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Continuous Patient Surveillance – Can
it Prevent Adverse Events?
Jon Carlson, Director of Respiratory Care Services
Mercy Hospital of Buffalo, Buffalo, NY
Optimizing the ROI Of Patient Safety Monitoring
The Respiratory Therapy Role in
Accelerating Patient Safety Outcomes
Learning Objectives:
Explain the data driven impact continuous surveillance monitoring has had in
a community hospital setting.
Outline the diagnostic process followed and how to apply data extraction for
identifying nocturnal desaturations patterns consistent with sleep apnea.
Prepare structuring metrics for determining cost benefit and ROI for
continuous monitoring financial outcomes in addition to patient outcome data
Disclosure:
Current or past relationship of product development and/or application
development of clinical products with Masimo, Siemens, Philips-Respironics,
and Smith’s Medical
Agenda
Nursing time in direct patient care
Review the drivers behind recommendations for patient monitoring
Share the decision process followed to achieve monitoring success
Why any safety monitoring project needs Respiratory participation
Business model for continuous oximetry monitoring
• Respiratory
• Sleep
• COPD
• Readmissions
• Homecare
Nursing and patient time…
Only 44% of nursing time spent in direct patient care
14 medical-surgical nursing units
Storfjell J, Journal of Nursing Administration May, 2008-V38-5 244-249
Only 19% of nursing time spent in direct patient care
36 medical-surgical nursing units
Hendrich A, Permanente Journal Summer 2008
25% time in direct patient care
Two wards in a teaching hospital Sydney, Australia
Westbroook J, BMC Health Services Research 2011, 11:319
Nursing and patient time…
Safety Takes Time
• Many Care Improvements Take Time
• May be time taken away from patient care
• Computers in Rooms and on Wheels
• Medication Administration
• Duplicate Charting (paper and electronic)
Safety Solutions Must Be
• Scientifically Sound (evidence based)
• Economically Feasible
• Minimize or Reduce the Time Burden
Safety = placing 1 nurse at every bedside
What patients expect and don’t expect…
•
Compassion
• Pain
•
Caring
• Infection
•
Healing
• Short Staffed
•
Pain Free
• Gossip
•
High Quality
• Loneliness
•
High Tech
• Risks
•
Good Food
• Falls
More than a decade of increased public
awareness that unsafe care exists here
and abroad
In 2004 IHI drove focus on dynamic change
Key Elements
• Deploy Rapid Response Teams
• Deliver Evidence Based MI Care
• Reduce Rx Harm with Medication
Reconciliation
• Prevent Central Line Infections
• Prevent Surgical Site Infections
• Prevent Ventilator Associated Pneumonia
In 2004 IHI drove focus on dynamic change
Key Success
• Set a Goal
• Set a Deadline
• Provided Common Focus
• Unified the team
• Taught us rapid change process
• Raised awareness that preventable
deaths occur in our hospitals
Post assessment identified 126,000 fewer deaths in participating hospital group
Rapid Response Teams
Key factor in 100k campaign
The fastest response is still just responding… the goal needs to be prevention
Raised awareness that preventable deaths
occur in our hospitals
The projected number of premature
deaths associated with preventable harm to
patients was estimated at more than 440,000 per year
Failure to rescue and death in low risk hospital
admissions accounted for the majority of deaths
Serious harm predicted to be 10 – 20 times more common
than lethal harm
Medical errors now claim the spot as the 3rd leading cause
of death in the United States
James JT, A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care.
Journal of Patient Safety: 2013 9(3); 122–128
The Joint Commission issued Sentinel Event Alert #49 on the safe use of
opioids in hospitals (August 2012):
• Recommendations to implement better dosing along with oxygenation and
ventilation monitoring in post-surgical patients.
• Recommended continuous monitoring (instead of spot checks) of both
oxygenation and ventilation.
Anesthesia Patient Safety Foundation released “Essential Monitoring
Strategies to Detect Clinically Significant Drug- Induced Respiratory Depression
in the Postoperative Period Conclusions and Recommendations” (June 2011):
• Recommended that all patients should have oxygenation monitored by
continuous pulse oximetry
• Capnography or other monitoring modalities that measure the adequacy of
ventilation and airflow is indicated when supplemental oxygen is needed
• Intermittent “spot checks” are not adequate for reliably recognizing clinically
significant evolving drug-induced respiratory depression
Advised Against Spot Checks…
Mercy Hospital’s Assessment Policy
Upon admission
15 minutes x 2
30 minutes x 2
60 minutes x 2
2 hours x 2
4 hours for duration of PCA or pain medication
Even with Increased Frequency –
A gap is a gap no matter
how small
Two year study – Dartmouth Hitchcock Medical Center
400 bed regional leader in innovation
Positive outcome from continuous patient monitoring
• 65% reduction in Rapid Response Team activations
• 48% reduction in transfers to critical care
• 100% elimination of medication related mortality
Expanded to 100% monitored beds after the study
Mercy Hospital of Buffalo
> 389 Bed Community Hospital
> 21,000 Annual Discharges
> 36 Adult Critical Care Beds
> 78,000 Annual ER Patient Visits
Specialization: Cardiac, Cardiovascular & Neurology Surgery, NICU, Pulmonary,
Emergency Medicine
© 2014 Masimo Corporation
Multidisciplinary Approach: Options/Data
Multidisciplinary Team evaluated options
Initial focus on opioid administration
•Monitoring with infusion pumps
RRT data not unique to opioid patients
•Goal – Continuous Surveillance Monitoring
Admit to discharge
•Established pilot floor and 15 month baseline data
Surveillance Alarm Parameters
SpO2 Low alarm limit
Low pulse rate alarm
High pulse rate alarm
Low respiratory rate
High respiratory rate
•
•
•
80%
50
140
7
30
Actionable alarms vs. Nuisance alarms
AMA or MD order required to be removed from monitoring
93.7% patient compliance for admit to discharge
System Deployment
Oximeter mounted at every bed on post-surgical pilot floor (ours is with a
central monitor at the nurses station)
Alarm threshold must be reached and maintained for 15 seconds
If patient remains in alarm status, oximeter continues to alarm in room for 15
seconds – then pages nurse
If patient remains in alarm status nurse and
charge nurse are re-paged at 1 minute
Most patients self-recover with initial alarm
in room – “take 3 deep breaths”
Safety & Patient Outcomes
• Increased Acuity for Monitored Floors
(CMI 1.8 to 2.0)
• RRT activations increased
(7.6 vs. 10.7 / 1,000)
– Variable pulse rate #1 RRT reason
• Decrease in Naloxone Usage 27%
• 88% Reduction in All-Cause Mortality
Carlson J. Respiratory Care 2013, 58 (10) 1784
“The system provides safety and also helps us to better manage our patients’ pain,
which is important for enhancing the overall patient experience. The reduced mortality
and impact on patient experience while improving patient safety and outcomes has
made the project a great success.“
- Kathleen Guarino, CNO, Mercy Hospital of Buffalo
Lessons in Monitoring:
Monitoring Recommendation
Monitor during post-op period
Monitor patients receiving opioids
Review of 15 month baseline
Monitoring 24 hrs would miss 55% of deaths
Monitoring 48 hrs would miss 45% of deaths
“You cannot look down the nursing unit
corridor and know where your next code
will come from.”
Connecting the Dots for Optimizing
Patient Care Outcomes
•
The business model of continuous oximetry monitoring is based in safety
while identifying diagnostic opportunities and improving patient health.
•
Safety  Optimal Care  Post-discharge Health Impact
•
We have an obligation to maximize
the quality of care we deliver and
to optimize our patients’ health
after discharge.
Safety is only the tip of the iceberg…
Respiratory
Sleep Apnea
COPD
Sleep
Readmissions
Home Care
The Mercy ROI of
Continuous Oximetry Surveillance
Building on Success
• Expanded from 64 to 254 Beds
• Medical – Surgical Nursing Units
• Telemetry Nursing Units (55% telemetry beds)
The Respiratory Business Model:
• Performing an overnight oximetry on 250+ patients
• Trigger for Sleep Apnea (OSA) Follow-up
• Developing Screening for COPD Support Post-discharge
• Building Metrics for Readmission Tracking
Overnight Oximetry = Opportunity 1. Sleep
RRT/RPSGT begins each day reviewing oximetry trends for 250 patients
(1.5 hours)
Review process builds sleep
criteria for follow-up MD order
We report:
• Oxygen Desaturation Index
• Average Desaturation %
• Maximum Desaturation
(% and time)
Saw-tooth oxygen desaturation pattern consistent with sleep apnea drives
orders for portable sleep testing.
Portable Sleep Testing
a.k.a. Home Sleep Testing
•
Multiple variations and monitors
can perform the test
•
Online services available if your
facility doesn’t have a sleep
program
A minute about sleep
Sleep apnea is about a loss of ventilation and the corresponding desaturation
Quality Review
Averaging 23 positive patients each night
Zero false positives after 12 months of data
Patient may be referred to
sleep lab or homecare after
discharge
Sleep and Patient Safety
•
Safe Use of Opioids in Hospitals
•
Opioid analgesics rank among the drugs most frequently associated with
adverse drug events
•
Research shows that opioids such as morphine, oxycodone and methadone
can slow breathing to dangerous levels, as well as cause other problems
such as dizziness, nausea and falls
•
The reasons for such adverse events include dosing errors, improper
monitoring of patients and interactions with other drugs
•
Various patients are at higher risk including patients with sleep apnea,
patients who are morbidly obese…
Issue 49, August 8, 2012
Sleep and Patient Safety
•
•
•
•
Living with sleep apnea requires an ongoing arousal and recovery
Repetitive desaturations may drive nuisance alarms
Medications with influence on respiratory depression increase risk that
arousal and recovery may fail
This is a result of medication induced incomplete recovery resulting in
cerebral hypoxemia and loss of arousal
Lynn & Curry, Patterns of unexpected in-hospital deaths: a root
cause analysis. Patient Safety in Surgery 2011, 5:3
Mercy Hospital
trigger point
Identifying and Screening for Sleep
Continuous Pulse Oximetry Monitoring: 91% of patients with ODI > 30
do not have a positive RN admission assessment sleep screen
Prevalence of Sleep Apnea
2006 ASA meeting – Kevin Finkel, MD presented results of an OSA study at
Barnes-Jewish Hospital,
St. Louis, MO
• Study of 2,500 elective surgery patients
• 22% screen positive for OSA
Mercy Hospital’s continuous oximetry monitoring identified repetitive
nocturnal desaturation patterns in 29% of patients on the two trial floors.
A 12 month review of 250 beds of continuous oximetry monitoring has
identified 11% of med-surg patients exhibit a nocturnal desaturation pattern
consistent with severe sleep apnea.
Prevalence and Cost (simplified example)
158 million adults age 25 and over have some degree of sleep apnea
10.3 million men and women moderate-severe, untreated and undiagnosed
4.5 times more likely to have CVD
41,000 new cases of heart disease are attributed to OSA each year
Stanford.edu-dement
Mean annual medical cost $2720 OSA and $1384 control ($1336 greater cost)
Kapur V et al. Sleep 1999 Vol 22 June
10.3 million x $1336 = $13.8 billion
National Opportunity / Local Experience
628,000 medical-surgical beds in US – 2010
Estimate model of 100% monitored beds annually $550,000
$13.8 billion - $0.6 billion = $13.2 billion
Mercy Hospital: 11% of medical-surgical
patients trigger as moderate-severe
Refinement of referral to homecare
drives margin to offset full cost
of 100% continuous oximetry monitoring
Obstructive Sleep Apnea
Increases Healthcare Utilization
Patients diagnosed with OSA have been shown to utilize almost double the
degree of healthcare resources
(Ronald, Delaive, Roos, & Kryger 1998; Kapur et al., 1999; Berger et al., 2006)
Healthcare utilization is 1.7 times more in OSA patients when compared to
the control
(Tarusiak et al. 2005)
Reduction in hospitalization for cardiovascular and pulmonary disease with
CPAP compliance
(Peker and colleagues 1997)
An increase in healthcare utilization can be traced back ten years
(Ronald and colleagues 1998)
Hospital admissions increased significantly approximately four years prior to
diagnosis of OSA
(Ronald et al., 1998)
CPAP Tx for OSA Improves Health
CPAP therapy has been linked to a reduction of the severity of the comorbid
conditions associated with OSA.
Reduced fatal and non-fatal cardiovascular events by treatment of OSA with
CPAP therapy
(Marin and colleagues 2005)
CPAP use has also shown improvement in the control of Type 2 Diabetes
(Babu, Herdegen, Fogelfeld, Shott, & Mazzone 2005)
Overnight Oximetry = Opportunity 1. Sleep
In-patient setting
• RT setup and testing
• Rapid turn-around
Does not require a Sleep Lab
• Scoring and reading services
• Minimal equipment cost
With Board Certified Sleep MD interpretation
can progress directly to Homecare DME
• Supports patient management within system
• Net-margin from homecare supports system
Opportunity 2. COPD
•
Medicare’s Respiratory Assist Devices (RAD) Local Coverage Decision (LCD)
Policy Change for COPD – December 2014
•
The new policy changes the COPD qualification pathway by allowing
various documentation options to rule out OSA, thereby allowing an easier
pathway for COPD patients to qualify for a noninvasive bilevel device
(HCPCS E0470).
•
The revised LCD states:
•
Definitive testing via PSG or HST is not necessary to rule out sleep apnea
and CPAP therapy when the clinical picture is sufficient
•
Nocturnal oximetry is now a cumulative 5 minutes of testing, instead of
continuous
•
Sleep testing is not required if the medical record documents that sleep
apnea is not the predominant cause of awake hypercapnia or nocturnal
arterial oxygen desaturation
Longest duration: 1 min 24 sec
Cumulative: 8 min 41 sec
The benefits of using home NIV to treat the
severe COPD patient population are significant
and could prevent future acute exacerbations.
Research supports NIV at home:
•
Reduces the risk of death in chronic COPD patients over one year by 76%1
•
Reduces admissions and minimizes costs from the perspective of the
hospital2
•
Reduces recurrences of acute hypercapnic respiratory failure following an
initial event by up to two-thirds in the first 30 days following the event3
1. Köhnlein T et al. Non-invasive positive pressure ventilation for the treatment of severe, stable chronic obstructive pulmonary
disease: A prospective, multicentre, randomised, controlled clinical trial. The Lancet Respiratory Medicine 2014;2(9):698–705.
2. Tuggey JM, Plant PK and Elliott MW. Domiciliary non-invasive ventilation for recurrent acidotic exacerbations of
COPD: An economic analysis. Thorax 2003, Oct;58(10):867–71.
3. Cheung et al. A pilot trial of non-invasive home ventilation after acidotic respiratory
failure in chronic obstructive pulmonary disease. Int J Tuberc Lung Dis 2010;14:642–9.
Prevalence of COPD
Opportunity 2. COPD
Review of COPD admissions
• Review histogram for cumulative desaturation > 5 min
• MD notification – verify compliance
Does not require a Sleep Lab
May progress directly to Homecare DME
• Supports patient management within system
• Net-margin from homecare supports system
• Monitor for readmission
Nuisance Alarms
Current Focus is to reduce nuisance alarms
Oximeters at every bed may seem counter-intuitive
Requires a risk / benefit assessment to validate plan
Option of when and where alarms occur
Nursing Station
Room
Pagers
Alarm Management
Alarm Pilot 5C & 5N
1600
1400
1200
1000
-43%
-53%
800
Prior
After
600
400
200
0
PR Low
SpO2 Low
5.05 Clinical alarms per patient day to 2.56 clinical alarms per patient day -49%
Additional Quality Impact
Mercy Codes and 30 day survival
Non-critical Care Codes
120
100
6% Decrease in 2014
-30% Projected for 2015
80
60
Non-critical Care Codes
40
20
0
2009
2010
2011
2012
2013
2014
2015
After years of increasing code volume, 2014 posted a 6% reduction.
The “alive at discharge”/30 day survival rate increased 291%.
Safety Summary
Continuous oximetry monitoring with clinician notification maintains
surveillance even when RN is not in the patient’s room.
Increased awareness of patient status results in improved medication delivery.
Increased awareness resulted in early intervention for patients with
deteriorating status. Resulting in a 6% reduction in non-critical care codes.
Achieved 88% reduction in all-cause mortality
ROI Summary
The factors driving increased patient monitoring on a national level
Prospect for Respiratory Services in the decision making process
Comparing data collection processes and opportunities
Sleep screening implementation and results
COPD and Readmissions
Positioning your program for the future
Continuous Patient Surveillance – Can
it Prevent Adverse Events?
Jon Carlson, RT, RRT-NPS
Director, Respiratory Care Services
Mercy Hospital of Buffalo
Office 716-828-2177
[email protected]