New monitoring devices are improving outcomes for high-risk patients.
All of a sudden, without warning, a patient fresh out of the ICU dies of cardiac arrest. Should've never happened, says Timothy Sharkey, BS, RRT. Never.
Not in an age when the science of patient monitoring has evolved to such a level that clinicians can glimpse vital signs in an instant and make swift, informed decisions. Not in an age when one manufacturer recently introduced a system that measures electrocardiographs, blood oxygen saturation, blood pressure, respiration rate and body temperature, all from a box about the size of a 1950s radio that weighs a trifling two pounds. Not when the future promises even quicker, smaller and more reliable monitors, as well as the prospect of remote ICU telemonitoring.
"You have to provide a safe environment for your patients by monitoring them," Sharkey admonishes health care providers, urging them never to accept mediocrity in patient care. "If you are not providing safely for your patients, you're not doing what you went into the profession to do." Critical care patients return to the ICU because of inadequate monitoring, observed Korgi Hegde, MD, medical director of respiratory care at Forrest Park Hospital, St. Louis, MO.
"The patient may be hypoxic for some time without any health care providers realizing it," he said. "They may be congested and may need suctioning. If you don't suction them, they can develop respiratory distress and hypoxia and end up back in the ICU. When prevention is not done, it costs a lot more money."
It's essential to monitor the heart so patients don't have arrhythmias, Hegde continued. And video camera surveillance helps insure patients "don't fall out of bed or try to pull their tubes out. Lots of times they take their oxygen off. Sometimes patients are confused and may try to get out of bed."
Pay Now or Later
Cost pressures have elevated the importance of patient monitoring. Given the fiscal challenges hospitals face, patients are being wheeled out of high acuity/high cost areas while they are still critically ill. As a result, standing guard over their vital signs as they recuperate on the general floor or in step-down units is more crucial than ever.
Comprehensive patient monitoring does not come cheap…but, neither does hypoxemia that goes unrecognized. It's a "pay now or pay more later" situation.
Hypoxemia can cause myocardial ischemia, compromised wound healing, decreased resistance to infection, impaired cerebral function, short-term memory loss and "sundown" syndrome: confusion at night, which often makes a patient combative, Sharkey said. "These patients usually have to stay in the hospital an extra night or two, driving up costs," he said. Potential legal ramifications from these complications only make matters worse.
Likewise, patients can have desaturation events up to five days post-op or suffer bouts of apnea, studies suggest. Patients just out of the OR can't achieve REM sleep because they are too sedated on drugs, Sharkey said. So they acquire REM sleep debt. By about the fourth night post-op, they fall into deep REM sleep often accompanied by multiple apnea events.
More Monitoring Needed
Monitoring must occur during all three levels of patient sedation, according to Sharkey, a clinical consultant for Nellcor.
In the first level, procedural sedation, the patient can still communicate verbally. During this level, health care providers should maintain a patient's airway, protective reflexes and response to verbal stimuli.
The next level is conscious sedation, when the patient is slipping out of consciousness, followed by deep sedation, when the patient can no longer communicate. "It is difficult to predict any level of sedation without monitoring," Sharkey said. "Patients can slip from one stage of consciousness into the other quickly."
At Hegde's hospital, ICU patients are fully monitored for cardiac and respiratory problems. Patients in the step-down unit, however, are telemetrically monitored only for cardiac problems by a tech sitting outside patients' rooms. Hegde says monitoring respiratory rate and oxygen saturation might be useful here, too, at least with the sickest patients.
"(Full monitoring) probably could be done in the step-down unit," he said. "I would like it for respiratory patients out of the ICU on the floor or in step-down."
Studies conducted at the University of Pennsylvania Medical Center have demonstrated the cost-effectiveness of using continuous centralized pulse oximetry on a general care floor, according to Clinical Research Coordinator Gayle Devine, RN, BSN.
First, a 1998 study using it on 250 post-op patients reduced the hospital's overall ICU re-admission rate from 30% to 25%, she said. Specifically, respiratory related ICU re-admissions declined threefold, a major coup, as respiratory compromise is one of the most frequently cited causes of re-admission to the ICU.
In 1999, UPMC researchers tested 856 cardio-thoracic patients and found that those randomized to receive continuous pulse oximeter monitoring had shorter lengths of stay and required less intensive care than the control group. This study is continuing.
"Pulse oximetry can be effective in general care and seems better matched to clinical problems facing most post-op patients," Devine concluded.
Michael Gibbons is on staff at ADVANCE.