Bedside Monitoring

Brian S. Rothman, MD Vanderbilt University Medical Center

November 13, 2014

1

© 2014 Association for the Advancement of Medical Instrumentation www.aami.org

1. CLINICAL NEED/RESULT: Why did you institute continuous monitoring of patients on opioids? What were the results you saw after implementing continuous monitoring? 2. SOLUTIONS/VENDORS: How did you implement continuous monitoring? Where did you start? How did you collection/analyze the data? 3. ALARM STRATEGY: How did your institution ensure continuous monitoring did not increase non-clinically actionable alarms? Was there a policy? Strategy? Clinical/Patient Education? 4.CHALLENGES/BARRIERS What are some challenges/barriers you experienced? How did you overcome these barriers? 5.ROI DATA What kind of data did you collect that demonstrates this was a sound investment? Please show in terms of dollars for decrease in ICU transfers/reduced LOS? How did you show improved patient outcomes? 6. INSTITUTIONAL STANCE Does your institution have a policy or stance on continuous monitoring of patients on opioids? Please insert stance or policy excerpt.

2

Acknowledgements

• Liza M Weavind, MBBCh., FCCM, MMHC

• Sharon Mullins, RN, BSN, MA

Clinical Need

Failure to Rescue • Healthcare systems safety target • Institute of Medicine • Anesthesia Patient Safety Foundation

• Definition(Silber, 1992) • Hospital death following an adverse occurrence..

• Retrospective reviews demonstrate adverse events are preceded by a period of physiologic instability 6- 8 hours prior to the event.

• Early recognition of such physiologic change prompts early intervention potentially minimizing the occurrence of escalation in care and adverse events. (Taenzer 2012).

Clinical Need

• No current continuous patient physiologic monitoring provision outside of the intensive care units

• General care floors • Continual monitoring, but • No continuous monitoring

Continual/Periodic Vital Signs

Like checking to see if the fridge light is on...

http://www.niemanlab.org/images/smart-refrigerator.jpg

Current State

http://4.bp.blogspot.com/_UD1TRPOssR0/RswK910GEUI/AAAAAAAAAIU/4CSLjP61NsE/s400/3+monkeys.jpg http://www.presspartners.org/wp-content/uploads/2013/05/monkeys_22027_lg.gif

Possible Ideal Future State

http://1.bp.blogspot.com/-rlT-Alch12M/T3S5ci84JdI/AAAAAAAAAUw/GtvGIv5lw3A/s1600/3monkeys.jpg

http://photos.merinews.com/upload/imageGallery/bigImage/1220001163553.jpg

Purpose & Objectives • Evaluate monitoring technology for its ability to

increase detection and intervention for patients showing early signs of decline • Impact on Patient Safety • Primary alerting of patients at the bedside • Transmission of data via Wi-Fi signal • Escalation of Alerts through paging system if not

resolved • Limitation of Alert fatigue by setting alarm

parameters and technology • Assess Nurse and Staff satisfaction

Implementation

Project • Implement a continuous physiologic

monitoring system and process for general care floor patients

• System facilitates early recognition of deterioration and cues rescue interventions

• Notifications to • Patient’s nurse via pager when limits

violated • Escalation if no nurse response

Operational Objectives • Pilot - Install continuous physiologic

monitoring system in selected units. • Parameters may include • Pulse oximetry • Heart rate • End tidal carbon dioxide (not included in

first phase) • Establish clinical alerting and escalation

model • Integration with nursing documentation

excluded

Technology • Covidien Vital Sync Monitoring Platform

with Nellcor pulseox probes • Measures patient vital signs • Delivers values to database • Algorithms to generate alerts

• Connexall Alert/Alarm System • Receives alerts from Covidien system • Delivers alerts and escalations

The Pilot - 2 General Care Floors • Design and configure hardware and software • Create and validate current and future business work flow

operational processes • Design and develop new incoming interfaces • Design and develop new outgoing interface • Create and execute a Testing Plan • Document and execute a Business Continuity Plan • Create and execute a Training Plan • Develop and implement a Go Live Plan • Transition the system to Support Teams post Go Live • Document Lessons Learned and create a Post Implementation

Review

Infrastructure and Maintenance

• Establish technical support model • Monitor data and alarms • Reporting (real-time, dashboard, etc.) • Retention

Institutional Support and Governance

• Project team and steering committee • Stay within scope

Alarm Strategy

Low Thresholds Wide Ranges

• Sufficient latencies offset artifacts

• Decreased false positives • Identify only those at risk regardless of

definition

Alert Parameters and Escalation Pages

Challenges/Barriers

Data Retention Medicolegal Risk

• Benefits • Analysis • History and research

• Risks • Medicolegal discovery • PHI exposure (non-Medicolegal

discovery)

Data Retention • Policy creation • Retain what data • Identifiable data • Snapshot concept

• Multiple location data collection • One-size-fits-all? • Customized policy/case-by-case

exceptions

Assumptions

• WIFI can support • Increased use by new devices • Real-time data flow

• Sufficient storage available • Technology scalable from 2 floors to

over 300 beds

Don’t Assume

• WIFI connectivity issues • Thought to be vendor based

• Actually WIFI configuration issue -

improved WIFI performance house-wide

Technical Requirements Not Met • Connectivity was inconsistent • Monitors could not all be linked to

patients or staff • Escalation of alerts did not occur when

monitors not connected • Data collection ceased with Server

Failure • Reporting function was unavailable

Nursing acceptance

• Changing culture

• Support culture change

Nursing Identified Barriers

• Connectivity • Ergonomic Impact • Perceived unreliability • Usability of Software Programs • Lack of Support • Cleaning of Machines • Monitors were not available for all patients at

Risk • Negatively affected Patient Satisfaction

Nursing Identified Patient Satisfaction • Too many false positives when patient is using their hands

• Finger probe uncomfortable • Probe interferes with personal hygiene • Patients don’t see necessity- “I’m not

that sick” • Impedes ambulation and inhibits

mobility • Rooms are too crowded

Survey Bias • Negatively worded survey questions

predominant • Skewed values and comments - still

valuable • Used comments for final

implementation criteria • Met resistance when we tried to remove

monitors from pilot locations

Results

37 Year Old Male…

• HCV, GERD, chronic pain s/p MVA ‘97 (L4 paraplegia, loop ileostomy, sacral decub, osteomyelitis), multiple prior surgical procedures.

• POD 10 from gluteus maximus myocutaneous flap

• On pulse Ox with bedside pilot on 9S

Abnormal…

PE!!

Saves and Fewer RRT

• PE identified, treated, excellent outcome

• Hypoglycemia treated - no ICU transfer

• After pilot - new onset atrial fibrillation • Transfer and cardioversion

ROI

ROI Goals • Higher level of care transfer rate

reduction • Reduction in Rapid Response

Activations • ICU bed LOS decrease per 1000 pt

days • Decrease ED diversion from bed

availability

Value Trend

• 2 saves and decreased RRT calls • Fewer ICU admissions • Shorter LOS patients without care

escalation • Trend but insufficient power to show

significance

Non-Financial Quality Improvements • Improved Nursing Satisfaction • Decreased use of Narcan in units • Decreased code rate on surgical units • Identification of patients at risk for Obstructive

Sleep Apnea (OSA) • Earlier interventions and increased awareness • PCAs and epidurals

• Inconclusive

Institutional Position

No, But...

• Continual monitoring policy for patients • Upon initiation of PCAs • Basal rate addition, or • Continuous narcotic infusion

Implementation Planned January

2015