Intelligent Patient Monitoring: More Control, Less Error

Sophisticated surveillance technologies have taken patient care to a new level

Clinicians are experiencing data overload, exacerbating the potential to stall decision making,  and, thereby, negatively impacting patient care. Experts agree that a shortage of intensivists, cardiologists and nurses in the U.S. will only worsen in the next five to 10 years as the need for their services increases. Advanced wired, wireless and telemedicine monitoring technologies are helping to meet the increasing demands of an aging population and decreasing healthcare resources, while leading to improved outcomes and reduced lengths of stay.

Swedish Medical Center in Seattle, a three-hospital, four-campus operation that generates about $1.3 billion in revenue annually, considers itself a digital leader in the Northwest, according to Rodney Hochman, MD, its CEO. The complex maintains a fully operational EMR, is involved in a telestroke project out of Massachusetts General Hospital and has installed the Visicu (Philips Healthcare) electronic ICU (eICU). Visicu allows intensivists and critical care nurses at the eICU command center to make virtual rounds of patients through an elaborate network of cameras, monitors and two-way communication links via T1 lines. Intensivists can remotely monitor the condition of patients, check vital signs and communicate with hospital staff, patients or family members.

“Remote intensive care monitoring is a big deal for the cardiology community,” Hochman says.  “It helps to relieve stress on cardiologists, as well as critical care physicians and nurses, because they do not have to be onsite and they know their patients are receiving the best care.”

Hochman previously held the position of senior vice president and chief medical officer for Sentara Healthcare in Norfolk, Va., when it installed the Visicu program. In its first year of use at Sentara Norfolk General Hospital, a 543-bed tertiary care facility, the eICU reduced intensive care mortality rates by 25 percent and shortened the average length of stay for these patients by 17 percent (Crit Care Med 2004;30:31-38). In addition, researchers found that Sentara Norfolk General was able to significantly reduce costs while upgrading the quality of care. Per patient costs dropped $2,150 based on reduced patient expenses and increased ICU capacity. The program generated roughly $3 million in savings above annualized program costs. Sentara Healthcare has since added three other hospitals to the remote monitoring program. 

The backbone of the eICU is the software that establishes base-line readouts for every patient, so that even slight changes in a patient’s vital signs are detected and treated. Dramatic changes in vital signs trigger automatic alerts to intensivists or critical care nurses who then work with on-site hospital staff to immediately respond to the patient’s needs. “The  important factors  are constant surveillance, providing the patient with immediate physician access and arming the physician with the patient information needed to make the right decisions quickly,” Hochman says. 

One of the benefits of the eICU model realized by Hochman is that it helps recruit and retain ICU physicians. “That in and of itself pays for the system,” he says. The cost of Visicu depends on the size of its deployment, but “with everything else we spend money on, we think it’s a relative bargain.”

More remote savings

A study presented at the 2009 annual meeting of the Society of Critical Care Medicine found that remote intensivist care through an eICU program saved Avera Health millions of dollars. Participating in the study were Avera McKennan Hospital and University Health Center in Sioux Falls, S.D., and several rural hospitals in the Avera eICU network.

Data were compared before and 30 months after eICU implementation. Among the findings:

• A 37.5 percent reduction in the number of patients requiring transfer from rural hospitals, saving more than $1.2 million;
• An estimated $8 million savings from reduced length of stay in ICUs;
• ICU and hospital mortality rates that were 65 to 80 percent lower than predicted outcomes;
• An overwhelming majority (90 percent) of rural hospital clinical leaders reported being very satisfied with the eICU;
• An overwhelming consensus (90 percent) among rural hospital leaders that patients and families are comfortable staying in the hospital with the added eICU care; and
• A 100 percent agreement among rural physicians surveyed that the remote critical-care team provides better, safer care than the conventional model.

Study author and director of Avera eICU Rural Care Edward Zawada, MD, says that the healthcare quality and safety benefits of ICU telemedicine are well documented. “What is becoming evident, however, are the significant financial benefits that can accrue from this improved quality. Equally important are benefits like less stress on rural physicians and nurses, and higher patient and family satisfaction.” Avera now provides tele-intensivist care to 16 hospitals across a rural four-state area, including seven community hospitals and eight critical-access hospitals.

“We have seen reductions in mortality and costs that have saved lives and more than covered the cost of the investment,” says David Kapaska, senior vice president and chief medical officer at Avera McKennan.

Smart patient monitors

It is no longer adequate for monitors or monitoring systems to passively transmit vital signs. Many vendors, therefore, offer a variety of systems with algorithms that help put into context the vast amount of data collected and then send that information throughout the enterprise. One of the latest products, Carescape Monitor B850 (GE Healthcare), which was cleared by the FDA in October, wirelessly integrates clinical measurements with other elements such as diagnostic images and lab results and then transfers the data to the EMR or the hospital information system.

Vendors also are addressing critical gaps in wirelessmonitoring that can occur during transport. The Intellivue MMS X2 monitor (Philips), for example, can be undocked—like a laptop—from a high-end monitor in the operating room, then used during patient transport to the recovery room and redocked into the bedside monitor.

In 2008, Philips acquired Emergin, a supplier of software to transmit medical alarm signals throughout hospitals. Philips incorporates the alarm software in its IntelliVue line of monitors. Changes in a patient’s base-line vitals—such as ST elevations and QT/QTc prolongation—can be sent to mobile phones, PDAs or a central monitoring station.

The AcuityLink Clinician Notifier (Welch Allyn), introduced earlier this year, has a three-tiered alarm escalation system that sends alarms to the primary caregiver, automatically escalates to a secondary clinician if the alarm persists and then transmits to all clinicians on the network if necessary.

The next breakthrough will be body sensor networks (BSNs), which would allow bedside wireless monitoring of many patient functions. GE, which is taking an initiative in this research, has requested that the Federal Communications Commission (FCC) dedicate a vendor-neutral radiofrequency band for BSNs and the FCC in September said it is considering the request. GE says BSNs could help “promote improved patient mobility leading to reduced lengths of stay and enhanced clinical outcomes.

Converged wireless networks

Once a facility has its wireless equipment in place, how does it ensure uninterrupted wireless access from end-to-end? The converged wireless network is emerging as a favorite among providers.

Memorial Health System in Colorado Springs, Colo., consists of Memorial Hospital Central (619 beds) and Memorial Hospital North (98 beds). Parts of Memorial Central are more than 100 years old, while Memorial North was built two years ago. Central’s wireless network is the conventional model, consisting of separate telemetry units installed throughout the hospital. This model tends to leave gaps in wireless access.

For the new construction at North, however, officials wanted to ensure that the entire hospital was wireless-enabled, including elevators, hallways and even the cafeteria. Memorial Health officials decided to install a converged wireless network (Carescape Enterprise Access; GE) at North, which allows one network for multiple wireless functions including medical telemetry, cell phone service, pagers, two-way radios, security alarms, data networks and radio frequency identification (RFID).

“In a traditional installation, you set up a separate network for each of those wireless capabilities,” says Tom Kerwin, CIO of Memorial Health System. “Converged technology allows us to install one network and then plug in additional modules as new wireless technologies are adopted.”

The system relies on a distributed antenna system, according to Bob Barrett, director of IT. Small antennas are installed throughout the facility that then link back to a central system, generally housed in a closet-sized room. When the hospital wants to enable a new wireless technology, Barrett installs the required module into the master switch of the central system, and that wireless signal is now available throughout the organization.

Earlier this year, Central installed the Enterprise Access system, but has utilized it so far only for cell phone coverage. There are plans to add wireless telemetry to the system, but for now, telemetry is done the old-fashioned way. Separate networks are installed in each area and the wireless signal does not transmit beyond the rooms to the halls or corridors, nor is the signal available in places like radiology and the emergency room. When patients have to be transported through halls or to radiology, for example, their vital stats are no longer being transmitted via a wireless monitor to the remote bank of 72 display monitors.

“Patients have to take off their portable wireless monitors for these trips,” says Dawn Lovejoy, RN, clinical coordinator for the coronary care unit (CCU). From a labor perspective, Kerwin notes, these patients have to be escorted everywhere. It’s a one-to-one ratio with the patient in transport. “It’s not always the most efficient process,” he says. 

At North, it’s a different story because the wireless telemetry signal is part of the converged network. Patients’ vitals are always streaming into the remote monitoring station, which is located on Central’s campus. “We are able to see patients on telemetry in the ER, in the surgical unit and even when they go down to the cafeteria to visit with their families,” Lovejoy says.  Telemetry techs who are cross-trained to perform critical-care tasks are stationed in the command center.

“If your goal is to have 100 percent coverage of all wireless signals at all places, a converged network is less expensive in the long run,” Kerwin says. “Even though the one-time installation of a converged network costs more money than installing a telemetry system in one unit, you will incur more costs trying to correct all the gaps in signal reception that can occur with multiple separate telemetry networks.”

In 2008, North installed ApexPro FH (GE), which protects the wireless signal from interference and dropout. The system uses a bi-directional, frequency-hopping, spread-spectrum infrastructure, allowing it to “hop around” the frequency spectrum to help prevent interference. “We  need continuous cell phone coverage throughout the facility in any location. Physicians are on call, they are receiving pages and they are communicating back and forth with patients and staff. The best way to ensure that the wireless signal is there for them is through the installation of such a system,” Kerwin says.

More space, fewer FTEs

Last year, Virginia Commonwealth University (VCU) Medical Center in Richmond, Va., opened a new critical-care hospital. Despite being three times the size of its predecessor, the new hospital needed to operate with the same number of nurse FTEs, meaning its staff required advanced communication technologies, including comprehensive wireless coverage, to enable full clinical mobility.

Challenges included a particular configuration of private rooms that made it tricky for nurses to communicate; larger patient care areas compared to the nursing units in the original facility, so new point-of-care processes would supplant repeated trips to and from the nursing station; and a restricted-use overhead paging system, according to Greg Johnson, chief technology officer and director of technology and engineering services at VCU Health System.

Nurses and the IT department collaborated to determine the best way to address these challenges and streamline workflow. Like Memorial Health, VCU Medical Center chose to install a converged wireless network (Horizon; InnerWireless).

“The converged wireless solution has provided us with a single managed platform that hosts virtually every wireless service, including Cisco WLAN, along with a wide range of mission- and life-critical applications operating on a diverse range of wireless devices,” says Heather Craven, RN, a nurse clinician in the acute-care medicine department at VCU Health System.

Integrated into the wireless platform are a number of wireless and mobile solutions that address the challenges identified prior to installation. For example, enhancements to the nurse-call system allows the nurses to be more responsive to patient needs, while the wireless voice-over IP communications system allows nurses to conduct more immediate and direct communications with other care team members.

In addition, VCU Medical Center provides ambulatory patient monitoring in more than 50 percent of the care area by utilizing wireless medical telemetry. And the clinical staff utilizes more than 300 mobile computers to electronically collect and review clinical information from the hospital’s information system.