Surveillance Monitoring: Current Challenges and Solutions

Tim Gee

Failing to recognize early signs that a patient is deteriorating and respond with effective treatment—“failure to rescue”—has long been a challenge for hospitals, particularly among low-risk patients in low-acuity care delivery areas. Failure to rescue often affects postsurgical patients on opioids, though it is not limited to this narrow patient population. To reduce its occurrence, hospitals have primarily adopted rapid response teams. Since their incorporation into Joint Commission standards in 2005, rapid response teams have reduced mortality and morbidity, but they have yet to provide the expected degree of improvement in patient outcomes.

Limitations in industry best practices regarding monitoring patients for deterioration may be responsible for these weak results. A key shortcoming is in the vital signs data used, especially its frequency and accuracy. Another factor is how long it takes the data to be recorded. When vital signs only make it into a patient’s chart at the end of a shift (or are not recorded at all), that data is unavailable for detecting deterioration.

Current best practice is to use spot vital signs monitors to capture accurate and consistent readings. Most vital signs monitors, however, lack a sensor for respiration, one of the best early indicators of patient deterioration. Manually counting breaths and recording an accurate respiratory rate is time-consuming—and difficult given the interruption-driven nature of nursing practice. Thus, many caregivers provide a quick “guesstimate” of the respiratory rate and can easily miss rate changes that signal deterioration. Key to maximizing the value of accurate vital signs is getting them entered and validated in the chart or patient record as they are acquired, rather than recording them all at once hours later.

Industry has responded to the need for more accurate and timely vital signs with various monitoring solutions that result in quicker and unambiguous recognition of patient deterioration. These solutions can be loosely referred to as surveillance monitoring.

Surveillance monitoring is most often applied in low-acuity areas with little or no established patient monitoring. While the patients in most failure-to-rescue events have not been monitored, some hospitals use cardiac telemetry packs as surveillance monitors for patients deemed at risk for deterioration. In the past, these patients were admitted to the telemetry unit, often leading to a shortage of telemetry beds and creating a hospitalwide patient flow bottleneck. To meet physician demands and mitigate flow problems, many hospitals extended telemetry wireless coverage to enable monitoring outside the telemetry unit. These packs were a good choice at the time because they were relatively inexpensive (about $8,000 per monitored patient) and well-tolerated by patients due to their size and wireless capabilities.

Unfortunately, telemetry packs fail to provide all of the vital signs required for surveillance monitoring. Telemetry packs monitor ECG, arrhythmia analysis, and heart rate, and some have the option for pulse oximetry. Arrhythmia and ECG parameters are a frequent source of non-actionable false positive and nuisance alarms, contributing to alarm fatigue. Most telemetry packs have no display, requiring the caregiver to leave the patient’s room to view data at a central station. Finally, telemetry packs are designed to monitor patients with arrhythmias; surveillance monitoring is an “off label” use.