Pro-Con Debate: Universal Versus Selective Continuous Monitoring of Postoperative Patients.

In this Pro-Con commentary article, we discuss use of continuous physiologic monitoring for clinical deterioration, specifically respiratory depression in the postoperative population. The Pro position advocates for 24/7 continuous surveillance monitoring of all patients starting in the postanesthesia care unit until discharge from the hospital. The strongest arguments for universal monitoring relate to inadequate assessment and algorithms for patient risk.

Understanding the "alarm problem" associated with continuous physiologic monitoring of general care patients.

Study Aim: The aim of this study is to investigate the impact of alarm configuration tactics in general care settings.

Methods: Retrospective analysis of over 150,000 hours of medical/surgical unit continuous SpO2 and pulse rate data were used to estimate alarm rates and impact on individual nurses.

Results: Application of an SpO2 threshold of 80% vs 88% produced an 88% reduction in alarms.

A Pragmatic Method for Measuring Inpatient Complications and Complication-Specific Mortality.

Objectives: The primary objective of this study was to develop hospital-level metrics of major complications associated with mortality that allows for the identification of opportunities for improvement. The secondary objective is to improve upon current metrics for failure to rescue (i.e.

Improvement of sepsis identification through multi-year comparison of sepsis and early warning scores.

Background: Sepsis remains a leading cause of death among inpatients. Scoring systems designed to identify inpatients with sepsis currently have limited effectiveness. This single institution, retrospective, case-control study aims to improve sepsis decision support tool performance using temporal analyses of sepsis-specific and general deterioration scoring systems.

Characterizing rescue performance in a tertiary care medical center: a systems approach to provide management decision support.

Background: Allocation of limited resources to improve quality, patient safety, and outcomes is a decision-making challenge health care leaders face every day. While much valuable health care management research has concentrated on administrative data analysis, this approach often falls short of providing actionable information essential for effective management of specific system implementations and complex systems. This comprehensive performance analysis of a hospital-wide system illustrates application of various analysis approaches to support understanding specific system behaviors and identify leverage points for improvement.

Patterns in continuous pulse oximetry data prior to pulseless electrical activity arrest in the general care setting.

The study objective was to understand if features derived from continuous pulse oximetry data can provide advanced warning of pulseless electrical activity arrest in the general care inpatient setting. Retrospective analysis of SpO2 and pulse rate data derived from continuous pulse oximetry was performed for pulseless electrical activity (n = 38) and control (n = 42) patient cohorts. Measures of central tendency and variation over time intervals ranging from 1 min to 1 h were used for inter- and intra-group comparisons.

Inpatient Respiratory Arrest Associated With Sedative and Analgesic Medications: Impact of Continuous Monitoring on Patient Mortality and Severe Morbidity.

Objectives: The primary study objective was to investigate the impact of surveillance monitoring (i.e., continuous monitoring optimized for deterioration detection) on mortality and severe morbidity associated with administration of sedative/analgesic medications in the general care setting.

A Systems Approach to Design and Implementation of Patient Assessment Tools in the Inpatient Setting.

Failure to rescue events, or events involving preventable deaths from complications, are a significant contributor to inpatient mortality. While many interventions have been designed and implemented over several decades, this patient safety issue remains at the forefront of concern for most hospitals. In the first part of this study, the development and implementation of one type of highly studied and widely adopted rescue intervention, algorithm-based patient assessment tools, is examined.

Failure to Rescue Event Mitigation System Assessment: A Mixed-methods Approach to Analysis of Complex Adaptive Systems.

Although it is widely acknowledged that health care delivery systems are complex adaptive systems, there are gaps in understanding the application of systems engineering approaches to systems analysis and redesign in the health care domain. Commonly employed methods, such as statistical analysis of risk factors and outcomes, are simply not adequate to robustly characterize all system requirements and facilitate reliable design of complex care delivery systems. This is especially apparent in institutional-level systems, such as patient safety programs that must mitigate the risk of infections and other complications that can occur in virtually any setting providing direct and indirect patient care.

Improving Patient Safety and Clinician Workflow in the General Care Setting With Enhanced Surveillance Monitoring.

Clinical monitoring systems have been implemented in the inpatient hospital setting for decades, with little attention given to systems analysis or assessment of impact on clinician workflow or patient care. This study provides an example of how system-level design and analysis can be applied in this domain, with specific focus on early detection of patient deterioration to mitigate failure to rescue events. Wireless patient sensors and pulse oximetry-based surveillance system monitors with advanced display and information systems capabilities were introduced to 71 general care beds in two units.

Characteristics of Desaturation and Respiratory Rate in Postoperative Patients Breathing Room Air Versus Supplemental Oxygen: Are They Different?

Background: Routine monitoring of postoperative patients with pulse oximetry-based surveillance monitoring has been shown to reduce adverse events. However, there is some concern that pulse oximetry is limited in its ability to detect deterioration quickly enough to allow for intervention in patients receiving supplemental oxygen. To address such concerns, this study expands on the current limited knowledge of differences in desaturation and respiratory rate characteristics between patients breathing room air and those receiving supplemental oxygen.

Surveillance Monitoring Management for General Care Units: Strategy, Design, and Implementation.

Background: The growing number of monitoring devices, combined with suboptimal patient monitoring and alarm management strategies, has increased "alarm fatigue," which have led to serious consequences. Most reported alarm man- agement approaches have focused on the critical care setting. Since 2007 Dartmouth-Hitchcock (Lebanon, New Hamp- shire) has developed a generalizable and effective design, implementation, and performance evaluation approach to alarm systems for continuous monitoring in general care settings (that is, patient surveillance monitoring).

Assessment of continuous acoustic respiratory rate monitoring as an addition to a pulse oximetry-based patient surveillance system.

Technology advances make it possible to consider continuous acoustic respiratory rate monitoring as an integral component of physiologic surveillance systems. This study explores technical and logistical aspects of augmenting pulse oximetry-based patient surveillance systems with continuous respiratory rate monitoring and offers some insight into the impact on patient deterioration detection that may result. Acoustic respiratory rate sensors were introduced to a general care pulse oximetry-based surveillance system with respiratory rate alarms deactivated.

Building a Foundation of Continuous Improvement in a Rapidly Changing Environment: The Dartmouth-Hitchcock Value Institute Experience.

Background: A performance improvement competency development program, known as the Value Institute (VI), was established at Dartmouth-Hitchcock (D-H; Lebanon, New Hampshire) in 2011 to develop a performance improvement-focused workforce and systems capable of meeting the challenges of creating a sustainable health system.

Methods: A tiered competency development program that provides patient safety, health care quality, and improvement science education, and an execution support infrastructure that enables access to performance improvement tools for all employees, comprise the core of the VI.

Results: At 20 months after the launch of the first VI classes, more than 10% of all employees were trained to the Yellow Belt level, and approximately 1.

A comparison of oxygen saturation data in inpatients with low oxygen saturation using automated continuous monitoring and intermittent manual data charting.

Background: The manual collection and charting of traditional vital signs data in inpatient populations have been shown to be inaccurate when compared with true physiologic values. This issue has not been examined with respect to oxygen saturation data despite the increased use of this measurement in systems designed to assess the risk of patient deterioration. Of particular note are the lack of available data examining the accuracy of oxygen saturation charting in a particularly vulnerable group of patients who have prolonged oxygen desaturations (mean SpO2 <90% over at least 15 minutes).

Developing a continuous monitoring infrastructure for detection of inpatient deterioration.

A physiologic database infrastructure, composed of a patient monitoring system and a data processing and storage system, enables the detection of deterioration in noncritical patients, thereby helping to prevent failure-to-rescue events.

A review of current and emerging approaches to address failure-to-rescue.

Failure-to-Rescue, defined as hospital deaths after adverse events, is an established measure of patient safety and hospital quality. Until recently, approaches used to address failure-to-rescue have been focused primarily on improvement of response to a recognized patient crisis, with limited success in terms of patient outcomes. Less attention has been paid to improving the detection of the crisis.

Pulse oximeter plethysmographic waveform changes in awake, spontaneously breathing, hypovolemic volunteers.

Background: The primary objective of this study was to determine whether alterations in the pulse oximeter waveform characteristics would track progressive reductions in central blood volume. We also assessed whether changes in the pulse oximeter waveform provide an indication of blood loss in the hemorrhaging patient before changes in standard vital signs.

Methods: Pulse oximeter data from finger, forehead, and ear pulse oximeter sensors were collected from 18 healthy subjects undergoing progressive reduction in central blood volume induced by lower body negative pressure (LBNP).

Impact of pulse oximetry surveillance on rescue events and intensive care unit transfers: a before-and-after concurrence study.

Background: Some preventable deaths in hospitalized patients are due to unrecognized deterioration. There are no publications of studies that have instituted routine patient monitoring postoperatively and analyzed impact on patient outcomes.

Methods: The authors implemented a patient surveillance system based on pulse oximetry with nursing notification of violation of alarm limits via wireless pager.

Identifying airway obstructions using photoplethysmography (PPG).

Objective: Central and obstructive apneas are sources of morbidity and mortality associated with primary patient conditions as well as secondary to medical care such as sedation/analgesia in post-operative patients. This research investigates the predictive value of the respirophasic variation in the noninvasive photoplethysmography (PPG) waveform signal in detecting airway obstruction.

Methods: PPG data from 20 consenting healthy adults (12 male, 8 female) undergoing anesthesia were collected directly after surgery and before transfer to the Post Anesthesia Care Unit (PACU).

Using a generalized neural network to identify airway obstructions in anesthetized patients postoperatively based on photoplethysmography.

Photoplethysmography has been recently studied asa non-invasive indicator of circulatory and respiratory function. In this study, photoplethysmographic (PPG) data were recorded from patients under the influence of anesthesia, but not intubated. Both time and frequency domain features were extracted from the PPG and used as inputs to a neural network classifier.

An experimental architecture for observation of triage related decision making.

The interpretation and use of standard triage protocols differ widely among first responders. We believe that experience among first responders is a major cause of these differences. The intent of this study is twofold; to present a novel design for an experimental architecture to observe first responders perform triage, and to use the experimental architecture in a pilot study to explore the hypotheses that expert first responders deviate from standard triage protocols, and experience makes expert first responders deviate from standard triage protocols and leads to more accurate triage assessments because experts consider physiological variables not looked at in standard triage protocols and recognize subtle physiological trends indicative of injury.

Using a forehead reflectance pulse oximeter to detect changes in sympathetic tone.

The extreme conditions of combat and multi-casualty rescue often make field triage difficult and put the medic or first responder at risk. In an effort to improve field triage, we have developed an automated remote triage system called ARTEMIS (automated remote triage and emergency management information system) for use in the battlefield or disaster zone. Common to field injuries is a sudden change in arterial pressure resulting from massive blood loss or shock.