Patient safety in the era of value-based care is increasingly defined as preventing adverse events before emergency interventions or costly escalations are required.

However, most common monitoring practices are reactive, not proactive; meaning, interventions are often applied only after a patient has deteriorated. A recent review of clinical surveillance initiatives noted that “nurses who are responsible for high acuity hospital patients believe that existing clinical processes and tools are inadequate to continuously monitor patients at-risk of deteriorating conditions.”

In addition to the clear risks to patient safety, monitoring’s status quo does little to reduce resource utilization, emergency transfers to intensive care units (ICUs), length of stay, hospital readmissions and other metrics of value-based care.

Continuous surveillance, on the other hand, has emerged as a viable solution for providing an accurate and real-time picture of a patient’s condition, enabling direct-care nursing staff and physicians to intervene well before a sentinel event.

Continuous surveillance is distinct from traditional monitoring practices. As such, operationalizing this capability may require hospitals and health systems to fundamentally rethink the concept of patient monitoring. In this post, I plan to demonstrate the ways continuous surveillance differs from monitoring, and how health system leadership can determine how this capability can be applied.

Shortcomings of Traditional Monitoring

For years, patient monitoring outside of the intensive care unit has traditionally meant sending data and alert signals from physiological devices to a central station or telemetry room and/or clinical staff performing episodic vital signs spots checks.

Each type of monitoring varies in complexity and comprehensiveness, but all have significant shortcomings:

• The volume of alerts sent by physiological devices can quickly and completely overwhelm clinical staff;
• Methods like spot vitals checks can leave patients wholly unmonitored for up to 96 percent of their hospital stay; and
• These methods often result in significant data gaps that do not capture key vital signs activity or deterioration that take place in the span of seconds to minutes with some patients.

Facilitation Issues

Adopting surveillance monitoring is disruptive, because it means changing the way certain things are done. It requires new technology and new policies and procedures for multiple roles at the point of care.

Several issues have to be addressed before a solution can be selected and implemented. First a cross-functional team focused on patient safety, patient monitoring, nursing, the rapid-response team and enabling technology (clinical engineering and IT) has to be assembled to acknowledge and define the problem.

Once consensus is reached, existing resources—monitoring technology, policies and procedures—must be proven to be ineffective in solving that problem. New hardware and/or software, plus revised policy and procedures are required to reliably detect clinical deterioration and initiate an effective intervention. For a review of available technologies and approaches see this post on Monitoring for Deteriorating Conditions.

Operationalization Issues

Once facilitation issues are squared away, the internal team must work to identify all the elements of an effective solution. This process is inexorably intertwined with the following operational issues:

• Which patients should continuously be surveilled—and why?
• Who orders surveillance monitoring?
• What type of patient monitor and parameters are used for surveillance monitoring?
• Who (or what) determines deterioration?
• What is the response to identified deterioration?

Continuous surveillance isn’t a matter of extending monitoring practices into new areas of the hospital; it’s a much more disruptive but effective capability. Though continuous clinical surveillance is regularly deployed in ICUs, this capability can be scaled to other departments, such as MED-SURG, critical care, step-down and telemetry. Safely surveilling high-risk populations across the enterprise and decreasing utilization of more expensive beds could provide significant cost savings for the institution and a more accurate and timely channel for clinical decision support regarding imminent, tractable problems.

When hospital leaders are considering a continuous clinical surveillance solution, they should look for a platform that fits seamlessly with their institution’s clinical workflow and technical infrastructure. The platform must also be a complement to and integrate bi-directionally with the institution’s EHR.

Many of the doomsday scenarios associated with failed technology adoption and implementation can be mitigated with adequate planning, training and collaboration. Involving direct care staff is critical to the success of any new technology. How will this new technology impact how nurses deliver patient care? What adjustments in workflow and practice need to be made—at go-live and beyond? Starting with these questions can foster buy-in from the staff that will be utilizing this capability.

For example, nursing staff are charged with the proper setting of the alarms and the prompt response when any of the devices send an alert. As the presence of alarming equipment and mobile notifications continues to grow, nurses find that their workflow and ability to engage with patients is disrupted as they chase down hundreds of (often non-actionable) alarms. Without proper education and implementation of alarming devices, it’s all too easy to imagine clinical staff arbitrarily adjusting alarm settings—or even turning them off entirely.

Thus, an expert project team should be formed, ideally comprised of leaders from myriad stakeholders; from IT networking and facilities, to informatics nurses and patient-facing clinical staff. This team will be responsible for every phase of deployment, including goals identification, vendor evaluations, business and clinical requirements, and progress assessments. The project team will also be charged with identifying the departments or units the integration will first impact.

Clinicians are beginning to recognize that continuous clinical surveillance can help them deliver better, more consistent, more efficient and safer patient care. Eventually, hospitals will use continuous surveillance with acutely ill patients in all care settings. The ability of analytics to interpret objective physiological data in real time and enable clinical intervention for deteriorating patient conditions that could otherwise be missed is just too powerful to ignore.

Market Intelligence: Continuous Surveillance

Click the links below for additional resources about continuous surveillance:

• Every hospital has patients who could benefit from increased surveillance. Watch this video conversation between Tim Gee and Brian McAlpine, Vice President of Strategy and Business Development at Bernoulli Health, about continuous surveillance and the migration of this capability to lower acuity floors.
• Download Continuous Clinical Surveillance: A Business and Clinical Case for Creating the Foundation for Real-Time Healthcare, a comprehensive guide to that leverages peer-reviewed research, literature reviews, market analysis and use cases to demonstrate how this capability can help clinical teams to anticipate the early signs of patient decline.
• Review the archives of the Bernoulli blog to learn more about the opportunities and obstacles for achieving real-time continuous surveillance opportunities.