Continuous Monitoring of Patients Provides Versatile, Improved Care Case Studies

As connectivity redefines healthcare administration and patient care, automation has become important to both inpatient and remote settings.

Susan McGrath, PhD, director of surveillance core analytics for Dartmouth Hitchcock Medical Center can pinpoint the case that drove them to expand their hospital automation and continuous monitoring of patients.

A patient in his 30s was admitted to a general care unit after undergoing minor surgery. The patient’s history of anxiety and pre-existing conditions was assessed and deemed to represent little perioperative risk. The patient was given medications for anxiety and opioids for pain. The patient’s initial postoperative assessment was normal. Yet, when a nurse entered the room at a regularly scheduled time to perform a vital signs assessment, the patient was found deceased.

“This was really the case that led us to say that this should never happen to a patient at Dartmouth-Hitchcock ever again,” McGrath said. “The act of intermittent, manual vital sign collection is just not at a frequency or detail that provides clinicians with the ability to really detect patient deterioration in a timely manner.”

With manual patient monitoring, clinicians are likely to miss significant changes in oxygen saturation, pulse rate, respiration rate, total hemoglobin and other clinical measurements.

“There’s indeed a lot of information that’s just not seen when you’re looking only at intermittent vital signs manually,” McGrath said.

Continuous Monitoring Makes a Difference

To address this issue, the healthcare center implemented an electronic surveillance patient monitoring system in its general care settings about 15 years ago and has continued to expand the use of automated systems in other areas since then. This helps aggregate data from bedside monitors and deliver the information directly to clinicians via their phones, pagers or computers so they can provide needed interventions.

“We believe that continuous monitoring of all patients in all settings is really something that is important in order to prevent deterioration from going too far and to bring resources to the bedside in an efficient way that brings treatment to patients,” McGrath said.

The healthcare center now aims to improve its ability to both detect and respond to patients in decline in a variety of care settings, as it leverages continuous monitoring to address numerous challenges, such as delays in information delivery; loss of information; and limited understanding of risks, warning signs and possible outcomes. Perhaps most importantly, the hospital is using automated systems to help clinicians deal with the “noise” associated with all the unnecessary information they are typically bombarded with when caring for patients.

“With all of the blinking lights and alarms, it’s often very difficult for clinicians to understand what is important and what is needed... and how to best care for that patient,” said Jennifer Jackson, director of connectivity for Masimo, which produces the monitoring technology.

Automated alerting, however, has enabled clinicians to take the actions that effectively meet the needs of patients in decline. In fact, “We recently published a study that looked back over the 10 years after implementation and shows that in monitored patients we had not a single death... from opioid-induced respiratory depression,” McGrath noted.

Some of the data from that study:

• Of 111,488 patients who were monitored during this time period, none died or experienced opioid-produced respiratory depression
• Out of the 15,209 unmonitored patients, three died

A more recent patient reveals how monitoring now benefits patients’ health at the hospital. A man in his 60s was admitted to the intensive care unit (ICU) with multiple injuries after a car accident. The automated surveillance system continuously monitored his health status via data from electrocardiogram (ECG) and pulse oximetry devices as well as periodic vitals charting from the EHR. After being in the ICU for three days, the patient was transferred to the general care unit. The electronic patient monitoring continued, and the rescue team was called when pulse oximetry alarms sounded. As a result, the patient was transferred back to the ICU to manage ventilation and his stay was extended an additional five days.

Keeping Tabs on Home-Based Patients

While Dartmouth-Hitchcock’s experience illustrates why it is important to electronically monitor patients in all inpatient areas, when the pandemic took hold, leaders at Renown Health recognized how crucial it is to automatically check on those receiving care outside of the hospital’s four walls, as well.

“The pandemic pushed the boundaries for parity when it comes to telemedicine. How long will it be before the entire healthcare system repositions itself to provide hospital-level care for patients at home through ongoing remote monitoring,” asked Tony Slonim, MD, DrPH, president and chief executive officer for Renown Health.

During the COVID-19 pandemic, addressing the needs of this community’s patients and families brought many issues surrounding home care to the forefront of the healthcare system’s approach to population health.

“How great would it be for people to not have to drive four hours because we can put wearable, continuous pulse oximetry literally at their fingertips, and measure oxygen saturation, pulse rate and respiration from 200 miles away,” Dr. Slonim asked. 

They utilized a pulse oximeter monitor to actively prompt patients to answer questions such as, are you having trouble breathing? Or what is your temperature? These responses, along with other data, are pushed to clinicians at Renown Health for evaluation.

This at-home model of care enabled patients to receive hospital-level care in the comfort of their own homes.

“There is now compelling evidence that well-monitored, at-home treatment can be safer, cheaper and more effective than traditional hospital stays, especially for patients who are elderly, frail and vulnerable to complications,” said Renown’s director of telehealth, Mitchell Fong.

“Our patients have the most sophisticated and reliable respiratory monitoring available anywhere,” Fong said. “We know that continuous physiologic monitoring with Patient Safety Net improves outcomes and saves lives. The ability to extend that capability to patients in nontraditional settings and at home during this crisis is transformative.”

In addition, to effectively act on all alerts, this healthcare system partnered with its local emergency medical services (EMS) agency. When hospital staff receive an alert and need additional resources to reach the patient or the emergency contact, the EMS unit will conduct a wellness check. This extra step ensures that patients’ needs are met.

“It’s about making sure that you have clear escalation pathways, that there’s coordination and resources available to take timely and appropriate action,” Fong said.

To accommodate this surge in patient volume due to COVID-19 cases, the hospital converted an adjacent parking garage into a fully equipped alternative care site-field hospital.

“This type of technology, is a game-changer in improving patient care,” said chief medical officer of acute services, Paul Sierzenski, MD. “Given the demand on our hospitals during this COVID-19 pandemic, we are pleased to provide appropriate patients with this telehealth solution, which uses wearable pulse oximetry, allowing us to help manage the surge in COVID-19 patients, and allowing patients the convenience of their own homes.”

Patients also reported high satisfaction levels with the care they received while on the remote patient monitoring system; 91% of those surveyed indicated that they would recommend Renown.

Addressing Challenges with Maturing Systems

The experiences at Dartmouth-Hitchcock and Renown illustrate the importance of leveraging automated monitoring systems across the care continuum. Without such electronic surveillance, healthcare providers are likely to struggle to meet patient needs because:

• EHR data is not sufficient to recognize immediate declines in patients
• Trend data from monitors in different settings is not available
• Risk scores are not shared across care settings
• State scores are not common
• Rescue resource allocation is not optimized

Fortunately, as electronic patient monitoring systems have evolved over the past 30 years, healthcare providers have been able to address these issues. In fact, these electronic systems now not only monitor oxygen levels, but also capnography, ventilator status, patient positioning and more in a variety of environments, including the operating room, ICU, neonatal ICU and other settings.

Most importantly, though, clinicians receive “contextualized information such as the location of the patient, the severity of the alarm and even the physiological values associated with that alarm, which enables them to take immediate action,” said Masimo’s senior vice president of software engineering, Omar Ahmed.

But the work is not done, as technology continues to advance. To further bolster effectiveness, it will also take fine tuning the alerts themselves.

“We are constantly looking at how to improve this notion of bringing the patient’s condition to the clinician. So again, it’s not just an instantaneous alert about a heart rate. Instead, we want to provide the clinician with information about what does that mean and what actions need to be taken to address the situation,” Jackson concluded.

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