Respiratory Complications Respiratory Depression Other Complications Heart Arrhythmias Low HR Medication Management Pain Management

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3 Table of Contents Table of Contents 3 Respiratory Complications 4 Aspiration at the medical-surgical unit 5 Respiratory Acidosis and Oxygen Desaturation at the medical-surgical unit 6 Acute Respiratory Distress Syndrome (ARDS) at the medical-surgical unit 7 Pulmonary Embolism (PE) at the rehabilitation center 8 Aspiration Pneumonia at the rehabilitation center 9 Intubation and Transfer to ICU at the medical-surgical unit 10 Respiratory Depression 11 Narcan Treatment at the medical-surgical unit 12 Combined Narcotic and Antipsychotic Use at the medical-surgical unit 13 Transfer to ICU at the medical-surgical unit 14 Respiratory Therapy Intervention at the medical-surgical unit 15 Other Complications 16 Gastrointestinal Bleeding at the medical-surgical unit 17 Sepsis and Metabolic Acidosis at the medical-surgical unit 18 Heart Arrhythmias 19 Atrial Fibrillation Conversion to Normal Sinus Rhythm at the medical-surgical unit 20 Atrial Fibrillation Intervention at the medical surgical unit 21 Atrial Fibrillation Transfer to ICU at the medical-surgical unit 22 Supraventricular Tachycardia (SVT) at the medical-surgical unit 23 Low HR Medication Management 24 Reducing Metoprolol Dose at the rehabilitation center 25 Discontinuation of Amiodarone Treatment at the medical unit 26 Pain Management 27 Pain in a Non-Verbal Patient at the rehabilitation center 28 Severe Abdominal Pain at the medical-surgical unit 29 Severe Postoperative Pain at the medical-surgical unit 30 3

4 Respiratory Complications 1. Aspiration At the medical surgical unit 2. Respiratory Acidosis and Oxygen Desaturation 3. Acute Respiratory Distress Syndrome (ARDS) 4. Pulmonary Embolism (PE) At the rehabilitation center 5. Aspiration Pneumonia At the rehabilitation center 6. Intubation and Transfer to ICU 4

5 Aspiration A 74 year old male with a PEG (percutaneous endoscopic gastrostomy) was admitted with a forehead laceration due to a slip and fall. High respiratory rate (RR) alerts led nurses to do an assessment and review trends. They identified aspiration of PEG feedings. The feedings were held and respiratory therapy was administered. The patient stabilized and was discharged the following day to a skilled nursing facility. The EarlySense System alerted nurses to high RR s and led to rapid identification of aspiration. Timely intervention by nurses prevented a potentially life-threatening complication. High RR alerts; Suspected aspiration. Suctioning and breathing treatments are performed. Patient discharged to a SNF. 5

6 Respiratory Acidosis and Oxygen Desaturation A 61 year old female with CHF (congestive heart failure), COPD (chronic obstructive pulmonary disease) and pneumonia was transferred from the ICU to the unit. High RR alerts led to the administration of BiPAP (bilevel positive airway pressure) and to obtain ABG s (arterial blood gases), which revealed hypoxemia, hypercapnea and respiratory acidosis. The patient was transferred back to the ICU with worsening respiratory failure. The EarlySense System detected deterioration in the respiratory status of a newly transferred patient from the ICU, and prompted diagnostic evaluation (ABG s) indicating the need for a higher level of care. BiPAP is ordered. ABG tests are done: ph = 7.34, 7.33 pco2 = 77, 81 po2 = 55, 58 HCO3 = 41.5, 42.7 SaO2 = 86%, 88% High RR alerts Patient is transferred to ICU 6

7 Acute Respiratory Distress Syndrome (ARDS) A 54 year old woman was admitted with peritonitis and an incarcerated ventral hernia. The patient underwent a laparotomy with abscess drainage and repair. On postoperative day #3, the patient developed agitation, tachypnea, and severe oxygen desaturation. High RR alerts led to a diagnosis of possible aspiration pneumonia, abdominal sepsis and early ARDS (acute respiratory distress syndrome). Patient was transferred to ICU for intubation and mechanical ventilation. The EarlySense System alerted the nursing staff to high RR s and respiratory distress, and caused transfer to the ICU for treatment of respiratory failure. 00:46 High RR alert 01:01 High RR alert 01:40 High RR alert 7

8 Pulmonary Embolism (PE) At the rehabilitation center An 84 year old male with a history of hypertension and CHF was admitted to the rehabilitation center with a right femoral neck fracture following a fall, and underwent a right hemiarthroplasty. The EarlySense System alerted for high HR (heart rate). The nurse confirmed that the HR was over 140/min and BP was 140/80. The patient was exhibiting shortness of breath and wheezing. The EarlySense System issued additional alerts for high HR. The physician was called and the patient was transferred to the ER for shortness of breath, tachycardia, and possible PE (pulmonary embolism). The diagnosis of PE status-post right hemiarthroplasty was confirmed. The patient was stabilized. The EarlySense System alerted high RR s in a post-op orthopedic patient, resulting in a diagnosis of PE, a potentially life threatening condition. The patient was transferred to the ER for further treatment. High HR alerts 8

9 Aspiration Pneumonia At the rehabilitation center An 81 year old woman was admitted to the rehabilitation center S/P sepsis and CVA (cerebrovascular accident) with right hemiparesis. During the night shift, the EarlySense System alerted for high RR. The patient vomited coffee grounds. Vital signs were BP 100/70, HR 118/min and RR 38/min. Maalox was given and patient was made NPO. High RR alerts continued and, during change of shifts, the patient exhibited shortness of breath and a nebulizer treatment was given. The EarlySense Patient Trend Report showed continued High RR and prominent increases in both RR and HR compared with preceding nights. Laboratory work showed an elevated WBC (white blood count). The patient was transferred to ER to evaluate possible sepsis / GI bleed / aspiration pneumonia. The patient was diagnosed with aspiration pneumonia. The EarlySense System alerted for high RR s and HR s, leading to additional evaluation, a correct diagnosis and a transfer to the ER for further evaluation and treatment. High RR and HR alerts High RR alerts High RR alerts Coffee ground vomiting. The medical director evaluates the patient. Blood work is ordered. Maalox is given. 9 Shortness of breath and trouble breathing Nebulizer treatment is administered. Medical Director is called to unit. Blood work results show elevated WBC. The patient is transferred to ER. Patient is diagnosed with Aspiration Pneumonia.

10 Intubation and Transfer to ICU A 38 year old woman with recently diagnosed Stage IV Hodgkin s lymphoma was admitted with fever and neutropenia. The EarlySense System alerted for high RR and HR, and the RRT (Rapid Response Team) was activated for worsening respiratory status, tachycardia and hypertension. Trend analysis shows increasing HR and RR for nearly 2 hours before RRT activation, demonstrating that early signs of deterioration can be detected and tracked by the monitor. The patient was intubated and transferred to the ICU. The EarlySense System alerted for both tachycardia and tachypnea, and provided a recognizable trend that anticipated the need to call the RRT. RRT Activation High HR alerts 10

11 Respiratory Depression 1. Narcan Treatment 2. Combined Narcotic and Antipsychotic Use 3. Transfer to ICU 4. Respiratory Therapy Intervention 11

12 Narcan Treatment A female patient diagnosed with left tibial plateau fracture underwent a left leg fasciotomy and ORIF (open reduction internal fixation). Following surgery the EarlySense System generated multiple alerts indicating a low RR of 8/min. The nurse identified postoperative respiratory depression. The patient was given Narcan and the RR increased to 12-16/min. The patient s postoperative respiratory depression was appropriately treated. A low RR alert helped nurses identify narcotic-induced, postoperative respiratory depression. Timely administration of a narcotic antagonist prevented a potentially life threatening complication. Multiple alerts indicating low RR Surgery Narcan was given due to respiratory depression following anesthesia. 12

13 Combined Narcotic and Antipsychotic Use A 56 year old male with metastatic squamous cell CA and schizoaffective disorder was admitted with soft-tissue inflammation and uncontrollable pain. The patient required narcotic analgesia, including a Fentanyl patch, in addition to the antipsychotics olanzapine and quetiapine. The EarlySense System detected a low RR; the patient was found to be lethargic with a RR of 6-7/min. The Fentanyl patch was removed. Following removal of the Fentanyl patch, the RR returned to normal. The EarlySense System alerted for a low RR secondary to respiratory depression, probably attributable to the combined effects of narcotic analgesia and antipsychotics, which resolved when the narcotic was withdrawn. One of the important features of the EarlySense system is the decision support capability to analyze several minutes of data before alerting, thus reducing false alarms due to artefacts or transient insignificant variation. 02:00 Low Respiratory Rate Alert 13

14 Transfer to ICU An 81 year old woman underwent a total knee arthroplasty revision. Postoperatively, the EarlySense System generated multiple low RR alerts over a time period of less than 30 minutes. The patient was found to be lethargic with a respiratory rate of 8-9/min. Anesthesiology was contacted and the patient was transferred back to the postanesthesia care unit. The patient was subsequently admitted to the ICU for overnight observation of her postoperative hypopneic episodes and was transferred out of ICU the following day. The EarlySense System alerted to postoperative hypopneic episodes, prompting additional close observation of this elderly patient. A Boston Globe front page article on 2/13 and 2/14/11 describes the risks of faulty monitors as well as alert fatigue in hospitalized patients. One of the strengths of the EarlySense system is the smart technology that markedly reduces false alerts and minimizes alert fatigue. The concept of smart technology was described in the article as the best future solution for reliable monitoring. Low RR alerts 14

15 Respiratory Therapy Intervention A 69 year old diabetic female underwent a below-knee amputation. Postoperatively, she was given narcotics for pain control. Respiratory depression was recognized in the recovery room and Narcan was administered. The patient was transferred to the unit. The nursing staff was aware of the patient s condition (drowsy following administration of narcotics) and monitored her vital signs using the EarlySense central nurse station screen. The EarlySense System generated a low RR alert of 5/min. The staff stayed at the bedside stimulating the patient and had her use an incentive spirometer, leading to normal respiratory rates and better lung expansion. Patient s respiratory status was stabilized. Two days later the patient was discharged. The EarlySense monitor alerted to postoperative bradypnea, which was successfully treated at the bedside. Reintubation and mechanical ventilation were avoided. 15

16 Other Complications 1. Gastrointestinal Bleeding 2. Sepsis and Metabolic Acidosis 16

17 Gastrointestinal Bleeding A male was admitted with respiratory failure, tachycardia, fever, diabetes and alcoholism. The EarlySense System detected consistent and gradual HR increases from 110/min to 155/min. The system generated five alerts of high HR ( BPM). The physician was informed. The patient was diagnosed with new GI (gastrointestinal) bleeding and was transferred to the ICU. After two days the patient s condition improved and he was discharged from the ICU. The EarlySense System s high HR alerts helped identify unsuspected GI bleeding. Timely intervention by clinicians prevented more serious complications. 1:00 am to 6:00 am - HR increasing up to 155 BPM. 4:03 High HR alert: 129 BPM 5:17 High HR alert: 142 BPM 5:18 High HR alert: 140 BPM 5:39 High HR alert: 151 BPM 5:46 High HR alert: 150 BPM 17

18 Sepsis and Metabolic Acidosis A 76 year old female was admitted to the unit with acute pancreatitis. Her chief complaint was severe, non-radiating abdominal pain. The patient s RR gradually increased and alerts of high RR were generated by the EarlySense System. The nurse assessed the patient; vital signs were HR /min, RR /min and O2 saturation was 90%. The patient was having difficulty breathing and right chest pain. The physician was notified. The patient was transferred to telemetry unit and later to the ICU. She was intubated and diagnosed with necrotizing pancreatitis and sepsis. The high RR was secondary to metabolic acidosis. Her condition gradually improved and she was transferred from the ICU to telemetry. The EarlySense System alerted the nurses to signs of sepsis and helped diagnose metabolic acidosis. Timely intervention by the clinical team was crucial to a positive patient outcome. RR: Br/min HR: BPM Sat: 90% High RR alerts Sepsis and metabolic acidosis diagnosed. Patient is transferred to telemetry unit. 18

19 Heart Arrhythmias 1. Atrial Fibrillation Conversion to Normal Sinus Rhythm 2. Atrial Fibrillation Intervention At the medical surgical unit 3. Atrial Fibrillation Transfer to ICU 4. Supraventricular Tachycardia (SVT) 19

20 Atrial Fibrillation Conversion to Normal Sinus Rhythm An 86 year old male with a history of Type 2 DM, CVA, CAD, chronic renal insufficiency and recurrent DVTs was admitted for possible aspiration pneumonia. The EarlySense system alerted for an elevated HR (150 s). The nurse confirmed an asymptomatic tachycardia and notified the physician. The patient was found on examination and EKG to be in atrial fibrillation. The patient was given intravenous metoprolol and converted to NSR (normal sinus rhythm). Following conversion, the patient remained in NSR. Three days later he was discharged. The EarlySense System alerted the staff to a tachycardia and an EKG diagnosed atrial fibrillation, which was successfully converted to NSR. High HR alerts 20

21 Atrial Fibrillation Intervention A 64 year old male with a history of hypertension underwent an exploratory laparotomy and hemicolectomy for bowel obstruction. The EarlySense System alerted the staff to an asymptomatic tachycardia (heart rate 159/ min). The nursing evaluation confirmed atrial fibrillation. Following treatment with metoprolol, diltiazem and diuretics (for suspected fluid overload), he was placed on telemetry. The ventricular rate improved followed by conversion to NSR. The patient was discharged home three days later. The EarlySense System alerted the staff to a tachycardia, prompting further evaluation, diagnosis and successful treatment of atrial fibrillation. High HR alerts 21

22 Atrial Fibrillation Transfer to ICU A 69 year old male was admitted to the Med-Surg unit with newly diagnosed small cell lung cancer. The initial HR was /min. The EarlySense System generated an alert indicating a high HR of 152/min. The nurse assessed the patient and found that O2 saturation was 86% and BP was 83/63. The physician was notified. Rapid atrial fibrillation was diagnosed, and the patient was transferred to the ICU. In the ICU the patient was converted to NSR and the HR decreased to normal values. The EarlySense System alerted the hospital team to identify previously undiagnosed atrial fibrillation, with appropriate transfer to a higher level of care and successful conversion to NSR. Multiple alerts of high HR 22

23 Supraventricular Tachycardia (SVT) A 53 year old female was hospitalized in the Med-Surg unit following hemicolectomy. The system alerted for a high HR of 191/min. An RN confirmed the HR of 197/min by pulse oximetry and the EarlySense System, simultaneously. The patient s physician was alerted and an EKG revealed an SVT. The patient was continuously monitored and given adenosine, leading to a HR reduction. he patient was transferred to the ICU. Five days later, the patient was discharged home. The EarlySense System alerted nurses to identify an SVT in a postoperative patient. Timely intervention by the hospital team contributed significantly to a positive patient outcome. Adenosine administration High HR alerts ECG reveals SVT 23

24 Low HR Medication Management 1. Reducing Metoprolol Dose At the rehabilitation center 2. Discontinuation of Amiodarone Treatment At the medical unit 24

25 Reducing Metoprolol Dose At the rehabilitation center A 94 year old woman was admitted with atrial fibrillation, dementia and muscle weakness. The patient was placed on metoprolol, with parameters to hold the medication for HR <60 or diastolic BP < 100. Within 24 hours the EarlySense System generated an alert for a low heart rate (40/min), with repeated episodes during subsequent hours. The nurse assessed the system s trends and notified the physician, who ordered holding the next dose of metoprolol and reducing subsequent doses by 50 %. Following the change in medication dose the patient s heart rate improved. The EarlySense System alerted the staff to a medication-induced bradycardia, prompting a reduction in the metoprolol dose. Alerts of low HR during the night 25

26 Discontinuation of Amiodarone Treatment At the medical unit A 61 year old male was hospitalized for a CHF exacerbation. Due to his medical history, the patient was taking amiodarone. The EarlySense System showed a baseline bradycardia, and specifically alerted for a very low HR (33 BPM). The physician was notified and consulted a cardiologist, who temporarily discontinued amiodarone. The patient s HR improved following the temporary discontinuation of amiodarone, and no other episodes of severe bradycardia subsequently occurred. The EarlySense System alerted for a severe bradycardia, which was corrected by temporary discontinuation of amiodarone. Low HR alert: 33 BPM Procor treatment temporarily discontinued due to bradycardia. 26

27 Pain Management 1. Pain in a Non-Verbal Patient At the rehabilitation center 2. Severe Abdominal Pain 3. Severe Postoperative Pain 27

28 Pain in a Non-Verbal Patient At the rehabilitation center An 85 year old woman with dementia, hypertension and a hairline fracture of the right shoulder was hospitalized in the rehabilitation center. She was non-verbal. The EarlySense System alerted for high HR and RR. The patient was unable to verbalize her needs, but appeared uncomfortable. The nurse notified the physician, who recognized inadequate pain control and modified the patient s pain control medication. The patient was more comfortable after the change in analgesics, and the HR and RR normalized. The EarlySense System alerted for a high HR and RR, reflecting inadequate pain control in a non-communicative patient. Alerts of high HR 28

29 Severe Abdominal Pain A 79 year old female was admitted with shortness of breath and hypoxemia. The patient had history of breast cancer treated with lumpectomy, chemotherapy and radiation therapy 2 years prior. The EarlySense System generated several high RR alerts. An RN assessed the patient and found that she was having severe abdominal pain. Morphine IV was administered. Following the administration of pain medication, the patient s pain was relieved and the RR gradually returned to normal. A new breast mass was identified and an endometrial cancer was suspected. The patient stayed in the med-surg unit for further tests and chemotherapy. The EarlySense System detected a high RR which alerted the staff to a patient with severe pain, which eventually led to further evaluation and new diagnoses. 8:00 pm - Morphine Sulfate 1 mg is given IV for severe abdominal pain. 11:00 pm Tylenol 3 is given for moderate abdominal pain. High RR alerts 29

30 Severe Postoperative Pain A 22 year old female was hospitalized in the med-surg unit with an ovarian cyst and underwent an exploratory laparotomy. The EarlySense System generated high HR alerts. The nurse identified that the patient was having severe postoperative pain, and analgesics were administered. Following the administration of pain medication, the patient s pain and HR decreased. Within 48 hours the patient was discharged from the unit. The EarlySense System detected high HR s, which alerted the staff to assess a patient with severe postoperative pain. Demerol administration Surgery High HR alerts 30

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