Rajagopal Parthasarthy was a chronic sufferer of chronic obstructive pulmonary disease (COPD). He was admitted to a reputed hospital in the city with complaints of breathing difficulty. As per hospital protocol, he was admitted directly into the ICU, where he was treated by technology and nurses. When his condition stabilized, he was shifted to a private room. His care plan in the private room was basic: a nurse would assess his oxygen saturation using a small finger probe. Despite the simplicity, his family was excited to see Rajagopal recovering and was looking forward to him returning home.
One night, Rajagopal’s blood oxygen started falling. As a COPD patient, he never said anything about his deteriorating condition. After all, COPD patients are chronically hypoxic. His family members, who were in the same room, did not notice his breathing getting more laboured. Early next morning, when his blood oxygen was checked, he was rushed to the ICU.
“Permanently damaged”, the doctor said explaining the impact of sustained hypoxia (low blood oxygen) on Rajagopal’s lungs.
There could not be any rescue. He passed away leaving behind a grieving family and loved ones. Rajagopal Parthasarthy’s death was not a medical problem. It was an information problem.
How many times have we heard and witnessed such an incident? How many times have we wondered what went wrong, when everything was apparently fine? A careful analysis of the situation, and indeed many such incidents, would point us to a common problem. A short-coming really, in a majority of even the best hospitals in the country. A lack of continuous monitoring outside of the ICU.
Drawbacks of a Non-ICU Setup
In an Intensive Care Unit, one-to-one nursing care of a patient along with 24×7 monitoring of a patient’s vital signs ensures patient safety. ICUs are the only place in the hospital where a patient is under continuous observation by the attending nursing staff. Not only are any deviations shared with the attending physician, but in the case of an emergency, the ICU staff can intervene immediately.
Unfortunately, there is no system for continuous monitoring when a patient is shifted outside of the ICU, either to a private room or a general ward. Nurses manually monitor patients at extended intervals and often miss imminent complications.
More than 50% of hospital deaths occur in patients who are not continuously monitored.
Without access to monitoring, vulnerable patients who are being cared for outside the ICU are at grave risk of death.
Current Dilemma of Hospitals
Who is at fault here? That’s a difficult question to answer. Hospitals are addressing a high number of complicated cases these days. These include cases of co-morbidities (two or more simultaneous health conditions) as well as cases caused by unknown and highly unpredictable risk factors. Patients both inside and outside of the ICUs are on complex pharmaceuticals where interactions with other drugs can lead to massive challenges. In such an environment where continuous monitoring is absent, deterioration in health can easily go unnoticed.
The old standards of nurses doing rounds and manually measuring vital signs have not kept pace with time. Even today, patients are assessed every 4 to 8 hours. In the Indian context, with a highly skewed patient to nursing staff ratio, this time interval could be even longer. Research shows that patients exhibit evidence of deterioration for 6 to 12 hours prior to the adverse event. However, without continuous monitoring, signs of deterioration are easily missed and interventions only begin once vital signs have already reached critical levels.
Enter Continuous monitoring
In a 2010 report from an international consensus conference on rapid response, it was suggested that “if practical and affordable, all patients should be monitored continuously.” Continuous monitoring should measure heart rate, blood pressure, temperature, pulse oximetry, respiratory rate and level of consciousness. These core vital signs are key to report physiological instability.
With a rapid response system, alarms for vital signs outside of accepted ranges allow for a successful rescue. Vital sign trending takes this a step further by assisting clinicians to identify true alarms and reduce “alarm fatigue.” Nursing and medical staff can visually see whether a patient is stabilizing or destabilizing and react appropriately.
The medical field admits to the shortcomings in monitoring and have no doubt in the value a “practical and affordable” monitoring system would provide. Professor Sir Bruce Keogh, Medical Director of National Health Service (NHS), England says
“…continuous monitoring devices hold enormous promise, and will be an important part of the medical landscape in the very near future. Monitoring of vital signs…will play a significant role in patient care because uninterrupted monitoring can give insight into a patient’s condition in real time.”
Tangible Advantages of Continuous Monitoring
According to a study published in the journal Critical Care Medicine, it was estimated that hospitals could save $20,000 per bed per year with the help of continuous monitoring. If an unmonitored patient develops a complication, a rescue can be resource-intensive. But if the patient is continuously monitored, a complication can be avoided before it can occur. This saves money, hospital resources, and heartbreak. More importantly, more than 200,000 lives per year can be saved. While these are US figures, it’s easy to imagine a large number of lives saved and the crores of rupees worth of savings in the Indian Healthcare system.
Continuous Monitoring: The Final Verdict
Hospitals don’t fail to rescue; they fail, often miserably, to recognize.
The gap between recognition and rescue could be a matter of life and death for a patient. This is the gap that a continuous monitoring system can bridge.
It’s clear that an ICU set up cannot be replicated throughout all the wards of a hospital. On the other hand, a low-cost, accurate, and practical monitoring system can certainly become part of a hospital’s non-ICU set up. Implementing a continuous monitoring system has a high return on investment. However, considering the number of lives it can save, implementing a continuous monitoring system is a clear decision for any hospital’s reputation.
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