Led by patient safety organizations such as The Joint Commission, calls for continuous monitoring of non-critical care patients, especially those taking opioids, are consistently growing louder.
According to the market research firm Berg Insight, the number of patients being remotely monitored jumped 51% to 4.9 million in 2015; the firm expects that figure to reach 36.1 million, a 48.9% increase, by 2020. But where and by what means patients are monitored makes a difference in outcomes.
Many patients die each year in general wards, due to late detection of respiratory depression, according to Joe Kiani, founder and CEO of Masimo and founder of the Patient Safety Movement Foundation. “Continuous monitoring allows clinicians to anticipate a serious adverse event at a time that it is preventable by an intervention. Measure Through Motion and Low Perfusion pulse oximeters now exist that can reliably help clinicians identify patients at risk without excessive false alarms,” he said.
Moreover, the Anesthesia Patient Safety Foundation, the Centers for Medicare and Medicaid Services (CMS), The Joint Commission and the Patient Safety Movement Foundation all recommend that hospitals adopt continuous monitoring to address serious adverse outcomes from the use of opioids on these non-critical patients, Kiani added. “Per the Joint Commission, the non-critical care patient on the post surgical floor is where most of these complications with adverse outcomes are occurring,” he said.
A 2014 clinical trial1 found an association between continuous monitoring in a medical-surgical unit and a decrease in length of stay and ICU days for transferred patients, along with lower code blue rates.
“Eyes and Ears”
Julia Strandberg, vice president and general manager for Health Informatics & Monitoring at Medtronic, explained that continuous remote monitoring (CRM) translates data to provide insights into a patient’s condition. “It’s the hallmark of patient monitoring,” she said. For instance, Medtronic’s Vital Sync Patient Monitoring Platform, a software and wearables-based solution, collects and uses data for the benefit of patient, clinician and facility.
“CRM serves as eyes and ears to provide clinical support and patient care when caregivers can’t be at the patient’s side,” she said. “Those patients truly at risk go well beyond respiratory compromise. There are clinical challenges for early detection of pressure ulcers, patient falls, ventilator-associated pneumonia, basically anything that comes under hospital-acquired conditions or never events,” she said. “These preventable events have high prevalence and are costly to an acute facility.”
Strandberg differentiates between two different types of monitoring: conditional and surveillance. The first modality focuses on the patient with known risk factors, such as respiratory compromise, obstructive sleep apnea, comorbid illnesses or those in need of opioid management. “These conditions require additional vigilance,” she said.
The latter solution is a reliable, minimally invasive system used on all patients to assist in detecting medical condition changes. Systems like Vital Sync Patient Monitoring Platform incorporate a number of individual monitoring devices, including pulse oximetry, capnography, ventilation and alarm management, which enable hospitals to recognize the risk of respiratory compromise and receive early warning of patient deterioration, according to Strandberg.
Furthermore, patient monitoring, when integrated into a hospital network, helps facilities comply with mandates set forth by the Affordable Care Act (ACA). “Hospitals have many medical devices and systems they have deployed over history and the lifespan of the facility,” said Strandberg. “If the goal is to drive data to insight, you have to integrate information, providing pieces of the puzzle that support effective, timely decision-making. You have to have the openness and ability to weave into the fabric of the system.”
Hospitalized patients require top-notch care, but equally as important is outpatient care, said Strandberg. “Once the patient is discharged, it’s important to focus on 30-day readmission and management of chronic disease.” She emphasized the disparity in risk factors between the hospital environment and the community setting, which can be addressed by a continuum of care that monitoring provides.
As patient monitoring becomes a central piece of patient care, new technology is enhancing the process. Three and a half years ago EarlySense introduced noncontact technology in which sensors are placed in a bed or under a cushion, according to company president Tim O’Malley. The system is designed to proactively treat non-ICU patients. A sensor plate, approximately the size of a pad of paper, detects vibration and motion from the body and alerts the clinician via a mobile device.
“When the heart contracts, the sensor detects blood flow. During the respiratory cycle, the patient breathes and the muscles in the ribs create motion. We pick that up in processing signals,” said O’Malley. “We also have bed exit and pressure ulcer prevention systems.”
The sensor captures data two times per second, while traditional monitoring typically acquires far fewer, since it takes place only every four hours when clinical staff record vital signs. O’Malley explained this data can be transferred to the patient’s electronic medical record and help track trends. “Many facilities are looking for earlier indicators of compromise, such as sepsis. If you learn how to identify it earlier, you’ll avoid a full-blown septic event,” he said. “Trending information gives insight into the patient condition and helps clinicians make better decisions.”
Admittedly, hospitals must consider the bottom line when implementing a continuous monitoring system. A return on investment analysis2 published in The Journal of Critical Care Medicine found a positive correlation between a community hospital that adopted such a system and cost savings. The authors used two models, one that estimated total cost savings (A) and one that assessed only the direct variable cost for the final day of length of stay (LOS) and treatment of pressure ulcers (B). Findings showed a decrease in LOS and total ICU days for both models as well as breakeven for the facility within a year. The average net benefit ranged from $224 per patient in model B to $710 per patient in model A annually.
Kiani noted that a 2010 landmark study3 by Dartmouth-Hitchcock Medical Center showed that clinicians using continuous monitoring on post surgical floors with Measure Through Motion and Low Perfusion pulse oximetry and notification system identified patient distress earlier, which reduced rapid response activations by 65% and ICU transfers by 48%, and saved $1.48 million annually.
Monitoring Sleep Apnea
Remote monitoring for patients with sleep-disordered breathing has long been industry standard. ResMed is wirelessly connected to more than 1.3 million such patients, according to Jeremy Malecha, company vice president, product management of Global Healthcare Informatics.
Through a cloud-based system, ResMed provides several remote monitoring products intended to control healthcare spending, while bringing more efficient care to patients. For instance, with myAir patients can track and manage their own therapy. Malecha explained that the web-based program syncs with the patient’s CPAP machine. Patients see and understand the data, which reinforces treatment compliance, helps develop patient confidence, drives efficiency and streamlines care. “The patient makes a mental shift. This has a direct effect on how the patient engages,” he said. “This could lead to standardized protocols. The benefits are twofold: for the provider and for the patient.”
A study4 published in Sleep and Breathing examined standard of care versus monitoring via telehealth messaging in patients newly diagnosed with obstructive sleep apnea (OSA) and found the latter group to have similar compliance and efficacy as the former, but showed reduced coaching requirements.
Another cellular solution, U-Sleep, monitors CPAP usage and sends voice, text and email notifications to patients when necessary. The technology separates patients into “actionable groups,” meaning that providers can focus on those patients that require closer follow up.
The practice of continuous remote monitoring has also been implemented in outpatient settings in Europe. Rupert Hipwell, strategic business manager for Philips UK division, oversees the company’s Hospital-to-Home program, which provides post-discharge monitoring. “We can be proactive as to when to step patients down,” he said, noting that respiratory therapists can play a key role in identifying patients who frequently return to the hospital. Patients recognized as “further down on the health scale” should be proactively monitored, according to Hipwell. “Patients have different tiers of needs. It’s all about supporting the patient,” he added. An algorithm translates data to sort out which patients are deteriorating or at risk of readmission to the hospital.
Research has shown that conventional monitoring reduces anxiety levels and helps the patient focus on managing self-care, said Hipwell. “Monitoring is a short-term intervention to help change behaviors.”
For example, Philips remotely monitored patients in Liverpool and found a 23% reduction in admissions, 20% decrease in costs and 18% fewer physician visits. Furthermore, 91% of patients reported more confidence in controlling and coping with their conditions; 63% reported an increase in self-care and a reduction in health care services use.
Admittedly, monitoring outside the confines of a hospital can be challenging, mostly due to facility pushback, Hipwell reported. In spite of documented positive outcomes, some hospitals are reluctant to adopt remote monitoring technology, and obtaining buy-in from general practitioners and community care staff is difficult. “It’s a complex environment and organizational change is hard to accomplish,” he said, particularly given the number of stakeholders involved. Philips provides training for facilities to help them recognize the value of remote monitoring and how to change pathways.
In the United States, Philips has launched eCare Coordinator and eCare Companion, applications that monitor chronically ill patients through its Hospital-to-Home telehealth program. These tools, which received 510(k) clearance from the Food and Drug Administration (FDA), are personalized, accessible by a tablet and help to drive patient engagement and self-management. The apps are currently supporting a pilot program at Banner Health in Arizona; a similar program will launch with the Henry Ford Health System in Michigan.
Training and Education
Device manufacturers provide various types and levels of training and maintenance on their systems. Strandberg indicated that Medtronic’s plan involves three formats: clinical use cases, workflow and change management. “Our responsibility is to not only provide the tools that caregivers can use, but to support the integration of these tools into their daily routines. This enables elevation to the level of care they provide in an efficient manner that ideally frees them to focus on other facets of patient care. We form a strong partnership with IT, biomedical and nursing organizations to implement the system wisely into the hospital network,” she said.
In addition, Medtronic makes an “outcomes pledge” that aims to educate hospitals about the dangers of respiratory compromise and how to eliminate it.
Research shows that whether patients are in the ICU, on the general floor or in the community, continuous monitoring can lead to earlier detection of respiratory compromise and/or other developing adverse events, prompt appropriate clinical intervention and reduced healthcare costs. RT
Phyllis Hanlon is a contributing writer to RT. For further information, contact [email protected]
SIDEBAR: EtCO2 Monitoring a Smart Tool in the PACU
A new study suggests that patients in the post-anesthesia care unit (PACU) with a high risk for respiratory adverse events should be monitored with both noninvasive end-tidal carbon dioxide (etCO2) and pulse oximetry using the Integrated Pulmonary Index (IPI). End-tidal CO2 monitoring is not regularly performed in the PACU, researchers noted.
Researchers conducted a retrospective study to test the efficacy of the IPI, a 10-point scale that combines a patient’s end-tidal CO2, pulse oximetry, respiratory rate, and pulse rate, for predicting adverse events in the PACU. The study included 163 patients with a high risk for hypoventilation in the PACU after general surgery. Patients were considered high risk if they were older than 75 years of age or had a body mass index greater than 28 kg/m2. The patients were enrolled at two centers from October 2014 to February 2015.
Overall, there were 11 patients who suffered an adver respiratory event, with one patient requiring operation and treatment in the ICU. The PACU stay for patients with an adverse evet was almost double the time of patients without one, according to research. The researchers also found lower initial IPI and SpO2 measurements for the adverse event group.
According to an Anesthesiology News report, the researchers concluded that IPI has better sensitivity and specificity, making it superior to pulse oximetry alone for predicting the onset of adverse respiratory events after surgery. “SpO2 can give you the oxygenation—if it’s good or not—but we cannot assess the respiration. IPI can give us a number, and this number is very easy to understand: 10 is okay; one is very bad,” lead researcher Hiroshi Morimatsu, MD, PhD, told Anesthesiology News.
Currently, there are no set guidelines for IPI scores and Morimatsu urged clinicians to pay more attention to any patient who scores less than seven on the index. Further research is needed and he is looking to conduct a larger multicenter study that will look at other types of patients.
Brown H, Terrence J, Vasquez P et al. “Continuous monitoring in an inpatient medical-surgical unit: a controlled clinical trial.” Am J Med. 2014 Mar;127(3):226-32. doi: 10.1016/j.amjmed.2013.12.004. Epub 2013 Dec 14.
Slight SP, Franz C, Olugbile M et al. “The return on investment of implementing a continuous monitoring system in general medical-surgical units.” Crit Care Med. 2014 Aug;42(8):1862-8. doi: 10.1097/CCM.0000000000000340.
Taenzer AH, Pyke JB, McGrath SP, Blike GT. “Impact of pulse oximetry surveillance on rescue events and intensive care unit transfers: a before-and-after concurrence study.” Anesthesiology. 2010 Feb;112(2):282-7. doi: 10.1097/ALN.0b013e3181ca7a9b.
Munafo D, Hevener W, Crocker M et al. “A telehealth program for CPAP adherence reduces labor and yields similar adherence and efficacy when compared to standard of care.” Sleep and Breathing. First online Jan 2016. doi: 10.1007/s11325-015-1298-4.