Patient monitoring and beyond

Desiree Chappell: Well, hello and welcome to TopMedTalk. I'm Desiree Chappell, co-editor-in-chief of TopMedTalk, a free, open access, global perioperative medicine podcast. We have over 2 million downloads with over 2,000 podcasts.

You can find all of our podcasts at topmedtalk.com. If you do go through topmedtalk.com, everything is searchable. You can find if you're interested in certain topics like enhanced recovery after surgery, patient safety, quality, prehabilitation.

We have loads of conversations on all of those and more. So please do check us out. We're just now kind of upping our game on our YouTube channel.

If you're on YouTube, hit the subscribe button, give us a thumbs up. If you listen to or watch some of the conversations that we've had over the year, that always does help us. So our conversation today is one that is very near and dear to my heart as a patient safety advocate and quality ambassador for surgical care.

We're going to be discussing early identification of patient deterioration, both in the context of medical and surgical patients, mostly surgical, as well as in the context of infection. Our next guest is Dr. Meera Joshi. She's a specialist registrar at Ashford and St. Peter's hospital. She's also a clinical research fellow in the department of surgery cancer at Imperial College London. She has recently completed a PhD on optimizing the identification of acute deterioration and sepsis through digital technology. And a lot of our conversation today is going to be centered around that work that she's done.

So I just want to thank our next guest for joining us today, Dr. Meera Joshi.

Meera Joshi: Thank you so much, Desiree, for having me on your channel. It's a channel I look forward to and listen to regularly. So I'm really grateful to be able to speak on here.

Desiree Chappell: Thank you so much. Why don't you tell us a little bit more about your background and your clinical research areas of interest?

Meera Joshi: Thank you. So I am a breast surgeon and have just gone through surgical training in the UK. My clinical interest is really looking at from seeing very early on in my career, patient deterioration and delays in detecting deterioration right through from being a medical student through to a junior doctor throughout my career.

So I felt like this was a problem time and time again. And I'm very interested in new technologies, especially in the wearable space, to see if we can look at new technologies to help us combat some of the challenges that we have in patient monitoring.

Desiree Chappell: You said you're a breast surgeon, so what types of cases are you doing on a regular basis in the patients that you're caring for? What does the patient profile kind of look like for you, an average patient?

Meera Joshi: Predominantly most of my case cohort is oncology patients, so patients with breast cancer. And that patient cohort can range from, unfortunately, very young patients through a whole wide range of demographics and ethnicities, but mainly in female patients. Although, of course, we do get the odd male patients with breast cancer.

Desiree Chappell: Unusual but still happens for sure. The area where you practice, are you seeing patients with lots of comorbidities? Or I know you said you have a lot of younger, unfortunately younger, healthy women.

Meera Joshi: I think that's certainly the problem, is that patients are coming in with lots of comorbidities, various medical problems, and that can make the operation itself challenging, but also post-operative recovery. And often breast cancer patients need other treatments or adjuvant treatments in the form of chemotherapy or radiotherapy. Sometimes we can give them before surgery, or sometimes it could be afterwards, depending on the demographic or depending on that patient, the cohort, and the type of tumor biology that they have.

So it's really important to have all of that planned, but also that can affect how well patients are.

Desiree Chappell: Yeah. And when you see your patients, or the cases that you do, are we, I'm sure you're looking at typical, just a very quick lumpectomy and, you know, needle localization lumpectomy or mastectomies all the way to pretty complex procedures. Just give us an idea of what space you're kind of working in.

Meera Joshi: Yeah. So more and more, the training in the UK is that we are trained as oncoplastic breast surgeons. So the training is that most people, we try and perform breast conservation surgery or a lumpectomy as much as possible, but sometimes we can't, and patients will require a mastectomy.

But more and more, we're sort of changing the boundaries of what we can do, and hopefully breast conservation is a better option because we know that patients have better outcomes ideally long-term. Well, certainly there's some new data to show that previously it was thought to be non-inferior to a mastectomy, whereas now actually when we look at survival data, patient outcome data, especially their reported outcome measures, they are a lot higher once patients have undergone breast conservation surgery versus, say, a mastectomy. And of course a mastectomy can be with or without reconstruction.

Desiree Chappell: Yeah. And that was going to be my next question. I mean, you know, some breast surgeries, at least the ones that, you know, I've been around and done can be quite complex and, you know, using muscle flaps and things like that that are very delicate, you know, microcirculation issues and things like that.

Meera Joshi: Yeah. Now, we very much work with our plastic surgeon colleagues for the free flaps, so I'm based at Imperial College NHS Trust in the UK, and we have an excellent relationship with our plastic surgeons and we do many of these cases a week, so that can be quite common for us to do. I work in a team of some brilliant breast surgeons in our team and we very much work together with our plastic surgeons.

So those sorts of patients can have a longer operation with potential monitoring of these patients is really important.

Desiree Chappell: Yeah. Well, and that's kind of where I was getting to is that, you know, we do, I'm sure you do, you know, a lot of outpatient easier cases on patients that are not as sick and have as many comorbidities, but I'm sure you're doing a fair portion that actually require stays in the hospital at least a day, if not longer. And we have these patients that are potentially higher risk.

Talk to me a little bit about, you know, what you're seeing and how you kind of got into this space of being concerned about patient monitoring post-surgery.

Meera Joshi: Patient monitoring, I think very early on in my career, I'd seen patients deteriorate and we know that the earlier that we detect deterioration, the better the outcome measures. So right through my medical student training, through being a junior doctor early on and breast surgeons in the UK, just as many other countries are trained in general surgery. So our general surgical patients often come in a lot sicker, multiple comorbidities.

And it's really this emergency group that we were looking at when I was doing my research. So we were trying to see, are there any novel new devices or certainly wearable sensors that we can use to help see if we can pick up deterioration quicker and really use them as an adjunct to care. So there's no like brilliant bedside care is fantastic, but it's what happens when we don't have enough nurses on the ward, what happens when there's a delay or some of our team have gone on a break.

And these are the sorts of what happens during the handover time when patients become sick. And we're trying to look at adjuncts to care. And I feel like the growth of wearable sensors has really accelerated massively over the last sort of 15 to 20 years with smaller devices that are able to detect greater vital sign parameters.

And so not only that, often the devices have buffers in them or algorithms that can make sure that only good quality data is getting through. Because as we know in a lot of data from the ITU setting, in terms of the alerts being generated, we want to make sure that the numbers that are coming through are just, you know, really related to only a sick person falls through the system and a nurse will get alerted to that. So some of my research was looking at new wearable technology in critically unwell patients.

So we did most of our studies at Imperial College London in a busy district general hospital, West Middlesex Hospital, which is part of the Chelsea and Westminster Hospital NHS Foundation Trust. And through that hospital, we've recruited a huge numbers of patients, both medical and surgical. And we were looking at really the acutely unwell patients with all sorts of comorbidities, both in medicine and surgery, but all sorts of medical problems.

And then hopefully they were having a wearable sensor as well as their standard of care. And then we were looking at firstly, is it feasible? You know, I think it's fine for monitoring patients that are stationary.

But what happens with the ambulating patients and how do we monitor them effectively? What is the quality of the data being transmitted? What we wanted to check, are we having lots of huge amounts of data dropout, which is what we didn't want.

And what happens if, you know, the patient goes to the bathroom? So that was reliability was one part of the work that we were doing. And the second part of the work we were doing was really looking at end user feedback because it's really both.

You've got to have both. So we really wanted to know what do patients think about it and what do staff think about it. So we did some questionnaire and interview studies in sort of both groups to see what they felt about this kind of monitoring that we were doing, because if it wasn't comfortable for patients, they were unable to wear it.

It was going to come off pretty quickly, I'd say. Likewise, if the health care team, both from junior doctors, junior nurses, right to senior matrons and senior attendings, if they weren't down with it, then it also wasn't going to work. So that's kind of what we were looking at.

Desiree Chappell: OK, well, then walk us through like on the patient side. Yeah. Tell me more about that.

So what did you find? How many patients did you end up looking at?

Meera Joshi: We looked at 600 patients in our first study and then we did some sort of cohort studies afterwards. So the real kind of take homes from when we did the patient's sort of study, mainly the questionnaire data is in the sense that we used 85 percent of patients out of nearly the 500 found it comfortable to wear. And 85 percent said that they were at home, sorry, that they were again in hospital, but also a significant percentage, 80 percent plus, would consider monitoring at home.

And I think that is the future direction of travel. So you're only looking at enhanced monitoring in the ward setting, but also looking at like postoperatively, it would be great if some of my high risk patients that we know that patients also, you know, prefer to be at home and we try and support them in their home as soon as possible. So it would be great to have monitoring at home and then we can sort of identify potential deterioration and know when to call them back into hospital or when we can support them in other ways.

So I think that was certainly something that was raised from the patient side.

Desiree Chappell: Yeah, that was a great question to include. Like, would you be willing to wear this at home? I don't think I asked her, you might have said, what are the vital signs that you are collecting or that you are looking at for this?

Yeah. Because that changes things up a little bit. Like if it's EKG or respiration, you know, respirations versus SAT and how well that picks up.

Meera Joshi: So at that initial study that we did, we were looking at the metrics of heart rate, respiratory rate and temperature, because I'm really interested in sepsis and detecting patient, often quite a big part of patient deterioration is infection and sepsis. And we know from the data that these vital signs change very early on. Blood pressure is a good metric, but it's normally there's a change in blood pressure once the patient has already undergone significant deterioration.

So it's quite a late sign, whereas we were looking at some of the very early signs in deterioration. So in this particular study that we did, we were looking at heart rate, respiratory rate and temperature.

Desiree Chappell: And temperature. OK. And then on the provider clinician side, what was some of the feedback?

Because I'm an ICU nurse by training, and so I've had that experience at Alarm Fatigue. We talked a lot about this, actually, on Top Med Talk and how it is a major issue for clinicians now, especially as we're getting a ton more data.

Meera Joshi: So staff already identified problems with current monitoring. So sometimes it could be really simple, like on the ward at the moment, they only had two sort of transportable OBS machines and one of them was broken. So just the logistics of having to wait for, you know, the next bait to be completed by that sort of normally they're very junior health care assistants that are sort of doing observations in patients or very junior nurses.

So it could be very simple things like that to also miss deterioration. So by that, certain things that were suggested in this work that we were doing was really looking at nighttime monitoring and over the weekend, where we knew that ideally we'd have great cover throughout the patient stay. But we know that there are certain times such as a weekend and overnight where staffing levels aren't as high as during the day.

And that was something that staff felt that this could really pick up deterioration. There's a lot of data to talk about, you know, the education of vital signs. So in the UK, we have the National Early Warning School has gone through various iterations.

The premise is that all patients use this school to help identify patient deterioration quicker. But there is also some data to say that people are scared to raise the alarm. And actually, some of the more junior members of the team were saying that a device like this could help give us the confidence to raise the alarm.

So that was something that was very interesting that was raised. And also, a lot of them felt like it could improve patient safety and very much be the future of monitoring. I think, you know, healthcare has changed so much in the last sort of 40 to 50 years at groundbreaking levels.

But now the way that we're monitoring patients of observations of four to five hours apart often perhaps could be better than what we're doing. And I'm just looking to see if new technologies can help support that. But also, at the same time, keep patients ambulating because we don't want them sitting in beds lined up to lots of wires, checking lots of things.

We want them to be able to move around and get back to their baseline, get home ideally as soon as possible.

Desiree Chappell: Yeah, yeah. And those are all those are all things. I just had a conversation with some colleagues and we were talking about post-op monitoring and the fact that we do need to get them up and going.

And, you know, you think about like enhanced recovery protocols and all the things that we're used to doing now. And it's like we still have to be able to do that, but still also have an early warning system and the monitoring of vitals. A quote or something that somebody said to me the other day I heard was that, you know, in instances like this, it's everything's gradual until it's sudden.

And that, you know, when I think about deterioration in patients and I'm seeing that myself and working in our space of surgery and anesthesia, it's and you made a good point that, you know, as you have teams that transfer over between different shifts and you have a nurse that may be taking care of them on Friday, but it's not the same nurse that's taking care of them on Sunday. There's something that, you know, you as the same person taking care of them the entire time may pick up on those subtleties

Meera Joshi: Yeah.

Desiree Chappell: 

You just can't if you're changing staff over like we know that happens. And again, talking a lot on TopMed Talk over the years about this particular subject, I think to me that's one of the finer pieces that having wearable technology that's continuously collecting data can show you that gradualness of deterioration.

Meera Joshi: Absolutely. And I think the real key to the wearable technology data is looking at trend analysis as opposed to just a snapshot window. So we know that that trend analysis of seeing that pulse rate coming up or vomiting or similarly with that respiratory rate, people can look at that as opposed to just having observations measured four to six hours apart.

That's a huge time lag for deterioration to occur, especially in something like sepsis where we know that deterioration happens per hour, if not minutes. So there's a real drive to try and identify these patients quicker. So certainly in the context of infection and sepsis, having those two minutes or very regular, more continuous observations, even if there's a little lag between them, you certainly have such a wealth of data compared to sort of static measurements in time at certain timeline.

Desiree Chappell: Absolutely. That you say like a snapshot at four hours, then four hours later, it's like you may have a it looks like nothing to someone who hasn't been looking at their trend over time.

Meera Joshi: So exactly. I think that it's a two sort of two ways of looking at it. One is having lots of data is good.

I'm very much a big fan of data and what we can do. But at the same time, it needs to be meaningfully packaged and delivered to our healthcare team, because what we don't want is to bombard them with lots of alerts. And that sort of fits in with alert fatigue.

So some of the work that we were looking at was looking at time windows of alerting. And maybe we don't send off an alert straight away. We package data at particular time windows.

And we did a lot of modeling of that data. I worked with a guy called Kenny McAndrew that developed this algorithm, which was fantastic. We were able to really model the patient data real time to see would they have had an alert generated at this time window or could it have been this time window and so on and so forth.

So that was really, really interesting and trying to have the best time window to use. The two smaller time window, you won't have as many alerts generated. Two bigger time window, that's bigger chance of deterioration or greater chance of deterioration, I should say.

So the optimal time windows was something very interesting to look at.

Desiree Chappell: Yeah, that's an interesting concept. I think I've heard that before, but you're putting that in the context of the clinician working on the staff, you know, having a time frame of when you can expect things to happen or when you may. It's not a constant bombardment where it's like as soon as you turn the alarm off, it's alarm again, just because you've delayed it or anything like that.

And how much feedback are you getting from clinicians about what is working and what is not when it relates to those alarms?

Meera Joshi: So we did a separate, so initially we were just getting baseline data and the second study that we did, it was in a much smaller cohort. We were actually looking at real-time alerting and seeing how that works and the way that we very much had involvement of all of the clinical teams in study design, which really helped. So we had a vetting or a triaging system that the first alert would just go to the, often the very junior nurse looking after that patient.

And then if that alert wasn't actioned for whichever reason, then it would go to the sister-in-charge of the ward. And so we had this sort of escalation of alerting model, which actually worked in real-time and they found that really helpful. The other thing with wearable devices is sometimes there can be systems alerts.

So by systems alert, I mean something like they often have adhesives to, like say perhaps an NEKG sort of sticker, so that the sensor is placed, but these were the types of sensor that we were using for our research. And if that was not correctly in the correct place or it had come off, the nurses would get an alert for that. So number one, splitting those alerts was really helpful.

So clinical deterioration alerts to the systems alerts and number two, having a mechanism of a time window, so that nursing colleagues weren't just being bombarded with alerts. So the first alert would be five minutes, they'd have to action it. And then we were also looking at ways to try and make actioning alerts easier.

So initially we had this sort of centralized monitoring platform, but actually we then had all of the nurses on the wards having an iPad or an iPhone away. This was how it was linked in. So they were able to action the alerts at real time on their personal device or on their device that they were given.

So we were changing the way that we were doing things all the time to try and make it as easy as possible, because they are often, nurses and doctors are so busy and have lots of different patients in lots of different clinical areas. So trying to make this transition as smooth and as possible and as easy for them as possible was really part of the key. I think what I'm talking about is really nurses' sense to design and trying to make that work.

Desiree Chappell: So let's switch gears a little bit to now, because didn't you say you started in 2016 on some of that work?

Meera Joshi: Yeah, we...

Desiree Chappell: Yeah, so there's been a little bit of an evolution, I'm sure, of technology and all the different things and questions that you actually may have are different now.

Meera Joshi: Yeah, so of course we had the COVID pandemic that came along and one of the ways that we were able to use what we learned in the hospital setting was actually to tailor that to partly an outpatient setting. So during the COVID pandemic, we were able to sort of really look at, could we use monitoring not only in the hospital, but outside? And so for patients, West Middlesex University Hospital is located geographically in the UK, not too far from Heathrow Airport.

We then did a study looking at patients travelling and self-isolating and trying to offer wearable sensor monitoring to patients that were isolating, but in a safe way so that the providers were able to monitor their observations. And so we actually engineered a hotel not too far from Heathrow to try and have that. So that was the first step in monitoring for us outside the hospital, looking at things that we'd learned.

And then in terms of some of the work that we'd learned from that and some of our hospital work, we're now looking at not only monitoring at home, but also we're working with GE Healthcare on their Portrait Mobile device and monitoring that in patients. And they're able to monitor different vital signs. So having greater abundance of vital signs is really helpful.

But also looking at, certainly for me, I'm looking at wearable technologies in the post-operative rehab setting. So different wearable technologies to help with exercises post-operatively. So this is some of the work that we are doing now, again, in the wearable space, but variations of how we can help patients.

So breast surgery patients often have staging of their auxiliary nodes. So we take out what we call the sentinel node, which is a separate scar in the armpit. And that, we either take out just one or two nodes, or sometimes we have to take out all of the nodes if they're involved.

And that can leave patients with problems with their arm function. So typically, breast surgical patients have these post-operative exercises that they're able to perform. And we're now looking at wearables to try and see if they can help.

We're doing some research on this at Imperial College London, looking at wearables to see if they can help with the rehab program.

Desiree Chappell: That's very cool. So adapting the technology that currently exists into ways that are more specific related to the types of surgery or the types of patients that it is.

Meera Joshi: One of my collaborators and colleagues that I really wanted to mention is Dr. Sadia Khan.

Desiree Chappell: Yeah, I was going to ask you.

Meera Joshi: She's a fantastic cardiologist and very much my mentor in this space. And she is doing some great work on monitoring of medical patients. So we sort of came together.

Dr. Khan is very experienced in this field and had a medical hat on and I came on with my surgical hat. And we've kind of collaborated, but she's doing a lot of monitoring at home of patients with heart failure, cardiac problems, respiratory problems. So looking at different ways that we can look at wearable technologies to support patients at home, I think is also going forwards.

Desiree Chappell: We have been so lucky. We've had several conversations with Dr. Khan on Top Med Talk. She is phenomenal, first of all.

And the work that she's been doing and she's kind of, she definitely has been on the journey for a while to look at these and look at different technologies and ways to utilize that with, you know, different patients and in the space of the hospital. Yeah. Which, you know, we've had other conversations about different types of wearable technologies, more about Portrait Mobile, all the different types of things that are available.

But, you know, one of the final pieces that I really wanted to talk to you about was specifically around just patient safety and kind of, you know, stick a pin in this and kind of the exclamation point at the end of this conversation and all the ones that we're having around the space is that, you know, when it comes right down to it, it's can we do it better than what we've been doing? And is that better and safer for our patients? Not just, you know, I think we should talk about how do we improve quality of care?

But really getting down to it is there's still a patient safety need, especially in this post-op space, don't you think?

Meera Joshi: A hundred percent. And this is what really inspires me because unfortunately, despite the advent of news and deterioration scores, we know that we're still missing patients and there are still delays. And this happens in every country, in most hospitals.

We know that challenges that we're having in the healthcare system in the UK are challenges that are faced in many countries in terms of workforce shortages, high numbers of agency staff and so on. So I think all of these factors are to play. But anything that we can do to enhance safety, I think is really important.

I feel like continuous monitoring is one sort of part of this big giant puzzle. But I feel that the way that with monitoring devices and how well developed they are, it's so much more improved to what they had before. So anything that we can do to improve that, I think, is really the key, especially now with patients accepting wearables.

A lot of patients now. But yeah, exactly. Apple, I was pointing to my Apple Watch.

Desiree Chappell: But there are other watches available rather than just Apple. But yes to my smartwatch.

Meera Joshi: So absolutely. People are used to monitoring stat counts and sleep cycles. And it's not, you know, it doesn't feel perhaps as intrusive as it may have felt 40 or 50 years ago.

Now it's actually, we're looking to, and I think if you monitor something, you can keep an eye on it. We actually know what's going on.   So for me, data and abundance of data is really the key and having a bigger data set as possible.

We know that looking at some of the research that we were doing, wearable sensors can pick up deterioration significantly quicker to the setting. And we did this in a quiet alerting. So we weren't alerting in real time and we looked at the data retrospectively to see how quick is a sensor compared to nursing observations.

And many a time it can pick it up hours and hours before, because it's having such a wealth of data set with lots of monitoring as opposed to static measurements. I'm very passionate about patient monitoring, trying to enhance safety. 

Desiree Chappell: The fact that patients are more willing to accept wearables.

And I think back to the days that we were starting Enhance Recovery. Again, you know, I mentioned this before, but we were asking people to wear pedometers and, you know, some different things to track timing and how many steps they were taking. And it was back then, you know, the pedometers were not great.

They didn't, they gave you literally maybe the number of steps that the patient was taking, give or take, but it was all we had. Now, I was just looking at, I rode a bike race this weekend and I was looking at my heart rate variability and my oxygen saturation and my VO2 max. I mean, all of this information is incredible.

And, you know, when you start looking at it and you start seeing your trends over time, then I can identify when, oh, I had a dip at this time, or, you know, my heart rate was really up during this. And so it's really empowering as a patient. Do you think that's going to change, you know, kind of the idea of all of this and especially the at-home monitoring?

Meera Joshi: Yeah, very much so. I mean, I'd love to know how patients were post-operatively at home. Just having that, often patients refer to it as a safety blanket, another extra layer of safety, and they felt safer knowing that somebody is monitoring them at home, so absolutely, I agree.

I think there are lots of different devices on the market. And through our research, we were able to fortunately test some. And I think what we need to make sure is that certainly in the hospital that we're looking at medical grade devices.

So one of my supervisors, Professor Aridazi, when I started my research, introduced me to several different companies, and let's say some of them don't measure exactly what they claim to measure as well, and so I think really making sure that regulatory approvals, that they have the appropriate CE markings and so on, because we need to make sure that we are measuring what we claim to be measuring, and that's why reliability data is key.

So often the study design is very in a controlled manner with healthy volunteers, but what we want to do is almost test assist them and kind of in a way, sometimes try and break it. You know, what happens on an emergency ward setting? What happens when do we get data drop?

Can we still monitor this patient when they are walking down the corridor? How good is that level of monitoring? Or does it just work if they are within a particular bed space?

Desiree Chappell: And like body habitus and the skin and all these different things make, I mean, as somebody who's tried to get electrodes to stick on patients, sometimes you just can't, you know, so all those things are a serious concern, right? 

Meera Joshi: Yes. And people can have skin reactions to certain, one of the sensors that we tried very early on when I was doing my research was a wrist device through a very large company, but it was so heavy.

And I was just thinking that a lot of our patients are elderly. I want them to be using their arm. And if I'm literally putting a weight on their wrist, they won't be able to do things very simple as picking up a cup of tea, like would be a struggle.

So I think trying to balance it out so that you have an easy system for patients to have, that doesn't... 

Desiree Chappell: For the most number of patients. 

Meera Joshi: Correct.

The most number of patients that doesn't inhibit their function in any ways is also really important. 

Desiree Chappell: Yeah. The last piece that I wanted to touch on, and we talked about it a little bit throughout the conversation, is the use of this technology and safety for patients, no matter what their comorbidities are, where they are, because, you know, for us, and I believe it's the same in the UK, so many surgeries now patients go straight home after, and even high risk patients can go home after surgery.

And of course we're seeing our higher risk patients or higher risk procedure patients staying in longer in the hospital, but those ones that are going home right now, I mean, they don't get any kind of monitoring at all. And sometimes they don't even have family members with them. And so I can really see where this truly is a patient safety thing.

And, you know, for us, I don't know, and us, the greater we, us of the healthcare community, don't necessarily know what happens when a patient leaves the hospital. Because so many times they may come back to the same hospital. They may go to a different emergency room if there was an issue, just because they have to go to the closest one or whatever is happening.

So there's a lot of unknown unknowns that are happening out there. So I can imagine, you know, as part of a greater patient safety movement, that this would be huge for us and at least surgical care, post-surgical care. 

Meera Joshi: Yeah.

And that's very much where I, I kind of sit on a lot of things too. So I think having that enhanced monitoring would be really helpful. At the moment, when patients are discharged, they have a telephone number from our breast care nurses and we see them very early on if there's a problem, ideally.

Most of our patients are generally geographically within the same area. So do come to, Imperial has a huge number of hospitals within their network. So if they have presented elsewhere that we would normally know about it.

So they're not covering the same distances as perhaps they are in other parts of the UK, but also in the US, so that's definitely something to think about, but absolutely having that extra layer of monitoring to support patients post-operatively, elderly patients, patients with comorbidity. We are unable to discharge patients home in the UK if they do not have somebody at home with them, certainly for the first evening. So anybody that we think is not able to have somebody at home, we admit them or we are unable to fall them on our day surgery list.

So because exactly that, especially if it's the last person that evening, we want to make sure that they've had enough monitoring. And again, this is wearable sensor monitoring can happen within the hospital. So if I'm in the OR operating, I might just have one vital sign on the final patient or the penultimate patient.

But actually, if I can see the OBs are really stable over a couple of hours with lots of observations as opposed to a few, that again would give me greater reassurance that, yes, actually she's been stable or he's been stable for the last few hours. We can send him home more confidently than if I just have a few vital sign readings. 

Desiree Chappell: Yeah, a couple of snapshots along the way.

Well, Meera, this has been a phenomenal conversation. I really appreciate you taking the time out of what I know is, I'm sure, a very busy schedule for you. But we really do appreciate it.

I hope we can, you know, continue this conversation as we go along as you're doing more of your research.

Meera Joshi: I'd love to, Desiree, and thank you so much for inviting me to give this podcast today. I'm a huge fan of Top Med Talk and, yeah, super grateful to be part of the bigger conversation.

Desiree Chappell: Well, you know, we've done quite a few conversations around this topic. You can find more of that at TopMedTalk.com. You mentioned Sadia Khan, again, just a superwoman in our space. J.W. Beard. I mean, the list goes on and on. So please do check those out.

And hopefully we'll be catching up soon to hear more. And thank you for listening to Top Med Talk. You can always find us at TopMedTalk.com on your favorite podcatcher. We're on YouTube now. So if you happen to listen to this on our YouTube channel, give us a thumbs up. Subscribe.

That always helps us out. Cheers, everybody. Thanks for listening.

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