BackgroundRespiratory alarm monitoring and rapid response team alerts on hospital general floors are based on detection of simple numeric threshold breaches. Although some uncontrolled observation trials in select patient populations have been encouraging, randomized controlled trials suggest that this simplistic approach may not reduce the unexpected death rate in this complex environment. The purpose of this review is to examine the history and scientific basis for threshold alarms and to compare thresholds with the actual pathophysiologic patterns of evolving death which must be timely detected.MethodsThe Pubmed database was searched for articles relating to methods for triggering rapid response teams and respiratory alarms and these were contrasted with the fundamental timed pathophysiologic patterns of death which evolve due to sepsis, congestive heart failure, pulmonary embolism, hypoventilation, narcotic overdose, and sleep apnea.ResultsIn contrast to the simplicity of the numeric threshold breach method of generating alerts, the actual patterns of evolving death are complex and do not share common features until near death. On hospital general floors, unexpected clinical instability leading to death often progresses along three distinct patterns which can be designated as Types I, II and III. Type I is a pattern comprised of hyperventilation compensated respiratory failure typical of congestive heart failure and sepsis. Here, early hyperventilation and respiratory alkalosis can conceal the onset of instability. Type II is the pattern of classic CO2 narcosis. Type III occurs only during sleep and is a pattern of ventilation and SPO2 cycling caused by instability of ventilation and/or upper airway control followed by precipitous and fatal oxygen desaturation if arousal failure is induced by narcotics and/or sedation.ConclusionThe traditional threshold breach method of detecting instability on hospital wards was not scientifically derived; explaining the failure of threshold based monitoring and rapid response team activation in randomized trials. Furthermore, the thresholds themselves are arbitrary and capricious. There are three common fundamental pathophysiologic patterns of unexpected hospital death. These patterns are too complex for early detection by any unifying numeric threshold. New methods and technologies which detect and identify the actual patterns of evolving death should be investigated.

Approximately forty million surgeries take place annually in the United States, many of them requiring overnight or lengthier post operative stays in the over five thousand hospitals that comprise our acute healthcare system. Leading up to this Century, it was common for most hospitalized patients and their families to believe that being surrounded by well-trained nurses and physicians assured their safety. That bubble burst with the Institute of Medicine’s 1999 report: To Err Is Human, followed closely by its 2001 report: Crossing the Quality Chasm. This review article discusses unexpected, potentially lethal respiratory complications known for being difficult to detect early, especially in postoperative patients recovering on hospital general care floors (GCF). We have designed our physiologic explanations and simplified cognitive framework to give our front line clinical nurses a thorough, easy-to-recall understanding of just how these events evolve, and how to detect them early when most amenable to treatment. Our review will also discuss currently available practices in general care floor monitoring that can both improve patient safety and significantly reduce monitor associated alarm fatigue.

The application of standard criteria to electrocardiogram telemetry admissions found that the majority of abnormal heart rhythms were found when patients met appropriate criteria.

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