Patient Surveillance - The Dartmouth Experience. AAMI Webinar - - - PowerPoint PPT Presentation

Introduction Intervention Results Conclusion

Patient Surveillance - The Dartmouth

• Experience. AAMI Webinar - February 6th 2013.

Andreas H. Taenzer

The Geisel School of Medicine at Dartmouth The Dartmouth Institute for Health Care Policy and Clinical Practice Dartmouth Hitchcock Medical Center

January 31, 2013

Introduction Intervention Results Conclusion

Disclaimers

Industry Products mentioned in this presentation: Patient Safety NetTMby Masimo Grants No compensation of any sort from any company (e.g. MasimoTM). Grant from the Anesthesia Patient Safety Foundation to study respiratory rate monitoring for patients in general care areas. Salary support via an Innovation Grant from CMS to work on the High Value Health Care Collaborative’s Sepsis Project for The Dartmouth Institute for Health Care Policy and Clinical Practice Government grants (FDA, NIH) for unrelated research.

Introduction Intervention Results Conclusion Outline

Dead in Bed

No Death or Hypoxic Brain Injury

since Dec 2007 in a 32-Bed Surgical Unit

Introduction Intervention Results Conclusion Outline

UCL=14.784 LCL=-5.657 CEN=4.564 UCL=5.889 LCL=-0.698 CEN=2.5955

• 10
• 5

5 10 15 20 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Rescue Events per 1,000 patient days per month over 2 years. Control limits adjusted for time of Start of Patient Surveillance.

Patient Surveillance

Introduction Intervention Results Conclusion Setting

Dartmouth Hitchcock Medical Center

20,000 Inpatient Discharges 90,000 Inpatient Days 8,500 Intermediate Care Days 24,000 ICU Days

Introduction Intervention Results Conclusion Problem Definition and Intervention

Introduction Intervention Results Conclusion Problem Definition and Intervention

Vocabulary

Condition vs. Surveillance Monitoring Nuisance Alarms - Actionable Alarms Alarm Burden - Alarm Fatigue - Alarm Mismanagement Rescue Events = RRT activations + Code Blues + Codes Care Escalations/ICU Transfers = Unanticipated Transfer of a Patient to a Higher Acuity Care Unit

Introduction Intervention Results Conclusion Problem Definition and Intervention

Goals

Reduce adverse events No staffing changes Minimize burden on RNs

Introduction Intervention Results Conclusion Infrastructure

Introduction Intervention Results Conclusion Infrastructure

• ver 12x109 data points
• ver 50,000 patient days of physiologic data sampled in
• ne-second intervals.

for adverse event review and research

Introduction Intervention Results Conclusion Alarm Settings

PSS Settings

Alarm Settings SpO2 < 80 HR < 50 HR > 140 Alarm adjustments

1 Standard Settings 2 Bracketed Adjustments (±10%) by RN 3 Physican ordered Adjustment

Notification Delays 15 sec at the bedside +15 sec (=30 sec total) for pager annunciation

Introduction Intervention Results Conclusion Description of Normality

40 60 80 100 120 140 160 180 0.5 1 1.5 2 2.5 3 HR (bpm) Proportion of Time Spent (%) HR Histogram Comparison Medicine Surgery 70 75 80 85 90 95 100 2 4 6 8 10 12 14 16 SpO2 (%) Proportion of Time Spent (%) SpO2 Histogram Comparison Medicine Surgery

Introduction Intervention Results Conclusion Description of Normality

18:00 00:00 06:00 12:00 18:00 50 60 70 80 90 100 110 Time HR (bpm), SpO2 (%) PSS Archive Plot

Example of archived physiologic data for one patient.

Introduction Intervention Results Conclusion Description of Normality

SpO2 data of one patient over hours with repetitive desaturations (but no adverse event).

Introduction Intervention Results Conclusion Original Study

Decrease of Rescue Events by 65%

Introduction Intervention Results Conclusion Original Study

Decrease of ICU Transfers by 45%

For each of the 32-bed surgical units, ICU days decreased by 160 for the 12 months after implementation.

Introduction Intervention Results Conclusion Original Study

Introduction Intervention Results Conclusion

Summary

DHMC has seen a sustained reduction in ICU Transfers and Rescue Events since the Introduction of Patient Surveillance despite an ever increasingly challenging patient population. Changes have been overall bigger on surgical than on medical units. The most important factor of success has been degree of utilization.

1 Collaborative effort by all stakeholders involved

(Administration, IT, RNs, Physicians, Engineers etc.)

2 Education for RNs and physicians 3 Continuous monitoring on all surgical and medical units

including pediatrics (and planned roll out to ER and OB)

4 Patients have to sign waivers to not be monitored