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Hospitalized patients who experience sudden unanticipated serious deterioration and subsequent cardio-respiratory arrests have very poor outcomes. In addition, the institutional and patient costs of such events are quite high23. A significant number of avoidable adverse and sentinel events occur on the medical-surgical floor, where nurse to-patient ratios often prevent continuous direct patient observation. Many of the patients that suffer either serious deterioration or sudden death have preceding predictive events1, 2, 3, 4, 5. Continuous monitoring of vital signs can provide early detection of deterioration and may improve patient outcomes.
A report by the Institute for Health Care Improvement (IHI) suggests that in many instances, subjective complaints and changes in vital signs could be noticed hours or even days in advance of cardiac or respiratory arrests, and majority of the events were observed to be preventable6,7.
According to CMS data extracted from Medicare patient discharge records between 2005 through 2007, respiratory failure and failure to rescue (prevent a clinically important deterioration) were two of the three medical indicators with the highest incidence, accounting for 26% of the 97,755 reported deaths and over $1.82 billion in excess Medicare costs. More than 80% of patients who experienced a cardiopulmonary arrest had evidence of deterioration within eight hours preceding the event. If they were on a medical-surgical floor, they often exhibited changes in respiratory function8. A retrospective multi-center study of 14,720 cardiopulmonary arrest cases showed that 44% were respiratory-related and more than 35% occurred on the medical-surgical floor9.
As patients’ acuity level continues to rise, hospitals are implementing new initiatives geared toward early detection of deterioration in a patient’s condition and faster intervention once a problem is recognized. New technologies previously utilized in critical care are being adapted to non-critical care areas, and many hospitals have set-up Rapid Response Teams to assist in the early intervention of patients presenting
with symptoms suggesting imminent deterioration. These Rapid Response systems rely on early warning indicators, including changes in pulse rate, respiratory rate and other information10, 11. Delays between the onset of patient deterioration and detection by clinicians on the medical-surgical floor significantly affect patient outcomes; delayed activation of the Rapid Response Team is the strongest predictor of patient mortality12.
The Joint Commission, in its 2010 Treatment and Services Standard PC.02.01.19, requires13 hospitals to:
1) Have a process for recognizing and responding as soon as a patient’s condition appears to be worsening;
2) Develop written criteria describing early warning signs of a change or deterioration in a patient’s condition and when to seek further assistance; 3) Have staff seek additional assistance when they have concerns about a patient’s condition; 4) Inform the patient and family how to seek assistance when they have concerns about a patient’s condition.
In addition to detecting patients at risk for in-hospital deteriorations, clinicians face challenges in preventable patient safety risks such as falls and pressure ulcers14. An estimated 1.3 to 3 million patients in the U.S. have pressure ulcers20; the incidence is highest in older patients, especially when hospitalized or in long-term care facilities. The World Health Organization (WHO) emphasizes that nurses have a vital role in prevention of pressure ulcers among hospitalized patients by regularly changing the patient’s position in bed. CMS no longer pays for hospital-acquired pressure ulcers, since they are considered preventable in the hospital setting15.
Falls are one of the major hazards leading to injuries, complications and mortality among hospitalized patients, especially in the elderly and those with dementia. Accidental falls in inpatients account for 30–40%
of reported safety incidents16. Falls occur at a frequency of 4–14 per 1,000 bed-days, or approximately 10 falls per month on a 28-bed ward17. Regulatory bodies have implemented strict standards regarding the use of restraints in the acute care setting.
In order to address the issues of detecting early clinical deterioration, and preventing falls and pressure ulcers, there is a need for continuous monitoring systems that alert nurses to risks in real time. Ideally, such a system should be noninvasive, user friendly, and easily integrated into nurses’ routine workflow.
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