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by Michael Wong
Vanderbilt University Medical Center (VUMC) is a highly respected comprehensive healthcare facility in the mid-southern region of the United States. Facilities like VUMC lead the way for safer patient care and improved health outcomes.
So when Brian Rothman, M.D., an associate professor in the Division of Multispecialty Adult Anesthesiology and medical director of perioperative informatics, recently spoke at the inaugural meeting of the National Coalition to Promote Continuous Monitoring of Patients on Opioids about VUMC's experience with continuous monitoring of low-acuity patients, I took the opportunity to interview him about this experience and what advice he would give to other healthcare facilities looking to similarly improve patient safety and outcomes.
Q: Why have Rapid Response Teams failed to improve outcomes?
A: Retrospective reviews of Rapid Response Teams (RRTs) show that there has been limited success in improving patient outcomes. This is because RRTs focus on improving response times to a recognized patient crisis rather than on anticipating when a crisis is likely to occur and initiating an intervention. Adverse events are preceded by a period of physiologic instability 6-8 hours prior to the event. We need to focus on early recognition of such physiologic change so that we can intervene at the earliest possible time. By doing so, we can potentially minimize escalation in care and the occurrence of adverse events.
Q: Why don't you think periodic checking of vital signs works?
A: Currently, monitoring of patients on the general care floor is continual (at regular intervals), not continuous. This means that a nurse assesses a particular patient on an intermittent basis. To me, checking on a patient every 4 or 6 hours is like checking to see if the fridge light is on.
Such checking can miss the early signs that the patient may soon deteriorate or that the patient may have already deteriorated. Missing these early deterioration signs can prevent us from intervening early, when intervention is most likely to be effective.
Q: So what is VUMC doing to improve the recognition of the moment of patient crisis?
A: We implemented a pilot program in selected general care floor units that continuously monitored patients' pulse oximetry and heart rate. This pilot didn't include end tidal carbon dioxide, but later phases to be implemented in 2015 will do so in specific patient populations. The objective was to facilitate early recognition of deterioration and cue rescue interventions at the earliest possible moment. Notifications were sent to a patient's nurse via pager when monitor values were outside established physiologic limits, with an escalation if there was no response.
Q: Were you concerned about a possible increase in alarm monitoring? If so, what did you do to minimize such events?
A: The possibility of increased alarms was certainly a concern. To proactively address this issue, we lowered thresholds and widened ranges consistent with the work done at Dartmouth. We have found that this decreased false positives, and yet still identified those at risk.
Q: What was the reaction of VUMC's staff to continuous monitoring?
A: When we surveyed nurses, we heard a lot of negative feedback, like there are too many false positives when a patient uses their hands, the finger probe is uncomfortable, the probe interferes with personal hygiene, patients don't see the necessity of continuous monitoring, monitoring impedes ambulation and inhibits mobility, and monitoring makes rooms too crowded. And yet, we met resistance when we tried to remove monitors from the pilot locations. We realized the survey told us more about the kind of survey we had conducted (for example, negatively worded survey questions were predominant) and what could be done to successfully implement the system rather than about the effectiveness of monitoring.
Q: What showed you and VUMC nurses that continuous monitoring was effective?
A: During our pilot, we saw a trend toward decreased RRT calls, fewer ICU transfers and shorter lengths of stay due to care escalation. We also saved at least two lives through early identification of physiologic instability and proactive interventions. As a result, we will be implementing continuous monitoring for all of our patients on the general care floor in 2015. By doing so, not only is VUMC improving patient safety and health outcomes through continuous monitoring, but we also may be benefiting financially as an institution.
Michael Wong, J.D., is the executive director of the Physician-Patient Alliance for Health & Safety and is the founding member of the recently created American Board of Patient Safety.
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