Sue Carol Verrillo, RN, MSN, CRRN The Johns Hopkins Hospital November 14, 2014
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1 Early Detection of Patient Deterioration Using Remote Patient Monitoring with Wireless Nurse Notification Sue Carol Verrillo, RN, MSN, CRRN The Johns Hopkins Hospital November 14,
2 Why Remote Patient Monitoring Anesthesia Patient Safety Foundation (2011)₁,₅ Continuous monitoring while on parenteral narcotics Caregiver notification system Joint Commission Sentinel Event Alert (2012)₁ Systematic protocols for assessing, management & opioid dosing Continuous monitoring of oxygenation & ventilation Center for Medicare and Medicaid Services (2012)₁ Respiratory Rate, sedation, and pulse oximetry monitoring of all patients receiving PCA Joint Commission New Safety Goal (2014) Alarm Management & Safety Reduce alarm fatigue Phased implementation by Association for the Advancement of Medical Instrumentation 2
3 Why Remote Patient Monitoring? "In Pursuit of High Reliability Sensitivity to operations: Preserving constant awareness by leaders and staff of the state of the systems and processes that affect patient care. This awareness is key to noting risks and preventing them. Remote Patient Monitoring: Changing historic vital sign collection process Total patient situational awareness vs. snapshot in time Recognizes the dynamic nature of patient condition Providing caregivers with essential data to intervene sooner Longitudinal data trending 2014 Association for the Advancement of Medical Instrumentation 3
4 Remote Patient Monitoring Project Goals Respond to national initiatives R/T failure to rescue and preventable harm Determine if a non-invasive system for physiologic data collection can improve recognition and response to deterioration Identify vital sign patterns predictive of patient deterioration Analyze inter-relationships between independent parameters Integrate alarm management with current nurse call equipment Development of meaningful alarm notification algorithms 2014 Association for the Advancement of Medical Instrumentation 4
5 Study Environment Non-Monitored, 32 bed, adult surgical general care unit Standard of Care: every 4-8 hr. VS collection Primary Patient Populations General Orthopaedics/Spine Trauma General Surgery Neuro Significant daily patient turnover Nurse/Patient Ratios 1:5-7 depending on shift Charge RN with patient assignment ClinTech assignment ranges 8-16 pts. depending on shift 2014 Association for the Advancement of Medical Instrumentation 5
6 Project Implementation Summer 2013 Education/Training: Project Introduction Group based training on system Role based individual competencies Technical integration with hospital/nurse call systems Soft Go-live November 2013 Phased full unit Go-live February 2014 Placed on admission; monitored for minimum of 48 hrs. or until clinically stable Pre-determined alarm parameters; lower threshold reduces delivery of self-correcting alarms₄ HR: < 45 or > 135 SpO2: < 85% RR: < 6 or > Association for the Advancement of Medical Instrumentation 6
7 Data Collection System FDA approved Masimo Patient Safety Net System Central View Station: Continuously view and trend data Remote Bedside Data Collection: Motion and low perfusion pulse oximetry Heart Rate Monitoring Acoustic Respiratory Rate Monitoring 2014 Association for the Advancement of Medical Instrumentation 7
8 Alarm Notification Integration Connexall Middleware Assignment management Pre-determined alarm escalation Ascom Wireless Communication System Alarm notification 2014 Association for the Advancement of Medical Instrumentation 8
9 Results / Patient Condition Changes Enrollment: approximately 500 patients since February 2014 Rapid Response Activation (17) Desaturation / pneumothorax/ PE- DVT Desaturation R/T mucous plugging Unresponsiveness/hypoxia/ adverse response to chemo-embolization Tachycardia/Arrhythmia ICU Transfers (10) 10 RRT required transfer New Onset Arrhythmias (provider response & management) x 5 4 codes with 2 deaths on the unit; 2 transferred to higher level of care Team Managed Conditions; early intervention Desaturation, tachypnea, tachycardia Interventions: fluid bolus, PE work-ups, med adjustment/consults Routine Nursing Interventions Supplemental O2, pulmonary toilet, pain management 2014 Association for the Advancement of Medical Instrumentation 9
10 Case Study: New Onset Arrhythmia 67 y/o male, s/p Total shoulder replacement Hx: BPH, DJD ankle/shoulder, palpitations, bradycardia PACU: isolated, asymptomatic 3 sec arrhythmia Admit VS: 140/71, HR 52, 100% 2L NC- PNC cath POD #1 5 am: alarm notification of tachycardia 145 (aflutter/afib) RRT called- transfer to ICU- adenosine/metoprolol, cardiology consult 1 pm: normal sinus, transferred back to inpt. unit; VS 105/58, HR 61 POD #2 6 am: EKG normal sinus, 7am: VS 120/70, HR 67- oral Metoprolol 9 am: alarm notification of asymptomatic tachycardia 150 (SVT); team managed/surgical intensivist consulted- ICU transfer POD #3 Cardiology advised DC on oral beta-blocker, outpatient cardiology management- DC home 2014 Association for the Advancement of Medical Instrumentation 10
11 Case Study: Hypoxia RRT 73 y/o female, ER admit s/p unresponsive at home Hx: schizophrenia, HTN, DM Type 2, CKD Stage III,COPD,pancreatitis, toxic megacolon s/p total colectomy 2012, gastric ulcers, PVD, alcoholism Complex ICU stay: small bowel ischemia/ex-lap, sepsis, renal failure, pleural effusions, CLABSI, pressure ulcer development, chronic vent dependence- tracheostomy, PEG placement POD #18: transfer to inpt. unit; VS 142/78, HR 94, 95% 35% FiO2 POD #20 730a: alarm notification O2 sats 76% (4am 100%) RRT called Aggressive suctioning, supplemental O2/bag valve mask- Transfer ICU POD #21: return to floor s/p ICU monitoring post mucous plug POD #23: alarm notification O2 sats 85%, unresponsive to suctioning, bag valve mask RRT called, respiratory therapy deep suctioning, ABG/CXR- mucous plug Maintained on floor with continued remote patient monitoring POD #36: Discharged to chronic care, still requiring supplemental O Association for the Advancement of Medical Instrumentation 11
12 Barriers Multi-system technical integration; software optimization Changing staff perspective on patient condition Appreciate physiologic variations post operatively Sustained vs. Transient vs. False Alarm events Ongoing Monitoring: compliance post-night of surgery Alarm fatigue: making wireless alarm messaging meaningful Patient Engagement Compliance with wearing monitoring devices doppler/pulse ox Hard-wired devices interfering with activity/independence Non-unit/float staff utilization, influx of new unit staff 2014 Association for the Advancement of Medical Instrumentation 12
13 Surveillance Monitoring Policy is under development with roll-out by January 1, 2016 Still in pilot- no ROI data yet
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