Monitoring Currently Unmonitored Patients
I came across some interesting posts in the Biomed Listserv. A biomed from a 250 bed hospital is looking for feedback on GE and Philips telemetry systems. This 260 bed community hospital is going to buy a 12 channel system, and ramp up to about 150 of the devices over the next few years. All sorts of questions came to my mind, and came to this fellow as well:
Instead of what to purchase, please assure that you ask the question – from a clinical patient perspective – what are you attempting to accomplish? Telemetry is intended to allow patients to ambulate and improve their outcome and therefore leave the hospital sooner. It was developed specifically to assist post open heart patients get out of bed and let clinical staff still watch the heart. If you are installing hundreds of channels of telemetry to just add monitoring – what is the patient benefit?
Also the clinical operating concerns can not be underestimated. What nurse is responsible for patient care? How many nurses per floor? Is there a central station, monitor techs? Most telemetry systems in hospital are (my opinion) not properly set up technically or operationally.
Most patients on telemetry do not ambulate, so why not have bedside monitoring? Most nurses taking care of patients on telemetry can not even see the ECG being technically transmitted as only the monitor tech can. Most monitor techs are not licensed to manage patient care – RN’s are. Most telemetry units also lack physician criteria for admission and discharge causing the need to always have more telemetry. I think most adult hospitals could benefit from the lessons learned at pediatric hospitals. If the patient needs to be monitored and is not ambulatory, put a networked bedside monitor at the patient bedside. Some vendors – Spacelabs – even have modules that allow for telemetry to be at bedside for those patients that require same.
Great questions. Fitting the monitoring device to match the patient profile is important. And effective alarm notification is essential.
Every hospital has some unmonitored patients that could benefit from being monitored. Patients on pain medications, especially PCA pumps, should be monitored. According to the literature, almost half of all cardiopulmonary arrests in hospitals are unwitnessed. While the survival rate of witnessed codes is 22%, the survival rate for unwitnessed codes is just 1%. Increased monitoring can reduce adverse events, improve outcomes, reduce length of stay, and minimize legal liability.
For these reasons and more, the current standard of practice for patient monitoring is changing. A greater number of hospitals are using telemetry monitors to monitor previously unmonitored patients. Patients that would normally not qualify for the telemetry unit or some other high dependency unit are being monitored – and usually this means telemetry packs.
Telemetry is a good choice because these patients are usually ambulatory, and telemetry transmitters are light weight and small. At the same time, telemetry monitors are a bad choice for several reasons. Telemetry transmitters have no local alarms; you can be right next to a patient in arrest, and unless you see their lips turn blue (or some other physical sign) you won’t know there’s an alarm condition. Telemetry alarms traditionally annunciate at the central station, and some installations include additional audible alarms, message panels or flashing lights. A related weakness of telemetry transmitters is the lack of a display. To view the patient’s physiological parameters you must leave the patient and go to the central station.
Another telemetry system limitation mentioned above is the requirement to have someone actually watch the central station displays. Some hospitals have monitor techs man central stations in a central location – frequently called the “war room.” While this is a safe approach, it is also very expensive – an 800 bed hospital can spend $1 million per year on their war room. Other hospitals distribute their monitoring techs on individual nursing units. Depending on patient volumes on nursing units, this could be more expensive than the centralized approach. Finally, many hospitals put central stations in nursing stations and make the nurses on the unit responsible for surveillance. This is certainly the most cost effective approach, but also the most vulnerable to alarm fatigue, especially when you have one or two patients who constantly throw off false positive alarms.
The final challenge is cost. Telemetry monitors, as inadequate as they are, cost about $8,000 per channel – still too high for the many hospitals that have yet to adopt broader patient monitoring. A contributing factor to cost is the use of WMTS by GE and Philips. While both vendors justify their use of WMTS on the fact that it is a “protected” frequency, that provides protection only against intentional interference (people purposely using the same frequency). The major source of interference in hospitals is from unintentional interference – noisy hair dryers, florescent light ballasts, elevator motors, microwave ovens, the list is endless. While WMTS is a frequency band authorized by the FCC, there is no mandate to use it. In fact, there are no operating standards for WMTS to ensure coexistence between vendors. When they first switched their access points over to WMTS, GE and Philips interfered with each other’s systems. It was only a gentlemens agreement (and time) that facilitated technical adjustments to allow both vendor’s systems to operate in the same hospital. Systems using WMTS simply cost more money than systems that use your hospital’s infrastructure – and the wider you deploy their proprietary WMTS infrastructure the more it will cost you when you want to change vendors (and you always do, sooner or later).
While we can’t solve the cost issue today, there are alternatives to the traditional telemetry monitor. Our perfect solution would include a real patient worn monitor, meaning a device with a display and local alarms, and you really should have both ECG and SpO2. Such devices include the new Draeger Infinity telemetry system, and a couple of Welch Allyn monitors – the Micropaq and the Propaq LT. The Draeger monitors run on 802.11 b/g, and Welch Alllyn just announced support for 802.11a/b/g on their monitors at HIMSS. None of these products is perfect, but you get important clinical features and you’re not investing unecessarily in a proprietary infrastructure that only works with one vendor’s products – and in the case of GE, only supports telemetry – all their patient monitors run on WiFi.
Pictured above is the Draeger Infinity telememetry monitor, shown in bedside dock with trickle charge.
UPDATE: Reader Dan Davis MD suggests that most hospitals looking to broaden their patient monitoring are trying to reduce failure to rescue incidents (that’s patients who have an adverse event, go into cardiopulmonary arrest and usually die). Certainly saving lives is a primary motivator for increased patient monitoring. But I would argue that there is a greater need (and hopefully market demand) for electronic surveillance that alerts caregivers long before patients become obvious failure to rescue statistics. This requires the ability to identify patients who are pre-arrest, at a stage when clinical intervention is less expensive and much more successful. Patients who arrest in hospitals have low survival rates – 22% for witnessed arrests and a grim 1% for unwitnessed codes.
Dan also mentions Hoana Medical, and their passive non-invasive sensors that can be incorprated into patient beds as a possible solution. I’ve written about them a number of times (here, here and here), and they have a very interesting system – check them out. The only thing that I can see that keeps it from becoming a natural choice for hospitals is that the kind of patients who would benefit most (currently unmonitored patients) are also active – they are encouraged to get up and walk around. Hospitals need solutions that cover patients in bed and when ambulatory.
Philips Issues Alarm Notification Warning Letter
Last November, Philips sent a formal medical device notification letter to their customers. Titled “Increased Number of Reports of Adverse Events Referencing Patient Monitoring Alarms,” the letter explains that over the past 3 years, reviews of customer complaints have noted an increase in the number of adverse events that refer to alarms on patients being monitored by Philips bedside patient monitors connected to central stations. All patient monitoring vendors receive these complaints, and their investigations found that the Philips monitoring systems performed as designed. (This post is no criticism of Philips or their products – in fact, they should be commended for issuing their warning letter.)
Issuing letters like this is not common, and it has caused a bit of a stir. You can read the letter here (pdf). I met David Jones, Philips’ Director of Worldwide Quality and Regulatory for the patient monitoring group – and author of the letter – at a recent meeting held at the FDA, and asked him about the impetus behind the letter. First he noted that this trend was a disturbing one, and that while their products were not found to be defective, their interest in patient safety caused them to want to raise their customers’ awareness of the trend. David also mentioned that with the advent of JCAHO’s National Patient Safety Goal on clinical alarm systems as a reason to issue the letter.
Philips’ review of these adverse events revealed three major contributing factors:
- Turning off ECG/Heart Rate alarms;
- Switching the alarm source from Heart Rate to Pulse without considering that ECG and arrhythmia alarming is not available in this mode; and
- Treating technical or INOP alarms (e.g., such as noise or leads-off alarms) to be low-priority, even though they indicate that the patient may no longer be monitored.
The above factors are classic symptoms of alarm fatigue. From time to time nursing units will admit patients who, due to their condition and unique physiology, will alarm frequently – sometimes continuously. There is no medical device in the world that can take the place of a clinician, and Philips is justifiably known for the quality of their arrhythmia alarm quality and the ability to minimize false positive alarms. Even so, in the frequently chaotic world of the nursing unit, caregivers can become desensitized to alarms as a result of their environment.
Certainly education and training can minimize alarm fatigue problems and improve patient safety (as recommended in the Philips letter), but other factors impact this problem as well. Patient characteristics vary from unit to unit based on admissions criteria and the type and methods of care delivery used. Because of this variability, vendors build considerable flexibility into their alarm management features in order to minimize impact on how care is delivered and to ensure patient safety. When a system of this type is installed, the vendor makes specific recommendations regarding alarm management and configuration in order to best match the system to the unit and ensure patient safety. Some hospitals feel they know better how to configure and use a vendor’s system and I have seen sentinel events result from this approach. Following vendor recommendations, at least as a starting point, is prudent.
The biggest factor impacting alarm fatigue is one that vendors have been struggling to overcome. Alarm annunciation at the device in private rooms, at the central station, or broadcast throughout the unit (via remote audible alarms and message panels) is inefficient and problematic. When you are one of five nurses on a unit, most of the alarms you hear have nothing to do with the patients that you are responsible for – but, due to the way alarms are delivered you must respond to determine if one of your patients is involved, and then determine if the alarm is valid.
There is a principle in information technology that the most reliable and efficient way to capture or manage a transaction is as close to the source of that transaction as possible. If you look around you can see expressions of this principal in bedside charting, direct data acquisition from medical devices, and in the design of meds delivery systems. Delivering alarms directly to caregivers is the best way to minimize alarm fatigue and improve patient safety.
