By Jan Linderbery, MSM, RN, and Shelley Derr, BSN, RN
In a “call for action” for greater vigilance in monitoring vital signs, physicians in the United States and Denmark noted that these key indicators are probably the most important information gathered on hospital patients (Kellett & Sebat, 2017). Yet even though vital sign changes can accurately predict clinical deterioration, a problem that affects as many as one in six inpatient admissions, these changes are either unnoticed or not detected in time to treat the patient (Ben-Ari, Zimlichman, Adi, & Sorkine, 2010). Kellett and Sebat (2017) concluded that “if vital signs were more accurately and frequently measured, and acted on promptly and appropriately, hospital care would be safer, better and cheaper.”
At Arnot Ogden Medical Center, a not-for-profit, 256-bed tertiary medical facility in Elmira, New York, we’ve long used traditional telemetry devices and methods in our four cardiology units to monitor patients’ vital signs. But we also wanted to give this added layer of protection to other hospital patients without incurring the costs of installing telemetry systems.
Our solution was to integrate contact-free, continuous monitoring powered by EarlySense into our Hill-Rom Centrella® Smart+ beds to provide real-time information and alerts on patients’ respiratory and heart rates. This article discusses the need for and benefits of contact-free, continuous monitoring and our experiences with using the smart bed technology. It also includes some of the findings from our poster presentation last December at the Institute for Healthcare Improvement’s annual conference.
When we began using this technology last August in a 26-bed medical-surgical unit, nurses collected data for every bed alert to evaluate the system’s effectiveness in detecting early deterioration and triggering appropriate interventions. In the first two weeks of using this system, we had seven cases in which bed alerts enabled our nurses to quickly respond and resolve patients’ problems, which included choking, the inability to verbalize pain issues, and opioid-induced respiratory depression.
How contact-free, continuous monitoring triggers timely interventions
According to the Academy of Medical-Surgical Nurses (2019), vital signs are generally assessed in medical-surgical settings every four to eight hours, though this can be done more frequently based on patient acuity or population. Although nurses regularly check on their patients, sometimes it can be an hour or more before they see a specific patient. Nurses also don’t want to wake patients when they’re sleeping, and some physiological problems won’t be evident from a quick look.
Two facts are noteworthy: 1) even the most perceptive and conscientious nurses will not always detect signs of patient deterioration, and 2) numerous studies have reported that changes in vital signs occur several hours before a serious adverse event (Churpek, Adhikari, & Edelson, 2016). For example, if a patient’s abnormal respiratory rate (where “abnormal” generally means above 30 breaths per minute) goes undetected, the lack of a prompt response could lead to respiratory failure, the most common primary cause of ICU admission from general hospital units (van Loon, van Zaane, Bosch, Kalkman, & Peelen, 2015).
Contact-free, continuous monitoring offers a simple solution to provide 24/7 patient vigilance for respiratory and heart rates, the most common and problematic signs of patient deterioration. When patients lie down on our smart beds, sensors under the mattress record these measures. If the rates fall outside preset parameters, the bed “alerts” using lighted floor projections and sounds; it also automatically sends a notification to the appropriate nurses’ smartphones.
Examples of patient “saves”
Like a goalie on a hockey team, contact-free, continuous monitoring technology can be a healthcare team’s last line of defense for detecting vital sign changes and preventing clinical deterioration, adverse events, and emotional distress. At Arnot Ogden, this technology made several great “saves” as soon as we turned it on. For example:
- One patient started choking while she was eating breakfast, and when caregivers saw her elevated respiratory rate, they rushed to the bedside to clear her airway. Not only was the patient greatly relieved to be breathing freely again, but this real-time intervention also prevented her from risking a fall by getting out of bed.
- In another instance, an elderly patient recovering from hip surgery became agitated but couldn’t verbalize her pain. After being alerted to her rising heart rate, our nurse gave the patient pain medication, which lowered her heart rate and calmed her down.
The value of even seemingly insignificant interventions should not be underestimated, since any vital sign change can have a disproportionally negative impact on a patient’s health. In one study of U.S. veteran inpatients, 16% had abnormal vital signs; more importantly, 35% of patients with abnormal vital signs experienced a serious adverse event compared to only 2.5% of patients with normal vital signs (Lighthall, Markar, & Hsiung, 2009).
Research also has shown that continuous smart bed monitoring on a medical-surgical unit is associated with a significant decrease in total length of hospital stays, ICU days for transferred patients, and code blue rates (Brown, Terrence, Vasquez, Bates, & Zimlichman, 2014). Soon after our initial trial began, our administrators decided to add contact-free, continuous monitoring technology to all our smart beds in two medical-surgical units and an observation telemetry unit.
Unexpected patient benefits
Not surprisingly, the most common causes of the bed alarms were pain and respiratory depression. One thing we didn’t anticipate, however, was that continuous monitoring of respiratory and heart rates would be so helpful in alleviating patients’ anxiety and empowering nurses to support and comfort their families.
For example, one of our patients refused to take her pain medications unless someone sat in the room with her because of her previous bad reactions to narcotics. When we explained how the monitors in the mattress worked and that her nurse would be immediately alerted if her respiration or heart rate dropped, she was no longer worried and took the medications.
In another instance, the alarm went off for a patient on end-of-life care and the nurse went to the bedside to find the patient had stopped breathing. When the patient’s family came into the room, they were relieved to find the nurse at the bedside and see that their loved one was not alone.
In less than a minute, a patient’s condition can worsen dramatically. And if such changes are not detected and addressed with timely, appropriate interventions, clinical deterioration can adversely affect patients’ health and well-being as well as hospital costs.
Continuous monitoring is an effective way to avoid the most common causes of clinical deteriorations, but many hospitals cannot afford to have telemetry systems in all their general medicine and surgical units. Conventional “wired” monitoring also has other drawbacks, including patient discomfort and increased staff workload from false alarms caused by sensor dislodgment. For example, one study in a medical-surgical unit found that its monitoring system was responsible for approximately 30% of the interruptions to care, but only 20% of these alarms were clinically meaningful and resulted in a clinical intervention (Gross, Dahl, & Nielsen, 2011). In addition, van Loon et al.’s (2015) study for pulse oximeters showed that about 2% of patients refused to wear sensors.
Less than five years ago, Brown et al.’s (2014) study on noninvasive continuous respiratory monitoring on hospital units noted that “the ideal monitoring strategy should include unobtrusive sensors that are well tolerated by the patient, have a high sensitivity and a high positive predictive value.” Based on our experiences, the contact-free, continuous monitoring technology in our Centrella Smart+ beds is a cost-effective, patient-friendly solution that meets these criteria. We haven’t had many false alarms, and those that do occur are easy to troubleshoot. As a result, nurses are more attuned and responsive to the alarms, because they know there’s a good reason to check on patients. Equally important, the bed sensors reassure patients that if something does happen, our nurses will be at their bedside in minutes.
Jan Linderbery is unit director of Arnot Ogden Medical Center’s 26-bed medical-surgical unit, which focuses on orthopedic and neurosurgical patients. Shelley Derr is clinical coordinator of the same unit.
Academy of Medical-Surgical Nurses. (2019, April). Question: What are the standards and frequency recommendations for taking “routine” and “post-operative” vital signs? https://www.amsn.org/practice-resources/care-term-reference/vital-signs/question-what-are-standards-and-frequency
Ben-Ari, J., Zimlichman, E., Adi, N., & Sorkine, P. (2010). Contactless respiratory and heart rate monitoring: Validation of an innovative tool. J Med Eng Technol, 34(7–8), 393–398. https://doi.org/10.3109/03091902.2010.503308
Brown, H., Terrence, J., Vasquez, P., Bates, D. W., & Zimlichman, E. (2014). Continuous monitoring in an inpatient medical-surgical unit: A controlled clinical trial. American Journal of Medicine, 127(3), 226–232. https://doi.org/10.1016/j.amjmed.2013.12.004
Churpek, M. M., Adhikari, R., & Edelson, D. P. (2016). The value of vital sign trends for detecting clinical deterioration on the wards. Resuscitation, 102, 1–5. https://doi.org/ 10.1016/j.resuscitation.2016.02.005
Gross, B., Dahl, D., & Nielsen, L. (2011). Physiologic monitoring alarm load on medical/surgical floors of a community hospital. Biomedical Instrumentation & Technology, 45(s1), 29–36.
Kellett, J., & Sebat, F. (2017). Make vital signs great again – A call for action. Eur J Intern Med, 45, 13–19. https://doi.org/10.1016/j.ejim.2017.09.018
Lighthall, G. K., Markar, S., & Hsiung, R. (2009). Abnormal vital signs are associated with an increased risk for critical events in US veteran inpatients. Resuscitation, 80(11), 1264–1269. https://doi.org/10.1016/j.resuscitation.2009.08.012
van Loon, K., van Zaane, B., Bosch, E. J., Kalkman, C. J., & Peelen, L. M. (2015). Non-invasive continuous respiratory monitoring on general hospital wards: A systematic review. PLoS One, 10(12), e0144626. https://doi.org/10.1371/journal.pone.0144626