Cost savings through continuous vital signs monitoring | ANESTHESIOLOGY® 2023

Top Med Talk

Desiree Chappell: Well, hello and welcome back to Top Med Talk. We are here in San Francisco for the annual meeting of the American Society of Anaesthesiologist, Anaesthesiology 2023. It's been a fantastic start of the day. We're first day, day one. I'm Desiree Chappell. I'm your host. I'm joined by my co-host, Mike Grocott and Guy Ludbrook. Gentlemen, thank you so much for joining me.

Mike Grocott: Great to be here.

Desiree Chappell: Yes. So in the co-host seat. Guy, we have talked with you a little bit today. But for those who are listening today, can you tell us a little bit more about your background?

Guy Ludbrook: Sure. I'm an anesthesiologist from Adelaide in South Australia, and I work in a number of fields, increasingly post-operative care, health economics, and drug and product development.

Desiree Chappell: Yeah, they're clapping for you over there. So we're live.

Mike Grocott: It is very, very famous.

Desiree Chappell: Thank you, guys. We're live here in the exhibit hall. So anytime it's live, you never know what's going to happen. So great meeting so far. Lots of great sessions. We've had three or four conversations already here on Top Med Talk. There is a buzz here in Exhibit Hall, I feel like, this weekend. So very exciting. Now, here on Top Med Talk, we have conversations with people around the world, key opinion leaders. And this conversation is no different. So we have a friend of Top Med Talk, someone who has joined us before last year, Anaesthesiology 2022, JW Beard. JW, thank you so much.

JW Beard: For coming back. Desiree, thanks for having me. Mike and Guy, thanks for having me.

Desiree Chappell: Of course. Well, we've always had really great conversations. I love talking to you and learning from you. So, JW, for those who may not know you, can you tell us a little bit more about yourself?

JW Beard: Yeah. So I'm an anesthesiologist. I'm the Chief Medical Officer of GE HealthCare, Patient Care Solutions, which is our business segment, which is focused on acute care hospital technologies that include anesthesia delivery, patient monitoring, diagnostic cardiology, digital and maternal infant care. And so here in the ASA 2023, we're focused primarily on anesthesia delivery and patient monitoring and those integrated solutions in the care of patients and the support of our clinical community.

Desiree Chappell:  Yeah, fantastic. I know last year, whenever we were here, similar focus. But you had just been working with the APSF, correct? The Anesthesia Patient Safety Foundation?

JW Beard: Yeah. And it was, I guess, both years we had. So last year, we were focused on non-operating room anesthesia and the APSF. And then this year, we just finished up a conference on advanced technologies in healthcare, which included the wireless wearable technologies for continuous monitoring and ambulatory patients like the ward environment. And then the collection of that data to integration with other sources of data and how that can be utilized to support clinical decision making and for precise, precision patient care.

Desiree Chappell: Yeah. So there's a paper that had come out about NORA that's just been published in ANA. And then some of the output from the AI discussion and technology should be coming out hopefully sometime over the next year, correct?

JW Beard: Yeah, the APSF Committee on technology, the committee on technology is meeting tomorrow to decide what the next steps are in that wrapping up that conference and the outputs there. Yeah. So, yeah, I hope to have news there soon, too.

Desiree Chappell: Good. Well, in those two conferences and what we've talked about over the last couple of years, it's been a focus on patient safety and some of the technological advancements and technology that's available to help with that. I think one of the questions that I still want to dig into is, what is the real problem that we're dealing with when it comes to specifically in this space, post-operative care, ward care? We've had all types of discussions about different types of wearables and solutions, but I want to dig into the problem again.

JW Beard: Yeah. So I think traditionally, there has been a focus on post-operative deterioration related to opioids. And I think rightfully so that opioids are a major contributor to adverse outcomes in the post-operative environment. But they're only they're part of the picture for sure. And there's additional causes of deterioration, and it's not just limited to post-operative patients and includes patients who are admitted with medical diagnoses as well. Some of the most important underlying etiologies for deterioration would include opioids, of course, but then may include sepsis as well. And while opioids would be primarily a diagnosis, which would be made through abnormalities in the respiratory system, sepsis is something that really requires a more integrated, multiparameter approach, because it's going to show up probably initially as maybe tachypnea and tachycardia, and that will eventually become hypotension and worsening deterioration from there. So it's really, I think, recognition that the broader hospital patient population is at risk for deterioration. And unfortunately, that is a problem that's experienced by many patients in the United States and other health systems globally.

Desiree Chappell: Yeah, and it's a major problem. Now, Guy, you've done some work in this space for looking at specifically postoperatively, not necessarily just medical patients. Is this something that is familiar to you?

Guy Ludbrook: Sure. I mean, it was 20 years ago, I think we started worrying about this, our patients post-op, especially overnight. And we had a belief that we had things like medical emergency response teams that would hoover up the problems, but it wasn't enough. There was a lot of stuff unidentified out there, and we've seen quite a lot of literature in that space. So we've worked on using very staff intensive approaches to deal with that, which I have lots of people alongside beds to sort the problem, which has proven very beneficial. But considering the access to staff these days and the cost of staff, it's a challenging paradigm going forward. So the opportunity to have things other than staff that will help us as precisely as possible as an early warning system is a great opportunity, I think.

JW Beard: Agreed. And I do believe the literature is pretty clear that when patients deteriorate, it's preceded by hours, sometimes days of changes in vital signs, the patterns, the trends. And I think all the staffing solutions that we can imagine aren't going to get to a one-on-one or a two-on-one environment in the ward environment. And as a result, there's going to be, with intermittent monitoring, there will be these gaps. They tend to be multi-hour gaps between vital sign checks, mental status checks, etc. And it's that gap where these more dangerous changes can take place and patients can be harmed.

Desiree Chappell: Yeah. And I'm a nurse by training and I remember the days of the ward and even in critical care where you're changing over shift changes, information may get lost. And you do pick up on those little nuances that you otherwise, if you're not doing monitoring, even if you're doing vital signs like me as a provider should be picking up on those and we're just not. We don't have the information that we need. 

Mike Grocott: We've talked in the past about the feeling that sometimes you might be safer at home because you've got one-to-one caring. Actually, if something goes wrong, you come back through the Emergency Department and you get all the bits and pieces straight away. Whereas if you're in the hospital, you might not see anybody for a little while. The measurements, as you comment, are intermittent. And then it's a challenge to actually access some of the facilities sometimes.

JW Beard: Yeah.

Desiree Chappell: So it's a real burden for patients and patient safety. There's also a cost burden to this as well, which sometimes we as providers and clinicians don't always really want to talk about that. But it is a legitimate issue, correct?

JW Beard: It absolutely is. And when a patient is admitted to have a course of care to correct their underlying issue, whether it be surgical or medical, and they pass through the system as efficiently and safely and effectively as possible, that's what we're going for. But when patients suffer complications, have adverse events in the hospital, extends that stay. And there's a tremendous amount of stress on health system finance today. And any extension of those lengths of stay significantly impacts those hospitals and their associated economics. And extending the floor stay is one thing because potentially it has this ripple effect. If the floor is full, then the ICU is full, and then the OR can't go, it just backs up and then maybe even backs up all the way to the ED. But it's when those patients who are moving from the floor to the ICU, I think that's where the real cost acceleration happens because the ICU is such a cost-intensive environment that really has an adverse economic effect.

Desiree Chappell: Yeah, absolutely. And Guy, I mean, again, this is right up your alley.

Guy Ludbrook: Yeah, and it's interesting that I used to think this was ICU. This is someone that goes pear-shaped on the ward, escalates to ICU with all the implications of that in terms of need and cost. And I guess increasingly we're recognized sitting behind that is this grumbling problem of people that are getting into problems that may not quite get up to that super intensive level, but they're nevertheless impactful on outcome and cost and recovery. So the ability to get in earlier, as you say, with trends that are not ideal or recognized or patterns that we know herald trouble and cut those off early, we get the sense that that will have a substantial impact as well.

JW Beard: Yeah, I think so.

Desiree Chappell: Yeah, it is a real burden. And Mike, you're a critical care anesthetist, and I'm sure you have seen these patients coming through where you probably could have avoided something beforehand, and now we're dealing with something that escalates care and costs, correct?

Mike Grocott: It's a really common story to patient that's progressively deteriorated with or without some observation from the ward. The approach is really appealing. I'm interested in how in all these interactions, the interaction between the devices, the kit and the people is really key. Do you get a false positive rate?

Mike Grocott: Do you get too much warning? People struggling with that? How does it work with your patients?

Desiree Chappell: That's a good question.

JW Beard: I mean, that's the balance. In the ideal world, the patients are having continuous monitoring done. They don't realize it, and they're just going about their recovery. But the reality is the devices are going to be worn by those patients, and those patients are going to be in some regimen where they're going to be out of bed, there's going to be physical therapy, activity, etc. So it needs to be wireless, wearable, and comfortable. That's a huge undertaking with a wearable technology. Not only does it have to be comfortable, it has to stay on the body. If perspiration just the expected changes of that patient's condition over that hospitalization, if the adhesive is falling off, if it's requiring readjustment, those are all major issues. And the technology that GE HealthCare has recently had cleared for the United States since it was the CE marked last year is a wireless wearable technology called Portrait™ Mobile. And that technology and the experience thus far has been very well tolerated by patients. As an anesthesiologist, one of my first questions is how do the patients feel when they're wearing it? Can they sleep with it? Can they do their physical therapy with it?

JW Beard: And how does that feel to them over a couple of days? Is it remaining in place? Is it remaining comfortable? And then the observations there have been very favorable.

Desiree Chappell: Yeah, I know. I actually tried on to apply to whatever earlier in the year, the ESA. And I was like, wow, you don't even realize that it's very non-invasive.

JW Beard: Yeah. And that is actually anecdotally, that's the exchange I've had with patients. It's like, how does it feel? And she's like, I don't even know that I'm wearing it.

Desiree Chappell: The other important aspect that I think when we talk about that, and we have talked about Portrait Mobile on Top Med Talk quite a bit. We were there at the launch last year at ASA, which was quite exciting, is the warning systems. Because what Mike said, and what we're ultimately getting to is what warning systems do we have earlier on and the fidelity of that information and alarms and things like that. And one thing I found very interesting about this particular solution is how good it filters out bad information and gives you good information.

JW Beard: Yeah. There's been a ton of engineering work, I think, to get the technology to where it is today. So to me, it starts with the patient comfort. Are they going to wear it? And then second, how robust is the technology itself? Because a continuous monitoring technology is only continuous as long as it's connected to the network. And to what Portrait Mobile has is a wireless communication protocol over, and it's called the Medical Body Area Network. And the proprietary name is called Byndr™. And it's this communication protocol that leads to a level of connectivity with the monitor-based station that is approaching, or if not, practically equivalent to a wired connection. So incredibly robust connectivity. And prior to ASA, actually, there was a poster we presented at the IEEE Body Sensor Network conference.

Desiree Chappell: Never heard of that one before, but that's very interesting. -

JW Beard: It is a very specialized conference that described the performance of the Byndr communication protocol in our testing environment, just to demonstrate the probability of the loss of data is exceedingly small. So we expect it to remain connected to the network.

Mike Grocott: Lots of data coming from lots of patients on the end of wireless communication, which can feed in at a ward level or a hospital level. How do you manage the processing and observation and reaction to that data?

JW Beard: I think that's a great point. If it's connected, and then I think maybe the next step when I think about it is, how well is it actually measuring what it's going to measure?

Desiree Chappell: Yeah, that's it.

JW Beard: So Portrait Mobile does respiratory rate, pulse rate, and oxygen saturation today. In all those parameters we've also published on, the respiratory rate parameters is very, very accurate. And the awake breathing patient who's being monitored with a reference of capnography, the correlation is very, very high. Pulse oximeter also has very solid performance. And we've also published last year its performance in motion and low perfusion conditions. Very, very high performance level, and that was benchmarked against additional technologies on the market. And then here at ASA, we just presented a poster today on its performance in patients with varying levels of skin pigmentation.

Desiree Chappell: Oh, good.

JW Beard: And identifying that the technology performs well in that simulated testing environment used for regulatory submissions on those with darker pigmentation. So then the question is, what are you going to do with it? Today, it's going to be monitored. It could be at the individual bed level if the clinician is there. If not, it goes to a central monitoring station, similar to just a station that would exist on a nurse's unit, like telemetry, like another monitor where there may be data from the rooms coming in.

JW Beard: That's one opportunity. Eventually, it could be something much broader. There could be a location where large groups of patients are surveilled at the same time, multiple units simultaneously. It could be in one hospital that multiple units are being monitored, or it could be a unit where there's multiple hospitals being monitored by dedicated teams. There are certainly advantages to that as well, just the redundancy and the personnel and the expertise they develop over time.

Desiree Chappell: And we've heard examples from this. I think Mike Scott's doing this with telly ICU. And so, I mean, there's now precedent.

JW Beard: Several models ticketing to consider in the future.

Desiree Chappell: Yeah. Yeah. So that's really interesting. So I wanted to wrap up our conversation and talk a little bit about the paper that you published earlier in the year. And time I have it pulled up right here, Cost Savings Through Continuous Vital Sign Monitoring in the Medical Surgical Unit. And I think this is getting to the point of like, okay, we've talked about the why, why do we need this and the patient and cost the burden of this. So can you walk us through a little bit about what you found? Because you were the first author on this. And I found it really interesting whenever you start looking at the numbers. I mean, the burden of these complications and all the issues is real.

JW Beard: Yeah, it's significant. So this is a paper that we published earlier this year in the Journal of Medical Economics. And it was really developing a model of the expected changes in patient outcome associated with continuous monitoring and the ward environment with Portrait Mobile at the average US hospital with the average number of discharges per year.

Desiree Chappell: Which I love that, not to interrupt you, but I love that it was in an average place. It wasn't in a huge academic facility or anything like that. It's what most of us are practicing in every day.

JW Beard: And so we built the model based on previously published data from those sources that we felt were the best conducted studies that involved similar monitored parameters as Portrait Mobile. We brought at current with today's dollar amounts from what had been published in the past and looked for opportunities and savings from length of stay on the wards, length of stay in the ICU, rapid response in hospital, cardiac arrest, and looked at the model impact of all of those outpoints associated with continuous vital side monitoring with Portrait and created two different implementations. One would be 50 % of patients, another would be 100 % of beds monitored, and determined that the cost savings would be substantial in the millions of dollars of cost avoidance, primarily through length of stay reduction. Even those who would be monitored with Portrait but still require that ICU stay because they deteriorated, but it was identified earlier, they ended up with a shorter length of stay both in the ward and the unit than in someone who got transferred to the unit without the continuous monitoring. So it suggests that those patients are arriving to the ICU in a morbid condition, requiring additional therapy and intervention over time.

Mike Grocott: The notion of reducing failure to rescue is double negative.

JW Beard: That's exactly right. That's exactly right. I think that this study also talks about the reduction of in-hospital cardiac arrest. There's others that address that same issue. There's going to still be rapid responses with continuous monitoring. There's still going to be some rapid responses because patients are going to need to be transferred. There's going to be patients who still deteriorate. But these technologies really have a chance of reducing the in-hospital cardiac arrest, those code blues that are getting called during shift change. The first time someone comes in and checks on them per routine, these technologies can really make a difference there.

Desiree Chappell: Yeah. Guy, does this speak to you?

Guy Ludbrook:  Very much so. One of the areas we see often in drug development, which is all my spaces, when we finally put the rubber on the road and we've got the product and it has to intersect with the health system, which is to be put, and then the money comes in. Do you see how that your sense how that might play out at the end of the day?

JW Beard: These technologies can really make a difference there.

Desiree Chappell:  Yeah, guy, does this speak to you?

Guy Ludbrook:  Very much so. One of the areas we kind of see often in drug development, which is kind of all my space, is when we finally put the rubber on the road and we've got the product, and it has to intersect with the health system in which to be put, and then the money comes in. Do you see how that, or sense how that might play out, at the end of the day?

JW Beard:  It's complicated. We're talking about Portrait Mobile now, but we talked about continuous. We talked about quantitative neuromuscular blockade monitoring earlier in the day. We know Portraits an example, quantitative monitoring is an example. We know there's a better way to care for patients, but there's a large percentage of hospitals, this is the United States, not sure, Australia and other countries, but there's a lot of financial pressure, and there's hospitals that are losing money year over year.

JW Beard:  And if we're not able to have the technology independently reimbursed, then it really does come down to a really thorough cost analysis. And you need internal champions. You need the cost analysis. We need those who are going to line around providing the best care for patients. Thinking about, we got a lunchtime symposium, and one of our speakers said, he's like, I am not afraid to bring out the: "if this was your mother, so if this was your family member you or your friend admitted to the ward, what would you want?" Well, I'd want to leave the OR with quantitative neuromuscular monitoring.

Desiree Chappell: Absolutely.

JW Beard: And then I'd want continuous monitoring once I got to the ward.

Guy Ludbrook: But as you say, the kind of spend to save paradigm, it can be very difficult for executives under cost pressure. The appetite for risk is often very low there. So do you see that's going to be an obstacle, or you think that the data coming out and the good economic arguments are likely to overcome that?

JW Beard: The economic arguments are going to help significantly, but it will continually be an obstacle, in my opinion, because it's not like there's x dollars waiting to be spent on continuous monitoring. It's x dollars, and it's either going to continuous monitoring or it's going to something else, and it is in different facilities are going to have different priorities over time. And so I think every time a continuous monitoring solution is going in, it's going to be competing against something, and I don't see this cost pressure.

Mike Grocott: Anesthesiology has introduced safety changes over the years and are thinking in particular of capnography, and the evidence was slim. There was no randomized control trials. But we accepted that it was clearly a good thing. We introduced capnography, and that's probably been hugely beneficial.

Mike Grocott: Do you think this is going to head down, that this will be something that will be, of course, it's a standard of care, or will we not get there?

JW Beard: I think we'll get there. Whether or not it becomes part of standards, I think that's kind of a much more complicated discussion, but I think we'll get there. Part of the reason is because I think of patient expectations. So, absolutely. You think about a patient who's maybe more or less continuously monitoring their physiologic data at home.

Desiree Chappell: Right.

JW Beard: And then they're going to come to the hospital and, like, take off your watch.

Desiree Chappell: Exactly.

JW Beard: We're going to check you every 6 hours. Patients are going to increasingly see this as just kind of an untenable situation, like they know these miniaturizations of technologies and wireless communication exists, and they have also heard in the news and heard various accounts of adverse events that could have been prevented. So there's going to be some patient pressure that I think that will eventually. Certainly the manufacturers increasingly recognize this and are trying to meet this need. The patient pressure, I think, is going to be experienced the hospital level at some point. It's going to be at the payer level if it's not there already. And overall, it's going to end up, I think, impacting the entire health system.

Desiree Chappell: Absolutely. It's so important, too, for patients to be informed consumers, and I think we are definitely moving in that direction. I still just don't think that they understand what happens when I go in the hospital. I should be well watched over, but don't understand how some of it works. So I think this is a great solution. JW, thank you so much for joining us today and talking about Portrait Mobile, but just about patient safety and how we could potentially do it better. That is something that is important to our specialty. And we've always been at the forefront, so hopefully we can continue to push that.

JW Beard: Desiree, thanks for having me again. And Guy and Mike, thank you as well. I'll look forward to hopefully getting another invite in the future.

Desiree Chappell: Absolutely. Well, if you want to find out more, we're going to put the paper in the show notes so they can take a look at that, a link to Portrait Mobile. Again, we've done various podcasts about this over the last couple of years, so do check that know you can find us at topmedtalk.com and all of our content there. We're on social X, as it is now known, LinkedIn, Facebook. We are there broadcasting throughout the rest of the weekend. So check us out. Thanks so much, you guys. Cheers.

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