Higher Acuity

In practice, the hospital has become the “intensive care unit” of the community.

Modern hospitals service patients of increasing complexity and co-morbidity. Despite advances in technology and the best efforts of hospital staff, several studies have demonstrated that 6-17% of all hospital admissions are complicated by serious adverse events. These events are often unrelated to the patient’s underlying medical condition and in approximately 10% of cases they will result in permanent disability and even death.

Jones D, Haase M, Bellomo R from Textbook of rapid response systems

Health Risk Scores for Admitted Patients, 2006-20103

health-risk

Higher Complexity

The evolution and availability of medical care means that more patients with chronic conditions are living longer. Diseases such as heart disease, cancer, hypertension, stroke and diabetes—often with complex treatment regimens—are often admitted to hospitals either for an elective procedure, or emergency treatment, and their chronic disease burden adds to their complexity.4

Adding to complexity:

  • Whenever possible, patients are managed in an out patient setting.
  • When admitted to the hospital the goal is to shorten lengths of stay and improve throughput. As a result, patients are moved more quickly through intensive care and recovery room settings.

Percentage of Seniors with Two or More Chronic Conditions, 1999-2000 and 2009-2010

percentage-seniors

Why All Vital Signs

Based on chart reviews of patients who experienced a cardiorespiratory arrest, the clearest signs of distress before the event were tachycardia, bradycardia, tachypnea, oxygen desaturation, low systolic blood pressure, respiratory distress and changes in mental status. That is to say, the highest specificity indicator for patients at risk was a combination of heart rate, respiratory rate, systolic blood pressure and change in mental status.5,6

Instability is not a static phenomenon. Because a patient’s compensatory mechanisms attempt to correct the physiologic causes of the instability, no single-parameter monitoring systems have proven to be wholly sufficient.

Hravnak M, Schmid A, Ott L et al: from Textbook of rapid response systems

Nurses at the Sharp End of Care

Nurses are the most common hospital personnel assessing patient condition, making decisions, and triggering intervention. Successful interventions depend on the early identification of deterioration in patients, the experience and confidence to seek help, and having that help readily available.

Lack of access to patient data, such as vital sign trends over a period of time, can lead to delayed recognition of deterioration.

DeVita M, Smith G, Adam S et al. from Resuscitation 2010; 81:375-382

Nurses Need Early Detection Tools

Nurses on a postoperative general care floor often manage 4-8 patients at a time, making it difficult for them to observe early signs adverse events in their patients. When detection is delayed, there is greater risk of more advanced deterioration that can contribute to higher morbidity and mortality.

It is now recognized that capturing vital signs as frequently as possible is needed if every patient deterioration is to be assessed and recognized.9

Curry J, Jungquist C from Patient Saf Surg

Postoperative Patient Risk

In postoperative surgical patients, adverse clinical events can manifest subtly, or be totally disguised by sleep.

The risk of deterioration is more likely to go undetected in patients where continuous monitoring is an exception, rather than a rule.

Prolonged hypoxemic episodes are common in post-operative patients.

Sun Z, Sessler D, Dalton J from Anesthesia & Analgesia

Detecting diminished oxygen saturation or hypotension in post-operative patients may be more clinically relevant to deterioration than previously thought. While post-operative periods of hypoxia (oxygen deficiency) have been well documented, recent reports suggest that myocardial injury after non-cardiac surgery (MINS) is a frequent occurrence.

It is possible that periods of hypotension and diminished oxygen saturation (Sp02)—whether symptomatic or not—can contribute to a higher risk of myocardial injury after non-cardiac surgery (MINS). MINS patients have a 30-day post-surgical mortality risk 10 times higher than those without MINS.1

Delays Are Costly

Delays in the discovery of patient deterioration directly impact outcomes and cost. In one study, the authors conclude that hospital mortality increases 3% for each hour an ICU transfer is delayed, and that those patients who are transferred experience a longer length of stay.10

Quiet At Night

Sleep is essential to recovery from illness or surgery, yet it is often very difficult to get a good night’s sleep in a hospital. The stress of hospitalization, sleep deprivation, an array of medications, and altered physical activity can result in patients leaving the hospital with risk factors unrelated to their reason for admission.11

Cardiac Telemetry Is Not The Answer

The fear of missing life-threatening arrhythmias likely contributes to the overuse of cardiac telemetry. Published study results suggest that using the American Heart Association guidelines for telemetry reduces use by as much as 43%, with no increase in mortality, cardiac arrest, or activation of the rapid response team. These data provide evidence that in patients with no known risk factors, ECG monitoring is not the tool to use to detect deterioration.12,13

Followup study affirms safety of reducing cardiac telemetry use outside ICU.

 

Higher Acuity

In practice, the hospital has become the “intensive care unit” of the community.

Modern hospitals service patients of increasing complexity and co-morbidity. Despite advances in technology and the best efforts of hospital staff, several studies have demonstrated that 6-17% of all hospital admissions are complicated by serious adverse events. These events are often unrelated to the patient’s underlying medical condition and in approximately 10% of cases they will result in permanent disability and even death.

Jones D, Haase M, Bellomo R from Textbook of rapid response systems

Health Risk Scores for Admitted Patients, 2006-20103

health-risk

Higher Complexity

The evolution and availability of medical care means that more patients with chronic conditions are living longer. Diseases such as heart disease, cancer, hypertension, stroke and diabetes—often with complex treatment regimens—are often admitted to hospitals either for an elective procedure, or emergency treatment, and their chronic disease burden adds to their complexity.4

Adding to complexity:

  • Whenever possible, patients are managed in an out patient setting.
  • When admitted to the hospital the goal is to shorten lengths of stay and improve throughput. As a result, patients are moved more quickly through intensive care and recovery room settings.

Percentage of Seniors with Two or More Chronic Conditions, 1999-2000 and 2009-2010

percentage-seniors

Why All Vital Signs

Based on chart reviews of patients who experienced a cardiorespiratory arrest, the clearest signs of distress before the event were tachycardia, bradycardia, tachypnea, oxygen desaturation, low systolic blood pressure, respiratory distress and changes in mental status. That is to say, the highest specificity indicator for patients at risk was a combination of heart rate, respiratory rate, systolic blood pressure and change in mental status.5,6

Instability is not a static phenomenon. Because a patient’s compensatory mechanisms attempt to correct the physiologic causes of the instability, no single-parameter monitoring systems have proven to be wholly sufficient.

Hravnak M, Schmid A, Ott L et al: from Textbook of rapid response systems

Nurses at the Sharp End of Care

Nurses are the most common hospital personnel assessing patient condition, making decisions, and triggering intervention. Successful interventions depend on the early identification of deterioration in patients, the experience and confidence to seek help, and having that help readily available.

Lack of access to patient data, such as vital sign trends over a period of time, can lead to delayed recognition of deterioration.

DeVita M, Smith G, Adam S et al. from Resuscitation 2010; 81:375-382

Nurses Need Early Detection Tools

Nurses on a postoperative general care floor often manage 4-8 patients at a time, making it difficult for them to observe early signs adverse events in their patients. When detection is delayed, there is greater risk of more advanced deterioration that can contribute to higher morbidity and mortality.

It is now recognized that capturing vital signs as frequently as possible is needed if every patient deterioration is to be assessed and recognized.9

Curry J, Jungquist C from Patient Saf Surg

Postoperative Patient Risk

In postoperative surgical patients, adverse clinical events can manifest subtly, or be totally disguised by sleep.

The risk of deterioration is more likely to go undetected in patients where continuous monitoring is an exception, rather than a rule.

Prolonged hypoxemic episodes are common in post-operative patients.

Sun Z, Sessler D, Dalton J from Anesthesia & Analgesia

Detecting diminished oxygen saturation or hypotension in post-operative patients may be more clinically relevant to deterioration than previously thought. While post-operative periods of hypoxia (oxygen deficiency) have been well documented, recent reports suggest that myocardial injury after non-cardiac surgery (MINS) is a frequent occurrence.

It is possible that periods of hypotension and diminished oxygen saturation (Sp02)—whether symptomatic or not—can contribute to a higher risk of myocardial injury after non-cardiac surgery (MINS). MINS patients have a 30-day post-surgical mortality risk 10 times higher than those without MINS.1

Delays Are Costly

Delays in the discovery of patient deterioration directly impact outcomes and cost. In one study, the authors conclude that hospital mortality increases 3% for each hour an ICU transfer is delayed, and that those patients who are transferred experience a longer length of stay.10

Quiet At Night

Sleep is essential to recovery from illness or surgery, yet it is often very difficult to get a good night’s sleep in a hospital. The stress of hospitalization, sleep deprivation, an array of medications, and altered physical activity can result in patients leaving the hospital with risk factors unrelated to their reason for admission.11

Cardiac Telemetry Is Not The Answer

The fear of missing life-threatening arrhythmias likely contributes to the overuse of cardiac telemetry. Published study results suggest that using the American Heart Association guidelines for telemetry reduces use by as much as 43%, with no increase in mortality, cardiac arrest, or activation of the rapid response team. These data provide evidence that in patients with no known risk factors, ECG monitoring is not the tool to use to detect deterioration.12,13

Followup study affirms safety of reducing cardiac telemetry use outside ICU.

 

The data is clear:

The less frequently vital signs are checked, the more likely evidence of patient deterioration will go undetected.

Real World Experience

ViSi Mobile® was evaluated for a 19-week period on a surgical care unit that had a high incidence of rapid response calls requiring escalation of care—the need for a clinical intervention to prevent harmful complications.

The failure to recognize patient deterioration was a major problem, and organizations need better means to detect patients at risk, followed by meaningful intervention.

DeVita M, Smith G, Adam S et al. from Resuscitation

Escalation of Care by Alarm Type

escalation-of-care

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Among ward patients, emergency team activation in response to acute deterioration triggered more than 15 minutes after detection and documentation of instability is independently associated with an increased risk of ICU admission and death.

Chen J, Bellomo R, Flabouris A et al from Critical Care Medicine

A study of mature rapid response systems with track and trigger mechanisms found that potentially avoidable cardiac arrests were missed due to intermittent patient evaluation.

Galhotra S, DeVita M, Simmons R et al from Quality and Safety in Health Care

Delayed ICU transfer is associated with significantly increased hospital length of stay and mortality.

Wendlandt B, Churpeck M, Adhikari R et al from Journal of Hospital Medicine

1. Sun Z, Sessler D, Dalton J et al.: Postoperative Hypoxemia Is Common and Persistent. Anesthesia & Analgesia 2015; 121:709-715.

2. Jones D, Haase M, Bellomo R: The impact of delayed RRS activation, Chapter 17 in DeVita M, Hillman K, Bellomo R: Textbook of rapid response systems. New York: Springer; 2011.

3. The Moran Company. Analysis of Medicare, 5% Standard Analytic Files.

4. Freid, V., et al. Multiple Chronic Conditions Among Adults Aged 45 and Over: Trends Over the Past 10 Years.

5. Schein R, Hazday M, Pena M et al.: Clinical antecedents to in-hospital cardiopulmonary arrest. CHEST Journal 1990; 98:1388-1392.

6. Hillman K, Bristow P, Chey T et al.: Duration of life-threatening antecedents prior to intensive care admission. Intensive Care Medicine 2002; 28:1629-1634

7. Hravnak M, Schmid A, Ott L et al: Causes of failure to rescue, Chapter 13 in DeVita M, Hillman K, Bellomo R: Textbook of rapid response systems. New York: Springer; 2011.

8. DeVita M, Smith G, Adam S et al.: “Identifying the hospitalised patient in crisis”—A consensus conference on the afferent limb of Rapid Response Systems. Resuscitation 2010; 81:375-382

9. Curry J, Jungquist C: A critical assessment of monitoring practices, patient deterioration, and alarm fatigue on inpatient wards: a review. Patient Saf Surg 2014; 8:29

10. Wendlandt B, Churpeck M, Adhikari R et al.: Association Between ICU Transfer Delay and Hospital Mortality: A Multicenter Investigation. Journal of Hospital Medicine 2015: 10 (suppl2)

11. Krumholz H: Post-Hospital Syndrome — An Acquired, Transient Condition of Generalized Risk. New England Journal of Medicine 2013; 368:100-102

12. Dressler R, Dryer M, Coletti C et al.: Altering Overuse of Cardiac Telemetry in Non–Intensive Care Unit Settings by Hardwiring the Use of American Heart Association Guidelines. JAMA Internal Medicine 2014; 174:1852

13. Kansara P, Jackson K, Dressler R et al.: Potential of Missing Life-Threatening Arrhythmias After Limiting the Use of Cardiac Telemetry. JAMA Internal Medicine 2015; 175:1416

14. Chen J, Bellomo R, Flabouris A et al.: Delayed Emergency Team Calls and Associated Hospital Mortality. Critical Care Medicine 2015; 43:2059-2065

15. Galhotra S, DeVita M, Simmons R et al.: Mature rapid response system and potentially avoidable cardiopulmonary arrests in hospital. Quality and Safety in Health Care 2007; 16:260-265

16. Wendlandt B, Churpeck M, Adhikari R et al.: Association Between ICU Transfer Delay and Hospital Mortality: A Multicenter Investigation. Journal of Hospital Medicine 2015: 10 (suppl2)