Continuous Monitoring in an Inpatient Medical …

1 Continuous Monitoring in an Inpatient Medical -SurgicalUnit: a controlled clinical TrialHarvey Brown, MD,aJamie Terrence, RN,aPatricia Vasquez, RN, BSN,aDavid W. Bates, MD, MSc,b,cEyal Zimlichman, MD, MScb,caCalifornia Hospital Medical Center, a member of Dignity Health, Los Angeles;bThe Center for Patient Safety Research and Practice,Division of General Internal Medicine, Brigham and Women s Hospital, Boston, Mass;cHarvard Medical School, Boston, :For hospitalized patients with unexpected clinical deterioration, delayed or suboptimalintervention is associated with increased morbidity and mortality. Lack of Continuous Monitoring foraverage-risk patients has been suggested as a contributing factor for unexpected in-hospital mortality. Ourobjective was to assess the effects of Continuous heart rate and respiration rate Monitoring in a Medical - surgical unit on unplanned transfers and length of stay in the intensive care unit and length of stay inthe Medical - surgical :In a controlled study, we have compared a 33-bed Medical - surgical unit (intervention unit ) to a sister control unit for a 9-month preimplementation and a 9-month postimplementation period.

2 Followingthe intervention, all beds in the intervention unit were equipped with monitors that allowed for continuousassessment of heart and respiration :We reviewed 7643 patient charts: 2314 that were continuously monitored in the intervention armand 5329 in the control arms. Comparing the average length of stay of patients hospitalized in the inter-vention unit following the implementation of the monitors to that before the implementation and to that inthe control unit , we observed a significant decrease (from to and days, respectively;P<.05).Total intensive care unit days were significantly lower in the intervention unit postimplementation ( and days/1000 patients, respectively;P .04). The rate of transfer to the intensive care unit didnot change, comparing before and after implementation and to the control unit (P .19). Rate of code blueevents decreased following the intervention from to and , respectively, per 1000 patients (P.)

3 02).CONCLUSIONS: Continuous Monitoring on a Medical - surgical unit was associated with a significantdecrease in total length of stay in the hospital and in intensive care unit days for transferred patients, as wellas lower code blue rates. 2014 Elsevier Inc. All rights reserved. The American Journal of Medicine (2014) 127, 226-232 KEYWORDS: clinical alarms; Hospital rapid response team; Heart arrest; Intensive care unitFunding:The study was funded by an industry grant provided byEarlySense of Interest:HB has received consulting fees from EarlySenseLTD; JT and PV have no conflicts to report; DWB has received consultingfees and Honoraria from EarlySense LTD and has received a research grantsupported by EarlySense LTD; EZ has received a research grant supportedby EarlySense :HB has contributed to conception and design, to acqui-sition of data, and to the analysis and interpretation of data. HB has draftedthe article and gavefinal approval of the version to be published.

4 JT hascontributed to conception and design, to acquisition of data, has criticallyrevised the manuscript for important intellectual content, and gavefinalapproval of the version to be published. PV has contributed to acquisitionof data, has critically revised the manuscript for important intellectualcontent, and gavefinal approval of the version to be published. DWB hascontributed to conception and design, to the analysis and interpretation ofdata, has critically revised the manuscript for important intellectual con-tent, and gavefinal approval of the version to be published. EZ hascontributed to conception and design, to the analysis and interpretation ofdata, has drafted the article, and gavefinal approval of the version to for reprints should be addressed to Eyal Zimlichman, MD,MSc, Center for Patient Safety Research and Practice, Division of GeneralMedicine, Brigham & Women s Hospital, 1620 Tremont St, Boston,MA -see front matter 2014 Elsevier Inc.

5 All rights RESEARCH STUDYA dult patients hospitalized in acute care facilities who arecritically ill requiring either ventilation or hemodynamicsupport or cardiac Monitoring , are usually admitted to eitheran intensive care unit (ICU) or a telemetry unit . These pa-tients benefit from frequent Monitoring of vital signs andpulse oximetry, Continuous electrocardiography Monitoring ,and higher nurse-to-patient non-ICU/telemetry bedsusually constitute the majority ofavailable beds in acute care hos-pitals and academic Medical cen-ters, most adult acute care patientsare admitted to Medical -surgicalunits where Continuous monitor-ing is not available. Unfortunately,these patients can experience un-expected clinical deterioration thatmay go undetected if it occurs inthe interval between routine vitalsign measurements, commonlymeasured every 4 to 6 et al1demonstrated thatpotentially avoidable deaths andICU admissions were associatedwith physiological deteriorationsthat may be overlooked.

6 Hravnaket al2showed that an integrated Monitoring system usingstandard measurements of heart rate, blood pressure, respi-ratory rate, and pulse oximetry in a step-down unit was ableto detect cardiorespiratory implementation of rapid response systems in acutecare hospitals has focused primarily on building the efferentlimb of the system the response team. The mixed resultsreported on the effectiveness of these systems in reducingmajor adverse outcomes have shifted the emphasis tostrengthening the afferent limb of rapid response systems the ability to detect patients at risk for these Monitoring of low- to average-risk patientsoutside of ICUs poses a challenge. Frequent vital signsperformed by nursing are labor intensive, and can be dis-tressing to patients, especially when they are trying to , a new generation of technologies can enablecontinuous Monitoring of vital signs and at the same timeare minimally intrusive.

7 We evaluated the efficacy of acontinuous, noncontact heart rate and respiration ratemonitoring system in a Medical - surgical unit of a commu-nity hospital to assess its impact on transfers from the unit tothe ICU, length of stay (LOS) in the ICU for transferredpatients, and LOS at the Medical - surgical SiteWe performed a study on a Medical - surgical service in a316-bed community hospital, using 2 control groups. Thestudy included a 9-month prospective intervention period(November 2009-July 2010) and a 9-month retrospectivebaseline period (January 2009-September 2009). Moni-toring was performed in a 33-bed Medical - surgical unit (the intervention unit ) whose population included generalmedical, trauma, and surgical patients. A similar sister 33-bed Medical - surgical unit served as a contemporaneouscontrol. Patients were admitted to one of the 2 units by thehospital s admissions office in analternating manner. As the 2 unitswere similar in patient population,level of supervision (both unitshad a nurse-to-patient ratio of 1:5)and services provided, the deci-sion on placement of patients toone of the 2 units was practicallyrandom.

8 All patients admitted ortransferred to the intervention unitwere monitored following theimplementation of the monitor-ing systems on October hospital s institutional reviewboard approved the TechnologyThe Monitoring system evaluatedwas the EarlySense system (Ear-lysense Inc., Waltham, Mass). The system consisted of apiezoelectric motion-sensing device embedded in aflatsensor plate placed under the patient s mattress and con-nected to a bedside processing and display unit , as previ-ously research has shown thesemonitors to be accurate in measurement of both heart rate(HR) and respiration rate (RR),4and has shown this sys-tem s potential in early recognition of clinical bed on the intervention unit was equipped with abedside unit that continuously monitored HR, RR, andmovement level. The alert thresholds for HR were usually40 and 135/min, and for the RR, 8 and 32/min. These couldhave been modified by the nurses with the approval of asupervisor to accommodate patients who regularly exceedthe limits, provided a bedside assessment has been annunciations were provided at both a central displaystation and directly to nurses using text messages onSpectraLink telephones.

9 The hospital had implemented andutilized a rapid response system beginning in 2005. Rapidresponse teams were staffed with an intensive care physicianand nurse. The system performance was reviewed periodi-cally through an institutional review and DefinitionsPrimary outcomes for the study included unplanned ICUtransfers, average ICU LOS for transferred patients, andmedical- surgical unit LOS. Unplanned ICU transfers weredefined as direct transfers from the study and control unitsto the hospital s ICU (general and cardiac) for patientsthat spent at least 12 hours in the general Medical -surgicalCLINICAL SIGNIFICANCE Continuous vital signs Monitoring ina Medical - surgical unit was found tobe associated with a reduction in inten-sive care unit utilization for patientswho require transfer due to clinicaldeterioration. Continuous vital signs Monitoring in amedical- surgical unit also was found tobe associated with a reduction in totaltime spent in the hospital.

10 Results may support the hypothesis thatcontinuous Monitoring leads to earlierrecognition of patient et al Continuous Monitoring in Medical - surgical Units227units where the transfer was not planned in the course ofthe hospitalization. An example of planned ICU transferswould include patients undergoing certain procedures(eg, gastrointestinal endoscopy, cardioversion, bronchos-copy), where there was felt to be a risk because ofcomorbidities, and the transfer was made before theprocedure for safety concerns. Research nurses deter-mined whether transfers were considered planned versusunplanned through a review of physicians daily progressnotes. Total ICU days were defined as total ICU days per1000 admissions to the Medical - surgical units for allunplanned ICU outcomes for the study included AcutePhysiology and Chronic Health Evaluation II (APACHE II)scores for unplanned ICU admissions, number of code blueevents, and unexpected II scores wereused to assess the severity of illness at admission to the arrests were defined as activation of code-blue teams in the study and control units as reported by thehospital.