcare equity are currently lacking, the overall quality and equity of pediatric care transitions could be enhanced by looking beyond the narrow lens of readmission rates to incorporate actual needs assessments of families.

In summary, Auger and colleagues identified deficits in existing readmission metrics—but creating a solution that is meaningful to all stakeholders will be more complex than simply identifying a better metric. Family-centered quality metrics show promise in creating value in pediatric care within an equitable health system, but long-term evaluation of these metrics is necessary.

The authors have nothing to disclose.

Despite concerted national efforts to decrease pediatric readmissions, recent data suggest that preventable and all-cause readmission rates of hospitalized children remain unchanged.¹ Because some readmissions may be caused by inadequate postdischarge follow-up, nurse (RN) home visits offer the prospect of addressing unresolved clinical issues after discharge and ameliorating patient and family concerns that may otherwise prompt re-presentation for acute care. Yet a recent trial of this approach, the Hospital to Home Outcomes (H2O) trial,² found the opposite to be true: participants receiving home nurse visits had higher reutilization rates than did participants in the control group. This raises interesting questions: Is it time to revisit postdischarge outreach as an intervention to reduce pediatric readmissions—and even pediatric readmissions altogether as an outcome metric?

In this issue of the Journal of Hospital Medicine, Riddle et al³ explored the perspectives of key stakeholders to understand the factors driving increased reutilization after postdischarge home visits in the H2O trial and obtained feedback for improving potential interventions. The investigators used a qualitative approach that consisted of telephone interviews with 33 parents who were enrolled in the H2O trial and in-person focus groups with 10 home care RNs involved in the trial, 12 hospital medicine physicians, and 7 primary care physicians (PCPs). Inductive thematic analysis was used to analyze responses to open-ended questions through a rigorous, iterative and multidisciplinary process. Key themes elicited from stakeholders included questions about the clinical appropriateness of reutilization episodes; the influence of insufficiently contextualized “red flag,” or warning sign, instructions given to parents in facilitating reutilization; the potential for hospital-employed home care nurses to inadvertently promote emergency department rather than PCP follow-up; and escalation of care exceeding that expected in a PCP office. Stakeholders suggested the intervention could be improved by enhancing postdischarge communication between home care RNs, hospital medicine physicians, and PCPs; tailoring home visits to specific clinical, patient, and family scenarios; and more clearly framing “red flags.”

We welcome the work of Riddle and colleagues in exposing the elements of home visits that may have led to increased utilization, and their proposed next steps to improve the intervention—enhancing contact with PCP offices and focusing interventions on specific populations—unquestionably have merit. We agree that this may be particularly true in children with medical complexity (a population that was excluded from this study), who have unique discharge needs and account for over half of pediatric readmissions.⁴ However, we suggest that the instinct to refine the design of the study intervention should be weighed against alternative possibilities: that postdischarge interventions are simply not effective in decreasing reutilization or, at the very least, that the findings of the H2O trial should not lead us to invest the resources required to further discern the efficacy of postdischarge interventions.

This counter-intuitive possibility is only compounded by the fact that reutilization rates were not improved in the study group’s H2O II trial, a follow-up study that focused on postdischarge nurse telephone calls as the intervention of interest⁵; and indeed, the results of these two, well-designed negative trials have been previously cited to propose postdischarge nurse contact as a potential target of deimplementation efforts.⁶ In the pediatric population, in which caregivers rather than patients themselves are generally responsible for seeking out care, postdischarge outreach may inevitably escalate concerning findings that will result in reutilization. Instead, perhaps the H2O study findings should prompt a broader exploration for alternative solutions to pediatric readmission reduction. One such solution could build on the finding by Riddle et al that stakeholders perceive ambiguity in whether discharging physicians, or rather PCPs, have ownership of clinical issues after discharge. Rather than asking visiting RNs to triangulate between inpatient and outpatient physicians, developing systems to directly integrate PCPs in the hospital discharge process for select patients—for instance, through leveraging the rapid expansion of telemedicine services during the COVID-19 crisis—may promote shared understanding of a patient’s illness trajectory and follow-up needs.

Importantly, the authors also noted that despite the findings of increased reutilization, parents who received home visits expressed their wishes to receive home visits in the future. While not a central finding of the study, this validates a hypothesis expressed in prior work by the H2O study group: “Hospital quality readmission metrics may not be well aligned with family desires for improved postdischarge transitions.”⁵ Given that efforts to reduce pediatric readmission have been largely unsuccessful and that readmission events are relatively uncommon in the general pediatric population,⁴ the parental wishes resonate with existing calls in the literature to consider looking beyond readmissions reduction in isolation as a quality metric. In contrast to the increasing presence of hospital reimbursement penalties among state Medicaid agencies for readmissions, a shift in focus toward outcome measures that are patient- and family-centered is imperative.^1,7 If home visits are not ultimately a solution to pediatric reutilization reduction, they may nonetheless still enable families to effectively manage the concerns that families endorse following discharge, including medication safety and social hardships.⁸

In summary, Riddle et al not only provided important context for the unexpected outcome of a well-designed randomized clinical trial but also provided a rich source of qualitative data that furthers our understanding of a child’s discharge home from the hospital through the perspective of multiple stakeholders. While the authors offer well-reasoned next steps in narrowing the intervention population of interest and enhancing connections of families with PCP care, it may be time to broadly revisit postdischarge interventions and outcomes to identify new approaches and redefine quality measures for hospital-to-home transitions of children and their families.

Despite concerted national efforts to decrease pediatric readmissions, recent data suggest that preventable and all-cause readmission rates of hospitalized children remain unchanged.¹ Because some readmissions may be caused by inadequate postdischarge follow-up, nurse (RN) home visits offer the prospect of addressing unresolved clinical issues after discharge and ameliorating patient and family concerns that may otherwise prompt re-presentation for acute care. Yet a recent trial of this approach, the Hospital to Home Outcomes (H2O) trial,² found the opposite to be true: participants receiving home nurse visits had higher reutilization rates than did participants in the control group. This raises interesting questions: Is it time to revisit postdischarge outreach as an intervention to reduce pediatric readmissions—and even pediatric readmissions altogether as an outcome metric?

In this issue of the Journal of Hospital Medicine, Riddle et al³ explored the perspectives of key stakeholders to understand the factors driving increased reutilization after postdischarge home visits in the H2O trial and obtained feedback for improving potential interventions. The investigators used a qualitative approach that consisted of telephone interviews with 33 parents who were enrolled in the H2O trial and in-person focus groups with 10 home care RNs involved in the trial, 12 hospital medicine physicians, and 7 primary care physicians (PCPs). Inductive thematic analysis was used to analyze responses to open-ended questions through a rigorous, iterative and multidisciplinary process. Key themes elicited from stakeholders included questions about the clinical appropriateness of reutilization episodes; the influence of insufficiently contextualized “red flag,” or warning sign, instructions given to parents in facilitating reutilization; the potential for hospital-employed home care nurses to inadvertently promote emergency department rather than PCP follow-up; and escalation of care exceeding that expected in a PCP office. Stakeholders suggested the intervention could be improved by enhancing postdischarge communication between home care RNs, hospital medicine physicians, and PCPs; tailoring home visits to specific clinical, patient, and family scenarios; and more clearly framing “red flags.”

We welcome the work of Riddle and colleagues in exposing the elements of home visits that may have led to increased utilization, and their proposed next steps to improve the intervention—enhancing contact with PCP offices and focusing interventions on specific populations—unquestionably have merit. We agree that this may be particularly true in children with medical complexity (a population that was excluded from this study), who have unique discharge needs and account for over half of pediatric readmissions.⁴ However, we suggest that the instinct to refine the design of the study intervention should be weighed against alternative possibilities: that postdischarge interventions are simply not effective in decreasing reutilization or, at the very least, that the findings of the H2O trial should not lead us to invest the resources required to further discern the efficacy of postdischarge interventions.

This counter-intuitive possibility is only compounded by the fact that reutilization rates were not improved in the study group’s H2O II trial, a follow-up study that focused on postdischarge nurse telephone calls as the intervention of interest⁵; and indeed, the results of these two, well-designed negative trials have been previously cited to propose postdischarge nurse contact as a potential target of deimplementation efforts.⁶ In the pediatric population, in which caregivers rather than patients themselves are generally responsible for seeking out care, postdischarge outreach may inevitably escalate concerning findings that will result in reutilization. Instead, perhaps the H2O study findings should prompt a broader exploration for alternative solutions to pediatric readmission reduction. One such solution could build on the finding by Riddle et al that stakeholders perceive ambiguity in whether discharging physicians, or rather PCPs, have ownership of clinical issues after discharge. Rather than asking visiting RNs to triangulate between inpatient and outpatient physicians, developing systems to directly integrate PCPs in the hospital discharge process for select patients—for instance, through leveraging the rapid expansion of telemedicine services during the COVID-19 crisis—may promote shared understanding of a patient’s illness trajectory and follow-up needs.

Importantly, the authors also noted that despite the findings of increased reutilization, parents who received home visits expressed their wishes to receive home visits in the future. While not a central finding of the study, this validates a hypothesis expressed in prior work by the H2O study group: “Hospital quality readmission metrics may not be well aligned with family desires for improved postdischarge transitions.”⁵ Given that efforts to reduce pediatric readmission have been largely unsuccessful and that readmission events are relatively uncommon in the general pediatric population,⁴ the parental wishes resonate with existing calls in the literature to consider looking beyond readmissions reduction in isolation as a quality metric. In contrast to the increasing presence of hospital reimbursement penalties among state Medicaid agencies for readmissions, a shift in focus toward outcome measures that are patient- and family-centered is imperative.^1,7 If home visits are not ultimately a solution to pediatric reutilization reduction, they may nonetheless still enable families to effectively manage the concerns that families endorse following discharge, including medication safety and social hardships.⁸

In summary, Riddle et al not only provided important context for the unexpected outcome of a well-designed randomized clinical trial but also provided a rich source of qualitative data that furthers our understanding of a child’s discharge home from the hospital through the perspective of multiple stakeholders. While the authors offer well-reasoned next steps in narrowing the intervention population of interest and enhancing connections of families with PCP care, it may be time to broadly revisit postdischarge interventions and outcomes to identify new approaches and redefine quality measures for hospital-to-home transitions of children and their families.

Despite concerted national efforts to decrease pediatric readmissions, recent data suggest that preventable and all-cause readmission rates of hospitalized children remain unchanged.¹ Because some readmissions may be caused by inadequate postdischarge follow-up, nurse (RN) home visits offer the prospect of addressing unresolved clinical issues after discharge and ameliorating patient and family concerns that may otherwise prompt re-presentation for acute care. Yet a recent trial of this approach, the Hospital to Home Outcomes (H2O) trial,² found the opposite to be true: participants receiving home nurse visits had higher reutilization rates than did participants in the control group. This raises interesting questions: Is it time to revisit postdischarge outreach as an intervention to reduce pediatric readmissions—and even pediatric readmissions altogether as an outcome metric?

In this issue of the Journal of Hospital Medicine, Riddle et al³ explored the perspectives of key stakeholders to understand the factors driving increased reutilization after postdischarge home visits in the H2O trial and obtained feedback for improving potential interventions. The investigators used a qualitative approach that consisted of telephone interviews with 33 parents who were enrolled in the H2O trial and in-person focus groups with 10 home care RNs involved in the trial, 12 hospital medicine physicians, and 7 primary care physicians (PCPs). Inductive thematic analysis was used to analyze responses to open-ended questions through a rigorous, iterative and multidisciplinary process. Key themes elicited from stakeholders included questions about the clinical appropriateness of reutilization episodes; the influence of insufficiently contextualized “red flag,” or warning sign, instructions given to parents in facilitating reutilization; the potential for hospital-employed home care nurses to inadvertently promote emergency department rather than PCP follow-up; and escalation of care exceeding that expected in a PCP office. Stakeholders suggested the intervention could be improved by enhancing postdischarge communication between home care RNs, hospital medicine physicians, and PCPs; tailoring home visits to specific clinical, patient, and family scenarios; and more clearly framing “red flags.”

We welcome the work of Riddle and colleagues in exposing the elements of home visits that may have led to increased utilization, and their proposed next steps to improve the intervention—enhancing contact with PCP offices and focusing interventions on specific populations—unquestionably have merit. We agree that this may be particularly true in children with medical complexity (a population that was excluded from this study), who have unique discharge needs and account for over half of pediatric readmissions.⁴ However, we suggest that the instinct to refine the design of the study intervention should be weighed against alternative possibilities: that postdischarge interventions are simply not effective in decreasing reutilization or, at the very least, that the findings of the H2O trial should not lead us to invest the resources required to further discern the efficacy of postdischarge interventions.

This counter-intuitive possibility is only compounded by the fact that reutilization rates were not improved in the study group’s H2O II trial, a follow-up study that focused on postdischarge nurse telephone calls as the intervention of interest⁵; and indeed, the results of these two, well-designed negative trials have been previously cited to propose postdischarge nurse contact as a potential target of deimplementation efforts.⁶ In the pediatric population, in which caregivers rather than patients themselves are generally responsible for seeking out care, postdischarge outreach may inevitably escalate concerning findings that will result in reutilization. Instead, perhaps the H2O study findings should prompt a broader exploration for alternative solutions to pediatric readmission reduction. One such solution could build on the finding by Riddle et al that stakeholders perceive ambiguity in whether discharging physicians, or rather PCPs, have ownership of clinical issues after discharge. Rather than asking visiting RNs to triangulate between inpatient and outpatient physicians, developing systems to directly integrate PCPs in the hospital discharge process for select patients—for instance, through leveraging the rapid expansion of telemedicine services during the COVID-19 crisis—may promote shared understanding of a patient’s illness trajectory and follow-up needs.

Importantly, the authors also noted that despite the findings of increased reutilization, parents who received home visits expressed their wishes to receive home visits in the future. While not a central finding of the study, this validates a hypothesis expressed in prior work by the H2O study group: “Hospital quality readmission metrics may not be well aligned with family desires for improved postdischarge transitions.”⁵ Given that efforts to reduce pediatric readmission have been largely unsuccessful and that readmission events are relatively uncommon in the general pediatric population,⁴ the parental wishes resonate with existing calls in the literature to consider looking beyond readmissions reduction in isolation as a quality metric. In contrast to the increasing presence of hospital reimbursement penalties among state Medicaid agencies for readmissions, a shift in focus toward outcome measures that are patient- and family-centered is imperative.^1,7 If home visits are not ultimately a solution to pediatric reutilization reduction, they may nonetheless still enable families to effectively manage the concerns that families endorse following discharge, including medication safety and social hardships.⁸

In summary, Riddle et al not only provided important context for the unexpected outcome of a well-designed randomized clinical trial but also provided a rich source of qualitative data that furthers our understanding of a child’s discharge home from the hospital through the perspective of multiple stakeholders. While the authors offer well-reasoned next steps in narrowing the intervention population of interest and enhancing connections of families with PCP care, it may be time to broadly revisit postdischarge interventions and outcomes to identify new approaches and redefine quality measures for hospital-to-home transitions of children and their families.

In the past five years, it has become increasingly apparent that hospital physiologic monitoring systems are not functioning optimally for children. On pediatric wards, 26%-48% of children are continuously monitored, and these children generate between 42 and 155 alarms per day.¹ Just 1% or fewer are considered actionable or informative, slowing nurses’ response times and placing patients at risk of delayed recognition of life-threatening events.^2,3 While some factors associated with alarm response times have been elucidated,³ in order to design safe and effective monitoring systems, further work is needed to understand the complex decision-making process that nurses face when encountering alarms outside a patient’s room. It is in this area that Schondelmeyer and colleagues strive to enhance our understanding in this issue of the Journal of Hospital Medicine.⁴

Schondelmeyer et al. conducted a single-center, observational study using mixed methods in a general pediatric unit. Trained observers shadowed nine nurses one to four times each, during which nurses were asked to “think aloud” as they managed physiologic monitor alarms, rationalizing their decisions about how and why they might respond for the observer to document. Observers accumulated 61 patient-hours of observation before investigators halted data collection because new insights about alarm responses were no longer emerging from the data (thematic saturation).

Nurses thought aloud about 207 alarms during the study, which the investigators estimated comprised about one third of the alarms that occurred during observation periods. Most of the 207 occurred while the nurse was already in the patient’s room, where a response decision is uncomplicated. More interesting were the 45 alarms heard while outside the patient’s room, where nurses face the complex decision of whether to interrupt their current tasks and respond or delay their response and assume the associated risk of nonresponse to a potentially deteriorating patient. Of the 45 alarms, nurses went into the room to evaluate the patient 15 times and, after doing so, reported that five of the 15 warranted in-person responses to address technical issues with the monitor, clinical issues, or patients’ comfort. Reassuring clinical contexts—such as presence of the medical team or family in the room and recent patient assessments—were the reasons most commonly provided to explain alarm nonresponse.

This study has two key limitations. First, the authors designed the study to observe nurses’ responses until thematic saturation was achieved. However, the small sample size (nine nurses, 45 out-of-room alarms) could raise questions about whether sufficient data were captured to make broadly generalizable conclusions, given the diverse range of patients, families, and clinical scenarios nurses encounter on an inpatient unit. Second, by instructing nurse participants to verbalize their rationale for response or nonresponse, investigators essentially asked nurses to override the “Type 1”, heuristic-based reasoning⁵ that research suggests regulates nursing responses to alarms when adapting to circumstances requiring high cognitive demand or a heavy workload.³ While innovative, it is possible that this approach prevented the investigators from fully achieving their stated objective of describing how bedside nurses think about and act upon alarms.

Nonetheless, the findings by Schondelmeyer and colleagues extend our emerging understanding of why alarm responses are disconcertingly slow. Nursing staff’s dismissal of monitor alarms that are discordant with a reassuring patient evaluation underscores the imperative to reduce nuisance alarms. Furthermore, the explicit statements justifying alarm nonresponse because of the presence of family members build upon prior findings of longer response times when family members are at the bedside³ and invite a provocative question: how would family members feel if they knew that they were being entrusted as a foundational component of safety monitoring in the hospital? In their recently published study conducted at the same hospital,⁶ Schondelmeyer’s team elicited perceptions that families are deeply concerned about staff nonresponse to alarms—as one nurse stated, parents “wonder what’s going on when no one comes in.” While there is a valuable role for integrating families into efforts to overcome threats to patient safety, as has been achieved with family error reporting⁷ and communication on family-centered rounds,⁸ this must occur in a structured, explicit, and deliberate manner, with families engaged as key stakeholders.

In summary, while Schondelmeyer and colleagues may not have exposed the depth of implicit thinking that governs nurses’ responses to alarms, they have highlighted the high-stakes decisions that nurses confront on a daily basis in an environment with exceedingly high alarm rates and low alarm actionability. The authors cite staff education among potential solutions to improve the safety of continuous monitoring, but such an intervention cannot be effective in a system that places impossible burdens on nurses. An openly family centered and multidisciplinary approach to reengineering the system for monitoring hospitalized children is needed to enable nurses to respond quickly and accurately to patients at risk of clinical deterioration.

Disclosures

The authors report no conflicts of interest.

In the past five years, it has become increasingly apparent that hospital physiologic monitoring systems are not functioning optimally for children. On pediatric wards, 26%-48% of children are continuously monitored, and these children generate between 42 and 155 alarms per day.¹ Just 1% or fewer are considered actionable or informative, slowing nurses’ response times and placing patients at risk of delayed recognition of life-threatening events.^2,3 While some factors associated with alarm response times have been elucidated,³ in order to design safe and effective monitoring systems, further work is needed to understand the complex decision-making process that nurses face when encountering alarms outside a patient’s room. It is in this area that Schondelmeyer and colleagues strive to enhance our understanding in this issue of the Journal of Hospital Medicine.⁴

Schondelmeyer et al. conducted a single-center, observational study using mixed methods in a general pediatric unit. Trained observers shadowed nine nurses one to four times each, during which nurses were asked to “think aloud” as they managed physiologic monitor alarms, rationalizing their decisions about how and why they might respond for the observer to document. Observers accumulated 61 patient-hours of observation before investigators halted data collection because new insights about alarm responses were no longer emerging from the data (thematic saturation).

Nurses thought aloud about 207 alarms during the study, which the investigators estimated comprised about one third of the alarms that occurred during observation periods. Most of the 207 occurred while the nurse was already in the patient’s room, where a response decision is uncomplicated. More interesting were the 45 alarms heard while outside the patient’s room, where nurses face the complex decision of whether to interrupt their current tasks and respond or delay their response and assume the associated risk of nonresponse to a potentially deteriorating patient. Of the 45 alarms, nurses went into the room to evaluate the patient 15 times and, after doing so, reported that five of the 15 warranted in-person responses to address technical issues with the monitor, clinical issues, or patients’ comfort. Reassuring clinical contexts—such as presence of the medical team or family in the room and recent patient assessments—were the reasons most commonly provided to explain alarm nonresponse.

This study has two key limitations. First, the authors designed the study to observe nurses’ responses until thematic saturation was achieved. However, the small sample size (nine nurses, 45 out-of-room alarms) could raise questions about whether sufficient data were captured to make broadly generalizable conclusions, given the diverse range of patients, families, and clinical scenarios nurses encounter on an inpatient unit. Second, by instructing nurse participants to verbalize their rationale for response or nonresponse, investigators essentially asked nurses to override the “Type 1”, heuristic-based reasoning⁵ that research suggests regulates nursing responses to alarms when adapting to circumstances requiring high cognitive demand or a heavy workload.³ While innovative, it is possible that this approach prevented the investigators from fully achieving their stated objective of describing how bedside nurses think about and act upon alarms.

Nonetheless, the findings by Schondelmeyer and colleagues extend our emerging understanding of why alarm responses are disconcertingly slow. Nursing staff’s dismissal of monitor alarms that are discordant with a reassuring patient evaluation underscores the imperative to reduce nuisance alarms. Furthermore, the explicit statements justifying alarm nonresponse because of the presence of family members build upon prior findings of longer response times when family members are at the bedside³ and invite a provocative question: how would family members feel if they knew that they were being entrusted as a foundational component of safety monitoring in the hospital? In their recently published study conducted at the same hospital,⁶ Schondelmeyer’s team elicited perceptions that families are deeply concerned about staff nonresponse to alarms—as one nurse stated, parents “wonder what’s going on when no one comes in.” While there is a valuable role for integrating families into efforts to overcome threats to patient safety, as has been achieved with family error reporting⁷ and communication on family-centered rounds,⁸ this must occur in a structured, explicit, and deliberate manner, with families engaged as key stakeholders.

In summary, while Schondelmeyer and colleagues may not have exposed the depth of implicit thinking that governs nurses’ responses to alarms, they have highlighted the high-stakes decisions that nurses confront on a daily basis in an environment with exceedingly high alarm rates and low alarm actionability. The authors cite staff education among potential solutions to improve the safety of continuous monitoring, but such an intervention cannot be effective in a system that places impossible burdens on nurses. An openly family centered and multidisciplinary approach to reengineering the system for monitoring hospitalized children is needed to enable nurses to respond quickly and accurately to patients at risk of clinical deterioration.

Disclosures

The authors report no conflicts of interest.

In the past five years, it has become increasingly apparent that hospital physiologic monitoring systems are not functioning optimally for children. On pediatric wards, 26%-48% of children are continuously monitored, and these children generate between 42 and 155 alarms per day.¹ Just 1% or fewer are considered actionable or informative, slowing nurses’ response times and placing patients at risk of delayed recognition of life-threatening events.^2,3 While some factors associated with alarm response times have been elucidated,³ in order to design safe and effective monitoring systems, further work is needed to understand the complex decision-making process that nurses face when encountering alarms outside a patient’s room. It is in this area that Schondelmeyer and colleagues strive to enhance our understanding in this issue of the Journal of Hospital Medicine.⁴

Schondelmeyer et al. conducted a single-center, observational study using mixed methods in a general pediatric unit. Trained observers shadowed nine nurses one to four times each, during which nurses were asked to “think aloud” as they managed physiologic monitor alarms, rationalizing their decisions about how and why they might respond for the observer to document. Observers accumulated 61 patient-hours of observation before investigators halted data collection because new insights about alarm responses were no longer emerging from the data (thematic saturation).

Nurses thought aloud about 207 alarms during the study, which the investigators estimated comprised about one third of the alarms that occurred during observation periods. Most of the 207 occurred while the nurse was already in the patient’s room, where a response decision is uncomplicated. More interesting were the 45 alarms heard while outside the patient’s room, where nurses face the complex decision of whether to interrupt their current tasks and respond or delay their response and assume the associated risk of nonresponse to a potentially deteriorating patient. Of the 45 alarms, nurses went into the room to evaluate the patient 15 times and, after doing so, reported that five of the 15 warranted in-person responses to address technical issues with the monitor, clinical issues, or patients’ comfort. Reassuring clinical contexts—such as presence of the medical team or family in the room and recent patient assessments—were the reasons most commonly provided to explain alarm nonresponse.

This study has two key limitations. First, the authors designed the study to observe nurses’ responses until thematic saturation was achieved. However, the small sample size (nine nurses, 45 out-of-room alarms) could raise questions about whether sufficient data were captured to make broadly generalizable conclusions, given the diverse range of patients, families, and clinical scenarios nurses encounter on an inpatient unit. Second, by instructing nurse participants to verbalize their rationale for response or nonresponse, investigators essentially asked nurses to override the “Type 1”, heuristic-based reasoning⁵ that research suggests regulates nursing responses to alarms when adapting to circumstances requiring high cognitive demand or a heavy workload.³ While innovative, it is possible that this approach prevented the investigators from fully achieving their stated objective of describing how bedside nurses think about and act upon alarms.

Nonetheless, the findings by Schondelmeyer and colleagues extend our emerging understanding of why alarm responses are disconcertingly slow. Nursing staff’s dismissal of monitor alarms that are discordant with a reassuring patient evaluation underscores the imperative to reduce nuisance alarms. Furthermore, the explicit statements justifying alarm nonresponse because of the presence of family members build upon prior findings of longer response times when family members are at the bedside³ and invite a provocative question: how would family members feel if they knew that they were being entrusted as a foundational component of safety monitoring in the hospital? In their recently published study conducted at the same hospital,⁶ Schondelmeyer’s team elicited perceptions that families are deeply concerned about staff nonresponse to alarms—as one nurse stated, parents “wonder what’s going on when no one comes in.” While there is a valuable role for integrating families into efforts to overcome threats to patient safety, as has been achieved with family error reporting⁷ and communication on family-centered rounds,⁸ this must occur in a structured, explicit, and deliberate manner, with families engaged as key stakeholders.

In summary, while Schondelmeyer and colleagues may not have exposed the depth of implicit thinking that governs nurses’ responses to alarms, they have highlighted the high-stakes decisions that nurses confront on a daily basis in an environment with exceedingly high alarm rates and low alarm actionability. The authors cite staff education among potential solutions to improve the safety of continuous monitoring, but such an intervention cannot be effective in a system that places impossible burdens on nurses. An openly family centered and multidisciplinary approach to reengineering the system for monitoring hospitalized children is needed to enable nurses to respond quickly and accurately to patients at risk of clinical deterioration.

Disclosures

The authors report no conflicts of interest.