As founder and executive director PPAHS, when I speak at conferences about the Physician-Patient Alliance for Health & Safety support for continuous electronic monitoring of patients receiving opioids, I am often asked two questions:
- Is PPAHS suggesting or recommending that technology replace nurses?
- Why has continuous monitoring been so slow to be adopted by hospitals?
Nursing and Technology
I personally believe that nurses play a vital role in the how well patients recover, how quickly they recover and are discharged from hospital and sent home. Ideally, a nurse should be at every patient’s bedside watching, observing and caring for that patient on a continual basis.
Lillee Gelinas, RN, MSN, FAAN (then vice-president and chief nursing officer, VHA Inc.; now Editor-in-Chief, American Nurse Today) told me, “Too much of nurses’ time is spent in activities other than in actual patient care. The majority of nurses’ time is spent in ‘hunting’ and ‘gathering’ types of activities, like finding the right supplies. In addition, they are documenting, coordinating care, and administering medications. Not enough time is actually being spent at the patient’s bedside, assessing, teaching and caring.”
We need nurses doing more nursing. A time and motion study of 767 medical-surgical nurses in 36 hospitals found that only 7.2% of their time (31 minutes during a typical 10 hour shift) is spent with the patient performing tasks, such as assessing the patient and reading vital signs. During a 10-hour shift, the study found nurses’ time was spent in numerous activities, as shown in the chart below:
That’s 24 x 7 observation – nurses scheduled a continuous basis with the task of observing the patient. Would this require more nurses? Yes! Is this economically feasible? No, hospital economics makes this prohibitive, if not impossible.
In addition, the reality of the current work environment is that a frenetic pace, high workload and numerous administrative demands reduce nursing time with patients. So, to deal with the demands of the work environment and the needs of multiple patients, technology should be seen as an adjunct to safe care, and used by nurses as a ‘technological safety net’ to support their practice in providing optimal patient outcomes. An average ICU, for example, has 15 different pieces of technology in the patient’s room, none of which talk to each other, so the nurse is the neural network. Instead, the right technology should help “connect the dots.”
As Julie Morath, RN, MS (then Chief Quality and Safety Officer at Vanderbilt University; now President/CEO, Hospital Quality Institute) explained, “Human vigilance is required but insufficient; continuous electronic monitoring needs to be there to support and backup nurses, and allow them to visit a patient while monitors are continuously assessing other patients for various physiological parameters (such as, oxygenation with pulse oximeter or adequacy of ventilation with capnography).”
“The stakes are just too high,” explained Morath. “We have a life in our hands – someone’s family member or loved one. If we want nurses to use technology, they need to be part of the decision to use it and buy it. They need to receive adequate training and continuing support. Doing this appropriately engages nurses as accountable and active partners and members of the problem-solving team in patient safety.”
Technology can assist better nursing care, by continuously electronically monitoring patients to support nursing rounds. This technological vigilance may provide nurses the piece of mind to care for patients, without jeopardizing patient safety. However, for monitoring technology to be of benefit, two issues must be addressed:
- Decreasing alarm fatigue: using “smart” alarm management technology can increase the number of actionable alarms and decrease false alarms.
- Easily assessing a patient’s status: using algorithms can help nurses easily assess a patient’s condition through the incorporation of multiple psychological parameters (such as, etCO2, SpO2, respiratory rate, and pulse rate) that have been combined into an uncomplicated single assessment. An example of an easy patient assessment tool was described in my interview with Hiroshi Morimatsu, MD, Ph.D (Okayama University Hospital, Okayama, Japan).
Slow Technology Adoption
The second question that I’m asked about continuous monitoring is “Why has continuous monitoring been so slow to be adopted by hospitals?” Underlying this question is the thought that if continuous electronic monitoring is “good”, then why are more hospitals and clinicians using it.
As Gina Pugliese (formerly vice president, Premier Safety Institute; board of advisors, PPAHS) recently wrote, “Despite efforts to increase awareness of electronic monitoring efficacy, the adoption on general patient care units has been relatively slow. The good news for this technology is that it has advanced significantly in the past few years to the point in which it can be used reliably on both intubated and non-intubated patients, adult and pediatric, as well as those patients receiving oxygen.” –
First, let me discuss whether monitoring is “good” – that is, whether it solves a real problem.
PPAHS has recommended that all patients receiving opioids be monitored with pulse oximetry for oxygenation and with capnography for adequacy of ventilation. Both pulse oximetry and capnography are not new technologies, as they are standard equipment mandated to be used in all surgeries by the American Society of Anesthesiologists.
Monitoring patients with pulse oximetry and capnography have been used for many years; however, the application of monitoring patients outside the operating room is a new application. ECRI Institute in its annual Top 10 Technology Hazards again named opioid safety in its 2017 list, saying:
“Patients receiving opioids—such as morphine, hydromorphone, or fentanyl—are at risk for drug-induced respiratory depression. If not detected, this condition can quickly lead to anoxic brain injury or death. Thus, spot checks every few hours of a patient’s oxygenation and ventilation are inadequate.
“ECRI Institute recommends that healthcare facilities implement measures to continuously monitor the adequacy of ventilation of these patients and has recently tested and rated monitoring devices for this application.”
But, it’s not just ECRI which believes that patients receiving opioids should be continuously electronically monitored. The AAMI National Coalition to Promote Continuous Monitoring of Patients on Opioids was co-convened by many organizations, including:
- The Anesthesia Patient Safety Foundation (APSF)
- Institute for Safe Medication Practices (ISMP)
- National Patient Safety Foundation (NPSF)
- The Joint Commission
- VA National Center for Patient Safety
This vision of continuous monitoring for patients receiving opioids has been endorsed by organizations, including:
- American College of Clinical Engineering (ACCE)
- American Association of Nurse Anesthetists (AANA)
- American Association for Respiratory Care (AARC)
- American Society for Pain Management Nursing (ASPMN)
The real reason I believe for the slow adoption of continuous electronic monitoring outside of the OR is cost. Lynn Razzano and I wrote in our article, “Financial Objections Don’t Add Up in Monitoring Debate” that there costs associated with not monitoring, as well as a return on investment for monitoring:
Although hospitals may have resource limitations, there are increased costs associated with failing to adhere to best practices. An analysis of more than 3,300 closed claims of the American Society of Anesthesiologists (ASA) by Julia I. Metzner, MD, “Risks of Anesthesia at Remote Locations” shows that the median payment per claim can be $210,000 for events that occur in the operating room and $330,000 for those outside the operating room. This analysis concluded that these adverse events were due to substandard care or preventable by improved monitoring.
Additionally, there are hospitals that have identified a significant return on investment with implementing continuous monitoring. For example:
St Joseph/Candler Hospitals in Savannah, GA, has experienced more than 10 years of “event free” years monitoring patients receiving opioids. During a five-year period, St Joseph/Candler calculated that it saved $4 million (estimated potential expenses averted, not including potential litigation costs) and had a five-year return on investment of $2.5 million.
In research conducted at Boston’s Brigham and Women’s Hospital, Eyal Zimlichman, MD, MSc, and his colleagues determined that implementation of a continuous monitoring system was “associated with a highly positive return on investment. The magnitude and timing of these expected gains to the investment costs may justify the accelerated adoption of this system across remaining inpatient non-ICU wards of the community hospital.” For a podcast with Dr. Zimlichman on this research, please click here.
These resource factors—professional liability associated with failure to monitor and a return on investment—would seem to indicate that continuous electronic monitoring saves hospital significant costs rather than resulting in higher expenditures.
We concluded our article by asking what are the real obstacles to continuous electronic monitoring?:
There are clearly patient safety initiatives that can be instituted and implemented that would result in cost savings, effectiveness, and a significant improvement in patient harm events from lack of or inadequate monitoring protocols.
This would suggest that it may not be resources, but resource allocation that may be the obstacle. If so, what really are the key obstacles within institutions that are stopping the implementation of these and other patient safety initiatives?