Using RPM in post-surgery wards without driving alarm fatigue
Research shows how wearable RPM tools can detect post-surgery deterioration earlier, helping reduce preventable deaths, without escalating alarm fatigue among clinicians.
Though the rate of postoperative deaths is low in the United States, a significant portion are preventable with effective post-surgery protocols. These include timely and accurate identification of patient deterioration. Technology has proven useful in alerting clinical teams to signs of patient deterioration, enabling early intervention.
In recent years, various types of technology have been employed to enhance the detection of patient deterioration, including artificial intelligence and remote patient monitoring. Prior research has shown that a wearable RPM device helped clinicians detect patient deterioration between 29 and 40 hours faster than standard monitoring methods.
Now, a new pilot study conducted by Cleveland Clinic and GE HealthCare adds to the evidence that RPM tools can provide critical information to clinicians without prompting alarm fatigue, enabling them to provide effective clinical responses, mitigate patient deterioration and reduce preventable deaths post-surgery.
According to the study's Principal Investigator Daniel I. Sessler, M.D., the risk of death during surgery has dropped compared with the death risk post-surgery.
"The background here is that almost nobody dies during surgery," he said in an interview. "Preventable anesthetic mortality during surgery is so rare that it's hard to quantify. In contrast, many people die postoperatively. If the 30 days after surgery were considered a disease, it would be the third leading cause of death in the entire world."
Thus, there is an urgent need to enhance post-surgery protocols and recovery to boost patient outcomes, and RPM could prove vital in this effort.
Benefits of RPM in post-surgical ward
Despite dramatic advancements in healthcare delivery, Sessler, formerly with Cleveland Clinic and now a professor and vice president for clinical and outcomes research at the University of Texas Health Science Center at Houston (UTHealth Houston), pointed out that post-surgery monitoring has remained largely the same for the last few decades, and this might be one reason for postoperative deaths.
"We still monitor patients in hospital wards the way we did a half-century ago," he said. "But a half-century ago, patients were admitted to the hospital two days before surgery. They stayed for two weeks after surgery. We didn't operate on patients over 60. We didn't operate on people with major comorbidities, and we didn't do really large operations. It's completely different now. Patients are admitted the morning of surgery; most go home within a couple of days. Half of our patients are over 60, and we do huge operations on people no matter what their comorbidities are. So, the average acuity on surgical wards is now way higher than it was a half-century ago, but we're still monitoring the [vital] signs the same way, that is, intermittently every four to six hours."
What the literature shows is that a patient's condition can precipitously change between those intermittent measurements. And what occurs then is that a patient who may have appeared well during an evening visit may have deteriorated substantially at the next visit the following morning or really [at] any interval across the course of a day.
John JW Beard, M.D.Chief medical officer of GE Patient Care Solutions, GE Healthcare
The intermittent nature of current monitoring standards prevents clinicians from identifying and mitigating patient deterioration in a timely manner.
"What the literature shows is that a patient's condition can precipitously change between those intermittent measurements," noted John "JW" Beard, M.D., study author and chief medical officer of GE Patient Care Solutions at GE Healthcare, in an interview. "And what occurs then is that a patient who may have appeared well during an evening visit may have deteriorated substantially at the next visit the following morning or really [at] any interval across the course of a day."
For that reason, continuous vital sign monitoring solutions could be critical in improving post-surgery outcomes, Beard added. Providing clinicians with a real-time view of patient health and the trends in their health metrics would support informed clinical decision-making and help clinicians minimize the risk of adverse events.
For instance, GE HealthCare's Portrait Mobile solution aims to provide insight into patient health via continuous monitoring of three vital signs: heart rate, oxygen saturation and respiratory rate. The wireless wearable solution includes a wrist-worn pulse oximeter and a respiratory rate monitor attached to the patient through three chest leads. Beard noted that the staff changes the batteries for the pulse oximeter and the respiratory rate monitor approximately once a day.
The device connects wirelessly to a monitoring hub in the patient room, which connects to the hospital's Wi-Fi network. This allows vital sign data to be transmitted to central viewers in the hospital.
"It creates a very high-reliability connection," Beard said. "And this is essential for a continuous monitoring technology. You can imagine if there are dropouts of patient signals, the patients are then going periods of time without being monitored, which does essentially defeat the purpose of continuous monitoring."
However, hospital leaders must understand the impact on the bedside provider to successfully implement this technology. RPM technology offers a wide array of information to the clinician, and administrators must be wary of overwhelming their clinical teams with alerts and data.
Mitigating alarm fatigue related to RPM use
In the post-surgery setting, using RPM tools could result in a high volume of alarms, prompting alarm fatigue among clinical care teams.
Alarm fatigue refers to the desensitization that occurs when a tool emits too many alarms or alerts, which could endanger patients who need timely treatment.
"Alarm fatigue is very real," said Sessler. "And so, if you have alarm thresholds set in a way that generates lots of alarms, most of which are not being used by clinicians, then they begin to ignore all of them, and then they miss the ones that are important."
Alarm fatigue and the resulting patient safety risks have been on the industry's radar for at least a decade. Efforts to mitigate alarm fatigue are ongoing, with The Joint Commission including reducing patient harm associated with clinical alarm systems as one of its patient safety goals for 2024.
Thus, Beard emphasized that it is essential that the alarms from RPM tools are valuable for clinicians; that is, they communicate information to clinicians that will improve their ability to care for their patients.
For instance, patients are usually encouraged to walk around and be active in the post-surgical period to support their recovery.
"But this level of activity can cause the monitors themselves to either disconnect from the patient or be uncomfortable for the patient during activity," he said. "And so, really, the technology has to account for this type of active patient environment and the possibility of delivering, essentially, alarms that are not representative of the patient's physiology to the bedside provider. So, it's really important that the alarms be minimized by the technology to remain impactful."
This was the primary goal of the Continuous Ward Monitoring with the GE HealthCare Portrait Mobile Monitoring Solution (COSMOS) pilot study. Researchers from Cleveland Clinic and GE HealthCare conducted the two-phase study to determine how to enable RPM use in post-surgical wards without contributing to alarm fatigue.
The first phase of the study was designed to identify suitable alert thresholds for continuous heart rate, saturation, and ventilation monitoring conducted using the Portrait Mobile solution. The second phase compared blinded and unblinded continuous ward monitoring.
The study included 250 adults undergoing major non-cardiac surgery at Cleveland Clinic, with 100 included in the first phase and 150 in the second.
In the study's first phase, the researchers determined thresholds for continuous saturation, heart rate, and respiratory rate monitoring. These thresholds generated about two alerts per patient per day.
What we found was that continuous monitoring in an unblinded mode, so the clinicians knew about the monitoring results, decreased the duration of vital sign abnormalities by about 25%.
Daniel I. Sessler, M.D.Professor and vice president for clinical and outcomes research, University of Texas Health Science Center at Houston
Of the 150 patients enrolled in the study's second phase, 75 were assigned to unblinded monitoring and 75 to blinded monitoring. Blinded monitoring meant that patient vital signs were monitored and recorded but were not available to clinicians, while clinicians had access to vital signs data in the unblinded monitoring group.
"What we found was that continuous monitoring in an unblinded mode, so the clinicians knew about the monitoring results, decreased the duration of vital sign abnormalities by about 25%," Sessler said. "So … the amount of time that vital signs exceeded the normal thresholds was reduced by 25%."
Not only that, but most nurses found the alerts valuable. About 15 minutes after each alert, nurses were asked to categorize it. They categorized 82% of the alerts as informative, important, critical, while only 18% were categorized as false or distractive.
Sessler noted that the study findings, while not statistically significant, were clinically meaningful.
"That's what you would expect from a pilot trial," he said. "We didn't expect it to be significant, and we were thrilled to see a 25% reduction, which is a clinically meaningful amount."
The researchers concluded that RPM could play a critical role in post-surgery settings without escalating alarm fatigue.
Beard further noted that the alarms led to meaningful changes in how those patients were being cared for.
"The study was not big enough to demonstrate statistical significance of findings, but the trends suggest that continuous monitoring with Portrait Mobile in this environment may lead to a reduced duration and reduced severity of abnormal vital signs," he said. "And that is by nurses getting information from the monitor and then intervening at the bedside,"
The next step in this research will be conducting a full clinical trial with 850 patients to examine statistical significance. Still, the pilot study results are encouraging enough for Sessler to believe that continuous ward monitoring will soon be the standard of care.
"Let me go back to what I said in the beginning, which is that lots of patients die after surgery, and one-third of those deaths occur during the initial hospitalization," he said. "That is under our care, and … we're not doing this well. We're not serving these patients well. But continuous vital sign monitoring seems like an obvious way to reduce postoperative mortality because it will allow clinicians to detect abnormalities early enough to intervene."
Anuja Vaidya has covered the healthcare industry since 2012. She currently covers the virtual healthcare landscape, including telehealth, remote patient monitoring and digital therapeutics.
