continuous vital sign monitoring in low acuity hospital settings
TRANSCRIPT
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Continuous Vital Sign Monitoring in Low Acuity Hospital Settings: Why
and How
Frank J. Overdyk MSEE, MD
AAMI FOUNDATION REGIONAL EVENT
September 27-28, 2016, Chicago, IL
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Disclosure
• Consultant; Covidien - Medtronic Respiratory Monitoring Solutions
• Consultant Medical Director; Qcore Ltd.
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Makary, MA. Etal. BMJ 353 (2016): i2139.
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AHRQ PSI’s: potentially preventable patient safety incidents PSI 02 Death Rate in Low-Mortality Diagnosis- Related Groups (DRGs)
PSI 03 Pressure Ulcer Rate
PSI 04 Death Rate Among Surgical Inpatients with Serious Treatable Complications
PSI 05 Retained Surgical Item or Unretrieved Device Fragment Count
PSI 06 Iatrogenic Pneumothorax Rate
PSI 07 Central Venous Catheter-related Bloodstream Infection Rate
PSI 08 Postoperative Hip Fracture Rate
PSI 09 Perioperative Hemorrhage or Hematoma Rate
PSI 10 Postoperative Physiologic and Metabolic Derangement Rate
PSI 11 Postoperative Respiratory Failure Rate
PSI 12 Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate
PSI 13 Postoperative Sepsis Rate
PSI 14 Postoperative Wound Dehiscence Rate
PSI 15 Accidental Puncture or Laceration Rate PSI 16 Transfusion Reaction Count
PSI 17 Birth Trauma Rate – Injury to Neonate
PSI 18/19 Obstetric Trauma Rate – vaginal delivery with/wo instrument
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March 2015
Indicator Description Numerator Denominator Observed Rate per 1000
PSI #2 Death Rate on Low-Mortaility DRG’s
1,822 5,636,509 0.32
PSI #4 Death Rate among Surgical Inpatients with Serious Treatable Conditions (Cardiac arrest, PE, pneumonia, Sepsis, GI bleed; aka “ FAILURE TO RESCUE”)
22,014 185,587 118.62
March 2015, 2012 data
_____ 23,836 28,703 prescript opioid deaths (2014)
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PSI #2
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Rachel
39 y.o. mother; Admitted on a Friday night to med-surg floor with kidney stones
Morphine PCA; standard q4 hour vital sign monitoring
“Increasingly lethargic; snoring and sleeping” @ 2100
Cardiopulmonary arrest @ 2135; Fatal
anoxic brain injury
With permission from patient family
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In-hospital Cardiac Arrest
Incidence of cardiac arrest: 1/ 1000 hospital bed days (190,000 in 2012)
Girotra, Saket, et al. "Trends in survival after in-hospital cardiac arrest." New England Journal of Medicine 367.20 (2012): 1912-1920.
38% of survivors had critical anoxic brain injury
PSI #4
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PSI #4: Better outcomes than expected…….
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PSI #4: Worse outcomes than expected…….
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Association of Opioids and Sedatives with Increased Risk of In-Hospital
Cardiopulmonary Arrest. Overdyk FJ, Dowling O, Marino J, et. al.
PLOS ONE 11.2 (2016): e0150214.
Opioids/Sedative Use
2007-1012
Cardiac Arrest
(n=96,554)
No Cardiac
Arrest
(n=12,180,137)
Odds
Ratio* 95% CI
Both Opioid and Sedative 41.0 % 21.8% 3.47 (3.40, 3.54)
Opioid only 28.0% 31.4% 1.81 (1.77, 1.85)
Sedative only 13.8% 14.3% 1.82 (1.78, 1.87)
Neither Opioid Nor Sedative 17.2% 32.6% Ref.
“Low Acuity” Patients Cardiac Arrest
General Care Floor 21,564
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Incidence, Location and Reasons for Preventable in-
hospital Cardiac Arrest in a District General Hospital Hodgetts T, Kenward G, Vlackonikolis I, et. al.
Resuscitation 54: (2002) 115-123
– 78% of general care ward cardiac arrests (139) were deemed ‘avoidable’.
– The odds of a potentially ‘avoidable’ cardiac arrest was
5.1 times greater for the general care ward than a monitored setting.
– Patients arresting at night and on weekends: 15% chance of survival until discharge and 89% chance of an hypoxic brain injury. (Peberdy, Mary Ann, et al. "Survival from in-hospital cardiac arrest
during nights and weekends." JAMA 299.7 (2008): 785-792.
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Sandra
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“…selecting the right hospital can reduce your risk of avoidable death by 50%”
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Action: Deploy Rapid Response Teams (RRT) at the first sign of patient decline
“The names of the patients whose lives we save can never be known. Our contribution will be what did not happen to them….." Donald M. Berwick, MD, MPP, Institute for Healthcare Improvement, Dec 2004
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Detection of deterioration (Afferent Limb)
Intervention (Efferent)
Vital Signs q4hr Lab Values Physical Exam EWS
trigger
Intensivist Critical care nurse Respiratory therapist
Rapid Response Teams (RRT) aka Medical Emergency Team
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AHRQ: Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013
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AHRQ: Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013
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Identifying the hospitalised patient in crisis”—A consensus Conference on the Afferent limb of Rapid Response Systems DeVita M, Smith GB, Adam SK et.al.
Resuscitation 81 (2010) 375–382
vital sign aberrations predict risk
monitoring patients more effectively may improve outcome, although some risk is random
There was agreement that, if practical and affordable, all
patients should be monitored continuously. concern that current technology is clinically inadequate due to
a potential for high false positive or false negative rates
the workload implications of monitoring on the clinical workforce have not been explored
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With permission; patient’s family
Left hand finger surgery
Dilaudid PCA.
Vital signs every 4 hrs
Found blue and
unresponsive at 5AM
Died at age 41
Tony
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Why should we monitor continuously?
What do we monitor continuously?
Who do we monitor continuously?
How do we monitor continuously?
Where do we monitor continuously?
✓
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Extremes of respiration rate are strong predictors of in-hospital mortality on the general ward
Buist M, Bernard S, Nguyen T, Moore G, Anderson J. Resuscitation 62 (2004) 137–141 et. al.
Event Odds Ratio (95% CI)
Bradypnea (RR < 6) 14.4 (2.6 - 80.0)
Tachypnea (RR > 30) 7.2 (3.9 - 13.2)
Loss of consciousness 6.4 (2.9 - 13.6)
Decrease of consciousness 6.4 (2.6 - 15.7)
Hypotension 2.5 (1.6 - 4.1)
Hypoxemia (SpO2 < 90%) 2.4 (1.6 - 4.1)
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Clinical antecedents to in-hospital cardiopulmonary arrest.
Schein RM, Hazday N, Pena M, Ruben BH, Sprung CL
CHEST 1990;98:1388-1392
Respiratory (38%) RR, SpO2 Metabolic (11%) enzymes, lactic acid Cardiac (9%) BP, EKG Neurologic (6%) level of consciousness Multiple (27%) Unknown (9%)
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Early Warning Score (EWS) Systolic blood pressure, heart rate, temperature, respiratory rate, [oxygen saturation,
level of consciousness]
Respiratory rate found to be best discriminator of all physiological data to identify patients at risk of deterioration1
Respiratory rate is the least documented vital sign in these systems2
1. Subbe CP et al. (2003) Effect of introducing the Modified Early Warning score on clinical outcomes, cardio-pulmonary arrests and intensive care utilisation in acute medical admissions. Anaesthesia, 58, pages 775–803
2. Chen J et al. (2009) The impact of introducing medical emergency team system on the documentations of vital signsResuscitation.80(1):35-43.
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Matt
13 yo for VP shunt revision D/C PACU 1 pm Peds floor: Dilaudid 0.5-1.0 mg IV q2hr prn Arrested on first POD night
With permission; patient’s family
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Continuous oximetry/capnometry monitoring reveals frequent desaturation and bradypnea during patient-controlled analgesia
Overdyk, Frank J., et al. Anesthesia & Analgesia 105.2 (2007): 412-418.
PCA SpO2 ETCO2
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Respiratory Depression Overdyk et. al. Cashman et. al. Walder et. al.
SpO2 < 90% > 2 min 24% 11.5% 15.2%
RR < 10 bpm > 2 min 74% 1.2% 1.6%
1.Cashman. Br J Anaesth 2004;93: 2. Walder B. Acta Anaesthesiol Scand 2001;45
92 patients had 1697 hours of continuous SpO2 and ETCO2 monitoring
0
20
40
60
80
100
120
1/31/06 23:45 2/1/06 0:57 2/1/06 2:09 2/1/06 3:21 2/1/06 4:33
SaO2 %
HR beats/min
PCA Bolus
ETCO2 mmHg
RR breaths/min
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0
20
40
60
80
100
120
140
160
2/3/06 18:43 2/3/06 18:57 2/3/06 19:12 2/3/06 19:26 2/3/06 19:40 2/3/06 19:55 2/3/06 20:09
HR beats/min
SaO2 %
"Code Blue"
RR breaths/min
ETCO2 mmHg
Continuous capnography/oximetry monitoring during PCA
Aspiration pneumonia
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Why not just monitor continuous SpO2?
Threshold alarm
MEWS;MET;RRT
Bradypnea (RR<8)
Hypoxia (SpO2 < 90%)
Overdyk F, Maddox R, et. al, A&A 2007:105;412-18.
+ suppl O2
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Louise
65 y.o. grandmother for elective total knee arthroplasty, opioid naïve
Postop pain plan: Femoral nerve catheter, OnQ and morphine PCA
Orders: Vital signs incl RR and SpO2 every 4 hours
Found Dead in Bed at 4AM
With permission from family (see LouiseBatz.org)
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Postoperative Hypoxemia Is Common and Persistent: A Prospective Blinded Observational Study
Zhuo Sun, MD,* Daniel I. Sessler, MD,*† Jarrod E. Dalton, PhD, et.al. Anesth Analg 2015;121:709–15
37% of patients had an SpO2 <90% for an hour or more.
The nurses were unaware of 90% of hypoxemic episodes (SpO2 <90% for at least one hour).
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Anesthesia Patient Safety Foundation
2006 Conference:
• No patient shall be harmed by undetected respiratory depression (zero tolerance)
• Continuous monitoring could prevent significant patient harm
2011 Conference: Essential Monitoring Strategies to Detect Clinically Significant Drug-Induced Respiratory Depression
• All patients should be monitored by continuous pulse oximetry.
• Monitoring the adequacy of ventilation and airflow when suppl O2 is needed.
• Applying monitoring selectively based upon risk is likely to miss RD in patients without risk factors
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Joint Commission Sentinel Event Alert #49 “Safe Use of Opioids in Hospitals” Aug, 2012
Root causes of preventable harm:
Lack of knowledge about potency differences among opioids.
Improper prescribing and administration of multiple opioids and modalities.
Inadequate monitoring of patients on opioids
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Why should we monitor continuously?
What do we monitor continuously?
Who do we monitor continuously?
How do we monitor continuously?
Where do we monitor continuously?
✓
✓
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JC SEA #49: Characteristics of patients at higher risk factors for oversedation and respiratory
depression (Aug 2012)
Sleep disorder/snoring (obstructive sleep apnea)
Morbid obesity (assoc w OSA)
Older age: >62 yo……
Opioid naïve
Opioid tolerant (> 60 mg/day morphine 1+ week)
Co-administration of sedatives
Smoking
Pre-existing pulm/cardiac disease;
Long anesthesia/surgery
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Non invasive monitoring Technologies
• Photoplethysmography (PPG)
• Impedance plethysmography
• IR detectors (capnography)
• Nasal pressure transducers
• Thermistors
• Bioacoustics
• Piezoelectric
• Severinghaus electrode
• Laser
• Processed EEG
Vital Signs
• Oxygenation: SpO2
• Chest excursion
• Ventilation: PET CO2, PtcCO2, VT, VE , RR
• Blood pressure: SBP, DBP, MBP
• Temperature
• Level of consciousness
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How do we monitor continuously on a ‘low’ acuity ward?
• Clinical Acceptability – Ergonomics
• Unencumbering
– Nursing workflow • Initiation monitoring
• Charting
• Actionable interventions
– Alarm Fatigue • Alarm threshold settings
• Notification
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JC SEA #50: Medical Device Alarm Safety in Hospitals (April 2013)
• 2009 – 2012 98 alarm related events
– 80 resulted in death
– 15 resulted in permanent disability
– 3 resulted in extended stay/care
• Major contributing factors
– 30 inadequate alarm system
– 21 improper alarms settings
– 25 alarms inaudible
– 36 alarms inappropriately turned off
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Photoplethsymography (SpO2, RR, HR)
Xhale Assurance: with permission
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Capnography (RR, ETCO2, patterns)
Covidien Medtronic: with permission
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* sleeping & snoring * awake *sleeping & not snoring * awakening
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Bioacoustics: RR
Masimo: with permission
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Impedance plethysmography: RR & Vt
Respiratory Motion; with permission
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The evaluation of a non-invasive respiratory volume monitor in surgical patients undergoing elective surgery with general anesthesia. Christopher J. Voscopoulos • C. Marshall MacNabb • Jordan Brayanov • Lizeng Qin • Jenny Freeman • Gary John Mullen • Diane Ladd • Edward George
Journal of clinical monitoring and computing 29.2 (2014):
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• Heart rate & variability • Oxygen saturation • Respiratory rate & depth
MultiSenseTM
Rhythm Diagnostic Systems; with permission
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Piezoelectric sensor: RR, HR
Early SenseTM: with permission
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Sotera: with permission
Impedance Pleth, PPG: Continuous RR, SpO2, HR and NIBP
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Sensogram Tech: with permission
Not a medical device!
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Sensoscan; with permission
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Sensoscan; with permission
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Elfi-Tech; with permission
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Barriers to adoption of continuous vital sign monitoring
• “Lacking evidence of improved outcomes”
• “Disruptive to nursing workflow”
• “Too many false alarms”
• “Too expensive”
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Impact of Pulse Oximetry Surveillance on Rescue Events and Intensive Care Unit Transfers. A Before-and-After Concurrence Study
Taenzer AH, Pyke JB, McGrath SP, Blike GT. Anesthesiology 2010, 112: 282-7
Methods: Before/after implementation in a 36-bed orthopedic unit.
Results:
• 50% reduction in transfers to higher levels of care
• 60% reduction in rescue events
• 0 Dead in Beds
Alarms:
• alarm rates 2-4 per patient per 12 hour shift.
• 85% of all alarm conditions are resolved w/i 30 sec
Financial:
• $85 per patient deployment year; $22 per patient
© 2015 Dartmouth-Hitchcock With permission
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Bob
63 y.o. BMI=38; Hx of OSA – home CPAP
Laparoscopic hiatal hernia repair
Morphine PCA; standard q4 hr vital signs
Ambulates to outside facility for UGI
Returns for one more night in hospital; PCA restarted (error)
12 MN; Snoring; spot check SpO2 = 92%; 2L O2 N/C added
Cardiopulmonary arrest @ 0500
With permission from family
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• A total of 1,500 patients were monitored for 60,000 hours
• At least 19 events that would have likely resulted in failure to rescue: PE’s, sepsis, MI’s
Wake Forest Baptist Medical Center: Presented at AAMI
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Wake Forest Baptist Medical Center: Presented at AAMI
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Continuous Monitoring in an Inpatient Medical-Surgical Unit: A Controlled Clinical Trial
Brown H, Terrence J, Vasquez P, Bates DW, Zimlichman E. Am J Med. 2014;127:226-32.
Control Unit Intervention Unit CU-IU
post
All
Units
Baseline (pre) Control (post) p value Baseline (pre) Intervention
(post) p value p value p value
LOS in med/surg unit
(days) 3.80 3.61 0.26 4.00 3.63 0.03 0.91 0.10
ICU transfers
Transfers / 1000pt 18.89 19.06 1.00 26.52 25.93 0.92 0.12 0.21
Days / 1000pt 32.69 85.36
0.01
120.11 63.44
0.05 0.02 0.014 LOS, mean (median) 1.73 (1.32) 4.48 (2.12) 4.53 (2.33) 2.45 (1.85)
APACHE II score 13.08 14.06 0.59 15.19 13.38 0.25 0.61 0.65
Code blue events n
(/1000pt) 6 (3.9) 5 (2.1) 0.36 9 (6.3) 2 (0.9) <0.01 0.45 0.02
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Alarm fatigue
12 Average number of alerts per 12 hours shifts (for all nurses)
2 Average number of alerts per 12 hours shift per nurse (assuming 6 nurses on shift)
0.60 Estimated false alerts per nurse per shift
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Andy
ASA II
Cholycystectomy at
noon on a Saturday
Found
blue/unresponsive at
5AM on Sunday
Hospital acknowledges
“minor procedural
lapses in supervising
(nurses)”
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Thank you!