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Failure to Detect Ward Hypoxaemia and Hypotension: Contributions of Insufficient Assessment Frequency - Cleveland Clinic

Abstract Background: Postoperative hypotension and hypoxaemia are common and often unrecognized. With intermittent nursing vital signs, hypotensive or hypoxaemic episodes might be missed because they occur between scheduled measurements, or because the process of taking vital signs arouses patients and temporarily improves arterial blood pressure and ventilation. We, therefore, estimated the fraction of desaturation and hypotension episodes that did not overlap nursing assessments and would therefore usually be missed. We also evaluated the effect of taking vital signs on blood pressure and oxygen saturation.

 

Methods: We estimated the fraction of desaturated episodes (arterial oxygen saturation <90% for at least 90% of the time within 30 continuous minutes) and hypotensive episodes (MAP <70 mm Hg for 15 continuous minutes) that did not overlap nursing assessments in patients recovering from noncardiac surgery. We also evaluated changes over time before and after nursing visits.

 

Results: Among 782 patients, we identified 878 hypotensive episodes and 2893 desaturation episodes, of which 79% of the hypotensive episodes and 82% of the desaturation episodes did not occur within 10 min of a nursing assessment and would therefore usually be missed. Mean BP and oxygen saturation did not improve by clinically meaningful amounts during nursing vital sign assessments.

 

Conclusions: Hypotensive and desaturation episodes are mostly missed because vital sign assessments on surgical wards are sparse, rather than being falsely negative because the assessment process itself increases blood pressure and oxygen saturation. Continuous vital sign monitoring will detect more disturbances, potentially giving clinicians time to intervene before critical events occur.

 

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Keywords: anaesthesia, hypotension, hypoxemia, hypoxaemia, nursing, postoperative complications, ward monitoring

Continuous Physiological Monitoring Improves Patient Outcomes - Mayo Clinic

Abstract Background: General patient acuity is increasing in the United States, with more patients having multiple comorbidities and acute-on-chronic conditions. Hospitalizations may also be complicated by serious adverse events, often unrelated to the admitting medical diagnosis. In our facility, the late detection of patient deterioration on general medical units often resulted in increased length of stay (LOS) in the ICU and poor patient outcomes.

 

Purpose: The purpose of this project was to improve patient surveillance and better identify early signs of patient deterioration through the use of continuous vital sign monitoring technology.

 

Methods: To improve detection of patient deterioration, a nurse-led monitoring and response system was developed using a wearable, wireless device for continuous vital sign surveillance. The patient data the device provided was used with early warning scores and sepsis screening protocols for timely goal-directed interventions.

 

Results: Ninety-seven percent of patient deterioration events were recognized and treated as a result of this continuous monitoring and response system. Rapid response team activations decreased by 53% between baseline and the intervention period. LOS among patients transferred to the ICU decreased from 2.82 to 2.19 days. Nurse satisfaction with use of the continuous monitoring device was positive, with 74% of nurses surveyed reporting that information provided by the device enhanced decision-making.

 

Conclusions: New technology for patient surveillance, in this case, a nurse-led monitoring and response system, can be successfully integrated into general care practice. Use of the nurse-led response system helped nurses recognize early signs of deterioration and continue meaningful patient interactions.

 

Keywords: clinical deterioration, early detection, patient monitoring, physiological monitoring, rapid response team, response system, vital signs

 

 

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Altering Overuse of Cardiac Telemetry - Christiana Care Health System

Non-intensive care use of cardiac telemetry to detect arrhythmia is among the most overused diagnostic tests in cardiovascular medicine, yet it is widely performed despite its questionable value to patients. Using the AHA’s non-ICU cardiac telemetry patient stratification, an 1,100-bed tertiary care system removed cardiac telemetry orders where clinical conditions for monitoring were not supported by the AHA guidelines. The study period commenced December 2012 and concluded August 2013 with redesigned telemetry orders implemented in March 2013 for a total of 11 and 22 weeks pre and post implementation. Outcomes measured included mean weekly number of patients with telemetry orders, mean duration of telemetry, frequency of rapid response activations, codes, and deaths among others.

 

 

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Incidence, Severity, and Detection of Blood Pressure Perturbations after Abdominal Surgery - Cleveland Clinic

Despite known associations of intraoperative and postoperative hypotension with myocardial and kidney injury and 30-day mortality, blood pressure in surgical wards is still limited to intermittent monitoring every 4 to 6 hours, leaving long periods of hypotension and hypertension undetected. A prospective, blinded, observational study with 312 patients with adequate Mean Arterial Pressure (MAP) data, 18 years or older and had abdominal surgery between February 2015 and December 2017 was conducted at the Cleveland Clinic. ViSi Mobile was used to evaluate whether noninvasive continuous BP monitoring detected more postoperative hypotension and hypertension than routine vital-sign 4-hour interval assessments.

 

 

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Evaluation of a wireless, portable, wearable multi-parameter vital signs monitor in hospitalized neurological and neurosurgical patients - Wake Forest University School of Medicine

Despite studies showing the benefits of continual, multi-parameter vital sign (VS) monitoring in general non-ICU patients, as demonstrated by a decrease in total length of stay in both hospital and intensive care unit days and a lower incidence of cardiac arrest1, alarm fatigue poses a concern and burden on nurses. A prospective, observational, 5-month pilot study in a 26-bed adult, neurological/ neurosurgical unit (non-ICU) at Wake Forest was conducted. ViSi Mobile was used to assess the impact of continual, multi-parameter VS monitoring on alarm rates, rapid response team (RRT) calls, intensive care unit (ICU) transfers, and unplanned deaths before and during the pilot study.

 

 

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Using Continuous Vital Sign Monitoring to Detect Early Deterioration in Adult Postoperative Inpatients - Johns Hopkins University

The current standard in patient monitoring, Episodic Vital Sign Collection (EVSC) is unable to provide a comprehensive view of a patient’s postoperative physiologic status, hindering the early intervention of patient deterioration. Delayed detection results in poor post-surgical patient outcomes. The study to compare the outcomes between EVSC and Continuous Vital Sign Monitoring (CVSM) was conducted at a 32-bed orthopedic, orthopedic-spine, and trauma general care ward. The control group (using EVSC)consisted of retrospective chart reviews of 427 patients spanning 12 weeks (Aug 11, 2015-Nov 8, 2015) vs an intervention group on CVSM(ViSi)of 422 patients over 12 weeks (Dec 11, 2015-Mar 8, 2016).

 

 

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Articles

Multi-parameter vital sign database to assist in alarm optimization for general care units

Continual vital sign assessment on the general care, medical-surgical floor is expected to provide early indication of patient deterioration and increase the effectiveness of rapid response teams. However, there is concern that continual, multi-parameter vital sign monitoring will produce alarm fatigue. The objective of this study was the development of a methodology to help care teams optimize alarm settings. An on-body wireless monitoring system was used to continually assess heart rate, respiratory rate, SpO2 and noninvasive blood pressure in the general ward of ten hospitals between April 1, 2014 and January 19, 2015. These data, 94,575 h for 3430 patients are contained in a large database, accessible with cloud computing tools. Simulation scenarios assessed the total alarm rate as a function of threshold and annunciation delay (s). The total alarm rate of ten alarms/patient/day predicted from the cloud-hosted database was the same as the total alarm rate for a 10 day evaluation (1550 h for 36 patients) in an independent hospital. Plots of vital sign distributions in the cloud-hosted database were similar to other large databases published by different authors. The cloud-hosted database can be used to run simulations for various alarm thresholds and annunciation delays to predict the total alarm burden experienced by nursing staff. This methodology might, in the future, be used to help reduce alarm fatigue without sacrificing the ability to continually monitor all vital signs.

 

 

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Wireless and continuous monitoring of vital signs in patients at the general ward

Background Clinical deterioration regularly occurs in hospitalized patients potentially resulting in life threatening events. Early warning scores (EWS), like the Modified Early Warning Score (MEWS), assist care givers in assessing patients’ clinical situation, but cannot alert for deterioration between measurements. New devices, like the ViSi Mobile (VM) and HealthPatch (HP) allow for continuous monitoring and can alert deterioration in an earlier phase. VM and HP were tested regarding MEWS calculation compared to nurse measurements, and detection of high MEWS in periods between nurse observations. Methods This quantitative study was part of a randomized controlled trial. Sixty patients of the surgical and internal medicine ward with a minimal expected hospitalization time of three days were randomized to VM or HP continuous monitoring in addition to regular nurse MEWS measurements for 24–72 h. Results Median VM and HP MEWS were higher than nurse measurements (2.7 vs. 1.9 and 1.9 vs. 1.3, respectively), predominantly due to respiratory rate measurement differences. During 1282 h VM and 1886 h HP monitoring, 71 (14 patients) and 32 (7 patients) high MEWS periods were detected during the non-observed periods. Time betweenVM or HPbased high MEWS and nextregular nurse measurement ranged from 0 to 9 (HP) and 10 (VM) hours. Conclusions Both VM and HP are promising for continuous vital sign monitoring and may be more accurate than nurses. High MEWS can be detected in hospitalized patients around the clock and clinical deterioration at an earlier phase during unobserved periods.

 

 

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White Papers

The Importance of Capturing All Vital Signs

The data is clear: as many as 50% or more of non-DNR hospital deaths occur outside the ICU. The three reasons why are: increased patient acuity, unpredictable or unknown patient risk factors, and patient deterioration that goes unrecognized. Most patients that decompensate show evidence of deterioration for as much as 6 to12 hours prior to their clinical event. For detecting patients at risk, the current standard of checking vital signs every 4 to 8 hours is simply inadequate. Healthcare leaders and clinicians need new ways to create a safer environment for patients.

 

 

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Addressing the Alarm Burden

Alarm-equipped devices are designed to provide safe care to patients in many health care settings and clinicians depend on these devices to guide treatment decisions and deliver appropriate care. The number and frequency of alarms is highest in ICU settings, where drug therapy and mechanical devices including monitors, ventilators, and IV pumps - all with alarm settings - are used to carefully control a patient’s physiology. Every aspect of care is highly sensitive. Alarm thresholds and delay settings are commonly set to ranges that quickly identify any deviation from expected values. In these settings, the monitoring done is called “condition monitoring” which is the use of a patient monitoring system that targets a patient’s risk profile. Another example of condition monitoring is the use of cardiac telemetry ordered for use when a patient with heart disease is considered at risk for a cardiac event.

 

 

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The Financial Benefits of Surveillance Monitoring

With the rising acuity of hospitalized patients, nursing leadership at the regional hospital where the trial was conducted realized that early detection of patient complications and proactive nursing intervention has the potential to decrease mortality and morbidity while increasing patient and clinician satisfaction. In October 2013, a team of nurse leaders, led by the hospital system’s Chief Nursing Officer, embarked upon a patient surveillance monitoring project. To develop an approach that could apply to hospitals in their system nationwide, the team selected two facilities with strong local leadership: a 49-bed acute care facility serving rural counties in southeastern Utah, and a 175-bed, full-service hospital located in Selma, Alabama.

 

 

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Surveillance Monitoring of General-Care Patients – Part 1 - A Call To Action

Perhaps the most interesting objects connected on the “internet of things” are all of us. With the advent of inexpensive sensors best exemplified by consumer-oriented fitness trackers, coupled with the communication, location, and computational power embedded within smartphones, we are experiencing the first steps towards connecting all of us in a way that says ‘who we are,’ ‘where we are,’ and ‘how we are’ all the time. Information gathered from consumer devices (heart rate, weight, glucose levels, activity levels, sleep patterns, caloric intake and more) can provide part of a person’s ‘health’ picture (the ‘how we are’), but it is best understood within the context of more formal data collected from traditional healthcare sources.

 

 

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Surveillance Monitoring of General-Care Patients – Part 2 - Nurses, Physicians and Cost of Care

As emphasized in an Institute of Medicine (IOM) report, nurses play a pivotal role in preventing and identifying complications and, therefore, are critically involved in identifying and rescuing patients from death following complications.1 Failure to rescue (FTR) occurs when complications are not recognized and/or interventions are not activated. Surveillance—the purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decisionmaking —is a nursing intervention used to help prevent FTR.

 

 

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Surveillance Monitoring of General-Care Patients – Part 3 - Alarm and Alert Management

When determining alarm and alert strategies for surveillance monitoring, the fundamental questions are: Why is the patient being surveilled? What are the primary goals of surveillance? Is monitoring to be primarily predictive, detective, or both? To help answer these questions, Devita et al divide monitoring goals into two broad categories: prediction and detection. They define prediction (prognostication) as the estimation of the risk of deterioration over various time frames, and detection as the recognition of critical illness at a particular moment. These two types of monitoring may have different data requirements, but since it is unknown when any given patient might begin to deteriorate, it makes sense that detection will be better served by frequent if not continuous measurements.

 

 

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A Blood Pressure Study Demonstrating Equivalence of the ViSi Mobile® System and GE DINAMAP™ CARESCAPE™ V100

The ViSi Mobile® and the GE DINAMAP™ CARESCAPE™ V100 both use a technique called automated cuff oscillometry to determine mean arterial pressure (MAP). Both monitors estimate systolic (SBP) and diastolic (DBP) blood pressure from MAP with proprietary algorithms. A study was conducted by an independent laboratory to compare non-invasive blood pressure (NIBP) determined by ViSi Mobile and the GE DINAMAP on the same person. Measurements were made on 79 separate individuals of varying ethnic origins, arm size and blood pressures. The average difference between ViSi Mobile and GE DINAMAP NIBP was 4 mmHg for both SBP and DBP. This difference is small and clinically insignificant; we can conclude that there is no difference in blood pressure determined with the ViSi Mobile and the GE DINAMAP.

 

 

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ViSi Mobile Resources & Videos

Enterprise Deployment

Reduce total cost of ownership by purchasing one flexible, scalable patient monitoring solution which leverages your existing IT and wireless infrastructure. Realize clinical workflow efficiencies by integrating with the EHR and mobile devices. Vital sign observations can be sent to the EHR and alarms to the mobile devices.

 

 

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ViSi Mobile InSight

ViSi Mobile® InSight delivers alarms to the appropriate clinician through configurable escalation paths to their mobile devices.

 

 

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How ViSi Mobile Can Help with Infectious Disease

The ViSi Mobile Monitoring System provides clinicians with a constant stream of data to help identify early signs of deterioration that can help prevent adverse events while keeping the caregivers safe. The ViSi Mobile System accurately captures and wirelessly transmits all core vital signs: Continuous Non-Invasive Blood Pressure, ECG, SpO2, Heart Rate / Pulse Rate, Respiration Rate, and Skin Temperature. ViSi Mobile can detect Life Threatening Arrhythmias as well as track and alert clinicians to undesirable patient positions, patient immobility, and patient falls.

 

 

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Enhanced Software Features and New Detection and Alerting

This document shares some of the newer features and alerts that were released in 2019 .

 

 

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