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Background Intervention Results Brief Comments
Reducing ICU Transfers and Rescue Events in theGeneral Care Area by Continuous Monitoring.
Andreas H. Taenzer
The Geisel School of Medicine at Dartmouth
Dartmouth Hitchcock Medical Center
October 26, 2012
Background Intervention Results Brief Comments
Disclaimers
No compensation of any sort from any company.
Grant from the Anesthesia Patient Safety Foundation to studyrespiratory rate monitoring for patients on general care areas.
Government grants (FDA, NIH) for unrelated research.
Background Intervention Results Brief Comments
Dartmouth
20,000 Inpatient Discharges
90,000 Inpatient Days
8,500 Intermediate CareDays
24,000 ICU Days
We currently have 3 Rescue Events and 1 Care Escalation per1,000 patient days.
Background Intervention Results Brief Comments
Background Intervention Results Brief Comments
UCL=14.784
LCL=-5.657
CEN=4.564
UCL=5.889
LCL=-0.698
CEN=2.5955
-10
-5
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5
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20
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Rescue Events per 1,000 patient days per month over 2 years. Control limits adjusted for time of Start of Patient Surveillance.
Patient Surveillance
Background Intervention Results Brief Comments
Infrastructure
Background Intervention Results Brief Comments
Infrastructure
over 10x109 data points
over 10,000 patient days of physiologic data sampled inone-second intervals.
for adverse event review and research
Background Intervention Results Brief Comments
Infrastructure
Vocabulary
Condition vs. Surveillance Monitoring
False Alarms - Nuisance Alarms - Actionable Alarms
Alarm Burden - Alarm Fatigue - Alarm Mismanagement
Rescue Events = RRT activations + Code Blues + Codes
Care Escalations/ICU Transfers = Unanticipated Transfer of aPatient to a Higher Acuity Care Unit
Background Intervention Results Brief Comments
Alarm Settings
PSS Settings
Alarm Settings
SpO2 < 80
HR < 50
HR > 140
Alarm adjustments
1 Standard Settings
2 Bracketed Adjustments (±10%) by RN
3 Physican ordered Adjustment
Notification Delays15 sec at the bedside +15 sec (=30 sec total) for pagerannunciation
Background Intervention Results Brief Comments
Description of Normality
40 60 80 100 120 140 160 1800
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1.5
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HR (bpm)
Pro
port
ion o
f T
ime S
pent (%
)
HR Histogram Comparison
Medicine
Surgery
70 75 80 85 90 95 1000
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SpO2 (%)
Pro
port
ion o
f T
ime S
pent (%
)
SpO2 Histogram Comparison
Medicine
Surgery
Background Intervention Results Brief Comments
Original Study
Decrease of Rescue Events by 65%
Background Intervention Results Brief Comments
Original Study
Decrease of ICU Transfers by 45%
For each of the 32-bed surgical units, ICU days decreased by 160for the 12 months after implementation.
Background Intervention Results Brief Comments
Three Surgical Units
Decrease of Rescues by > 50% across all Surgical Units
Background Intervention Results Brief Comments
Respiratory Rate Monitoring
RR vs. SpO2
Data based on 5,000 patient days.
Background Intervention Results Brief Comments
Developing Prediction Algorithms
0
0.5
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5C
tl.
HE
RT
PA
ll
HE
RT
−4h
r
HE
RT
−2h
r
HE
RT
−1h
r
HE
RT
−30
m
SpO2 Standard Deviation, Prior to HERT Comparison
Background Intervention Results Brief Comments
Developing Prediction Algorithms
Not so easy...
Classifier Sensitivity (%) Specificity (%)
Naive Bayes’ 64 73Neural Network 70 59Sample Entropy plus NB 78 60NB in resp. subset 75 63
Data from c©Dr. Joshua Pyke’s PhD Thesis
Background Intervention Results Brief Comments
Final Comments
Summary
DHMC has seen a sustained reduction in ICU Transfers and RescueEvents since the Introduction of Patient Surveillance despite an everincreasingly challenging patient population.Changes have been overall bigger on surgical than on medical floor.The most important factor of success has been degree of utilization.
1 Collaborative effort by all stakeholders involved(Administration, IT, RNs, Physicians, Engineers etc.)
2 Education for RNs and physicians
3 Continuous monitoring on all surgical and medical unitsincluding pediatrics (and planned roll out to ER and OB)
4 Patients have to sign waivers to not be monitored