Continuous electronic monitoring (CEM) of vital signs has begun to spread from intensive care units (ICUs) to medical-surgical floors and other low-acuity areas of hospitals. Some hospitals are using standalone bedside monitors that communicate with nurse call stations and supplement manual patient checks by nurses.
There is also a growing interest in alarms and notification (A&N) platforms, which apply sophisticated analytics to CEM. A&N platforms use middleware to filter device alarms for relevance, analyze alerts in the context of other patient data, and send alerts to nurses’ mobile phones and tablets. According to a recent Gartner report, healthcare CIOs should “familiarize themselves with the A&N platform value proposition” and deploy these solutions “to reduce alert fatigue and improve patient safety, staff utilization and morale.”
An A&N platform can reduce the frequency and number of medical device alarms and provide centralized surveillance of patients, the report says. By reducing the need for manual checks of patients, moreover, A&N platforms can increase nurse efficiency and productivity. “A&N platforms are important to operational efficiency and critical to patient safety and care quality,” the report states.
These A&N platforms are part of a larger infrastructure known as real-time health system solutions (RTHS), which also include platforms for clinical communication and collaboration and interactive patient care. Barry Runyon, a research vice president at Gartner, predicts that by 2020, 30 percent of nurse call systems—which are mandated for the licensing of hospitals—will be replaced by a combination of RTHS systems.
CEM, he says, is migrating from ICUs to general wards “because it’s possible now. Until recently, you needed specially equipped patient rooms and beds to accommodate the medical and patients monitoring devices. Now some of this can be done with wireless medical devices and wearables.”
Another reason for the new interest in CEM is the threat of opioid-induced respiratory depression (OIRD), which can occur in patients who have received anesthesia during surgery or have been heavily sedated. According to one estimate, OIRD accounts for over half of medication-related deaths in hospitals. Opioid administration and monitoring is included in the ECRI Institute’s 2017 list of the top 10 patient-safety concerns for healthcare organizations. Both the Joint Commission, which accredits hospitals, and the Anesthesia Patient Safety Foundation have called for CEM to detect OIRD early on.
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ECRI researchers recently examined the monitoring in low-acuity units of patients who had received narcotics, and “we have concluded that periodic vital signs checks and non-continuous monitoring are not adequate to detect OIRD,” says Tim Ritter, program manager in ECRI’s health devices group. The use of capnometers—devices that measure the carbon dioxide content in exhaled breath—would be a big step forward. Yet relatively few hospitals use any kind of CEM to supplement spot checks of patients at risk for OIRD, he says.
Lack of evidence
Beyond OIRD, early detection of patient deterioration—from sepsis, maternal conditions or postoperative complications, for example–could save many lives. But again, not many hospitals have applied CEM to identify declining patient conditions outside the ICU, says Priyanka Shah, project manager in ECRI’s health devices group. “Interest is growing, but it’s not yet there,” she explains. “There’s still a lack of peer-reviewed clinical evidence that suggests that the use of continuous electronic monitoring would provide better clinical outcomes as compared to spot checks.”
Even if the evidence were abundant, Shah adds, it would be difficult to know which devices to use to monitor patients for unexpected events. For example, an ECG monitor might be the wrong device to use with a patient who is heavily sedated.
In addition, Ritter says, nurses would have to be retrained for CEM. “When you put continuous monitoring into a low-acute area, it’s a big change in practice. There are workflow issues, and you have to make sure that people not previously accustomed to alarms respond to them and do what they can to minimize false alarms.”
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A&N platforms manage alarms by placing them in the context of other patient data and comparing them with large databases of similar alerts. Hospitals can use the latter capability to set their own alarm thresholds to minimize alert fatigue, Shah notes. But if the threshold is set too high, she cautions, nurses might miss important clinical events.
Cost is also a barrier, especially for smaller community hospitals. A traditional vital signs monitor without analytics can serve 10 patients at a time, Shah says, and might cost $5,000. But with analytics and filtering added, each bed would need its own monitor, which would substantially raise the cost of monitoring. In addition, the hospital would have to pay for the software and “consumables” such as the disposable tubing used in capnometry.
Device and mobile connectivity
A&N platforms are usually vendor neutral; that is, they can connect to any patient monitoring device from a major device vendor, Runyon says. They can also link to the leading electronic health record (EHR) systems, he notes. But Shah points out that this is less important than the ability of monitoring systems to communicate with nurse call systems.
Because of licensing requirements, Runyon notes, there must be a hardwired connection between patient rooms and nurse call stations on hospital floors. However, Shah says, she has seen some nurses using mobile devices to receive monitoring data on medical-surgical floors. A&N platforms can be used to send data either directly to clinicians or to nurse call systems, which can relay it to nurses.
Nearly everything that clinicians do in hospital EHRs, including the placement of orders and communication among nurses, can now be done wirelessly, Runyon notes. The hardwired criterion of nurse call systems, he notes, is a function of their evolution, but he expects that to change.
“Nurse call systems will be reinvented,” he maintains. “Because, outside of that one imperative of the hardwire between the patient and the nursing station, everything else that a nurse call system does can be done by interactive patient care, clinical communication and collaboration systems, and alarms and notification systems.”
Whenever clinicians use mobile devices, he adds, “The CIO is always challenged by coverage, responsiveness, privacy and security issues, and ownership issues—whether the device is owned by the hospital or the individual.”
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Coverage issues, however, detract much less from mobile communications in the hospital than they did five or 10 years ago, he notes. “Wireless is fairly pervasive,” he says, adding that signal strength is greater, mobile devices are better, and access points have improved.
Moreover, when clinicians leave the building, monitoring devices on an A&N platform can switch from wi-fi to cellular transmission, he says. That means that, in theory, physicians could receive alerts on their patients at home.
Runyon expects to see the advent of the mobile patient in the near future. Equipped with certain devices such as portable infusion pumps, a patient walking around the hospital could send alerts to nurse call, he notes.
All of this technology promises a safer future for hospitalized patients. “For the use case of CEM on general care floors, these monitors offer technology that’s comparable to ICU monitoring,” Shah says. “But people are still searching for peer-reviewed clinical literature that shows better clinical outcomes. And they also face the challenges of nursing workflow implementation and the cost.”