Implementation and Testing of an Experimental Near-Real-Time Patient Bedside Monitor Datastream Analysis and Alerting System in a Live Emergency Department

Academic emergency physicians and data scientists collaborated on a research program to reduce false alarms and to increase the utility of patient monitor systems for detecting significant cardiopulmonary events and clinical deterioration. An experimental hardware-software framework to study patient monitoring and alarm fatigue mitigation was implemented in 15 Emergency Department (ED) urgent care spaces of a regional medical center. Patients who triggered multi-parametric alerts [MPA] consisting of two or more red alarms (critical cardiac rhythm, heart rate [HR], blood pressure [BP], or oxygen saturation) within a 15-minute window were consented and matched into 1:1:1 study triads with patients who only triggered standard, single parameter (red) alarms [SPA] and those who remained in a non-alarm state [NA]. Study patients’ red alarms and triggering physiologic abnormalities (vital signs; cardiac rhythm and pulse oximetry photoplethysmography waveforms) were adjudicated and annotated for validity (chart review) and interpretability (clinician gestalt). Each subject was then followed for 3 months via in-network medical records. Subjects’ characteristics, alarms, clinical courses, and outcomes were descriptively and comparatively analyzed. The relationship between alarm-triggering waveform interpretability and alarm validity was analyzed with correlational statistics, along with the association between multi-parametric alerts and severity of patient state.Of 264 ED patients enrolled over 24 months, 183 matched into 61 triads matched for sex, age, Emergency Severity Index (ESI), and chief complaint; 27.1% of MPA, 10.9% of SPA, and 5.2% of NA subjects started care in ED critical care (X2(2)=6.47, p=0.04). MPA and SPA subjects triggered single parameter red alarms of all types, with a predominance of tachycardia and hypoxia alarms. Asystole and ventricular fibrillation/ventricular tachycardia (VFib/VTach) alarms were mostly adjudicated as non-valid, and hypoxia alarms were frequently of indeterminate validity, whereas HR and BP alarms were generally valid. Five (8.2%) MPA subjects and no SPA subjects (and no NA subjects) were transferred to ED critical care while monitored in the study area, X2(1)=9.41, p=0.002). Eleven (18.1%), five (8.2%), and two (3.3%) MPA, SPA, and NA subjects, respectively, were admitted from the ED to an intensive or intermediate care unit (p<0.001). Higher rates of symptomatic/unstable tachycardia (p=0.02) and post-ED escalation in care unit requirement (p=0.001) were recorded in MPA and SPA groups than in the NA group. Waveform interpretability scores in the 53 MPA subjects with complete data exhibited moderate positive correlation with the adjudicated validity of their red alarms, r(51)=0.528, p<0.001. The difference in composited 3-month tracer metrics between MPA and SPA groups did not attain statistical significance, although death (4.9%), Advanced Life Support (1.6%), and cardiac arrest (1.6%) were noted only in MPA patients.ED patient monitor datastreams were acquired and analyzed to explore novel biomedical engineering approaches to mitigate alarm fatigue. Safe experimentation in a live ED environment demonstrated the potential for near-real-time signals-level analysis of standard biomedical device outputs to differentiate true alarms from false alarms and to identify patients with a higher likelihood of poor outcomes.