Perioperative patient safety and post-operative ward monitoring

Top Med Talk.

 

Desiree Chappell: 

Well, hello and welcome to Top Med Talk. I'm Desiree Chapel, your host. Now, over the years here on Top Med Talk, we've been highlighting perioperative patient safety and exploring opportunities that we have as perioperative clinicians to improve the care that is being delivered before, during, and after surgery, especially within the hospitals and the floors and in the wards.

Now, back with us today is a previous guest and friend here on Top Med Talk. To discuss her work in this area of postoperative ward monitoring, Dr. Saadia Khan. Now, she's a consultant cardiologist at the West Middlesex University Hospital, which is part of the Chelsea and Westminster Hospital NHS Foundation Trust.

Saadia, welcome back to the show.

Sadia Khan: Thank you so much, Desiree, and it's a real pleasure and honor to be back.

Desiree Chappell: Yes, well, we were just reminiscing about the last time. I think it's been almost two years now. It has indeed been about two years, but it feels like it was only yesterday.

It does, it does. Well, Saadia, for our listeners, why don't you tell us a little bit more about yourself? Now, traditionally here on Top Med Talk, we talked to a lot of people from, and clinicians from the anesthesia space, you know, surgeons and things like that, but you're a bit of a non-traditional role for us here at Top Med Talk.

So, tell us more about yourself.

Sadia Khan: Well, I might be a bit of a non-traditionalist, but I've always felt more than welcome. So, I'm a physician, obviously, by background and a cardiologist. And since I started my consultant career, I've been really interested in remote monitoring technologies.

And one of the things that we've increasingly recognized is that ability for technology to bridge distance and bridge specialties. So, I originally started out doing a lot of remote monitoring work in the community, but my attention over recent years, particularly during COVID, shifted to what happens on the ward areas. And from there, it was a small step to looking at post-operative and surgical care and that patient safety challenge.

Desiree Chappell: So, we've had lots of conversations in the last several months, well, last year, really, talking about, you know, we want to provide safe care. We also want to improve care. Let's talk about, just for a moment, some of the concerns that you feel that we have in the post-op wards, monitoring in medical wards, when it comes to, you know, intermittent versus continuous monitoring, because there's some real variation, I think.

Sadia Khan: So, I think Desiree, you're right. And I think the other challenge we have and why the challenge remains a challenge rather than something that we have fixed is because the context keeps shifting so much. So, traditionally, obviously, we've not even had standardized models or methods of monitoring patients when they're in the ward areas.

And it's not that long ago since we started systematic track and trigger systems. For example, the United Kingdom, the National Early Warning Score, as we now call it, isn't that old in terms of how long ago we've implemented it. But despite that, we know that challenges remain in people's ability to be able to monitor things.

So, a respiratory rate would be the classic example of something that we clinicians actually find really difficult to do correctly. So, there's that. But there's also the element of what's happened in terms of acuity and staffing.

So, for me, who's been on the wards for longer than I can care to remember, if I think back, we used to have empty beds on wards. I can't remember the last time we've had anything less than 85-90% occupancy. And I also can't remember when we had simple things to look after.

So, these challenges mean that our patient safety challenge will get bigger and bigger.

Desiree Chappell: You mentioned something that I don't think we've talked much about the new system, the early warning. Can you just tell me a little bit more about that?

Sadia Khan: It's just a track and trigger system, because this patient safety challenge has clearly been identified for a long time. And one of the things we know that helps people improve quality and be on an improvement journey is having standardized methods of doing things. So, the NEWS-2 just essentially tracks parameters that you and I would be very familiar on that we can monitor at the bedside, things like heart rate, respiratory rate, temperature, blood pressure, pain scores.

And we track and use those as trigger measures when certain thresholds are crossed. The challenge, obviously, to that is, A, we've said you've got to do it accurately, but also they're intermittent. So, if your nursing rounds are every six hours, which is standard of care, there's quite a lot of time in between that you're then relying on other things, being able to flag that patient's deterioration, staff going round, patient reporting symptoms.

But we know that actually that's quite a long time and we often miss things.

Desiree Chappell: Absolutely. And I don't know about how it is in other countries. I've heard a little bit.

But in the US, typically when we are putting down respiratory rates and things like that that are not hard recorded, you know, as a blood pressure, it's basically, you know, 16, 18, 20. Does that happen?

Sadia Khan: So, it sounds quite funny you should say that. So, I was on a call earlier because the work that we're doing now is trying to really push into the surgical wards in terms of continuous patient monitoring. And my research manager was an ex-cardiothoracic specialist nurse.

The conversation was that the respiratory rates we know are 16, 18, 20 and maybe 22 and 23.

Desiree Chappell: Oh my gosh. Tell us a little bit about the work that you have been doing in continuous monitoring and getting that into the floors and what you've seen because that's kind of where we started our journey together a couple of years ago.

Sadia Khan: It is indeed. So, in between, I've had a little bit of a detour in the sense that the United Kingdom's had a virtual ward program rollout. So, I've done a lot of work in terms of bridging technologies into communities and helping provide specialist care for people at home.

But I've just come back to restart my inpatient work. So, at the moment, we're just about to launch the next phase of our work in the surgical wards because I think the work that we've done to date and we've written up and analysed and successfully had a PhD since we last spoke. Wow, that's great.

Really, yeah, it's great and it's really lovely to see my colleagues progressing with their research careers. But I think the work that we and others have done have really demonstrated very clearly the acceptability of this sort of technology to both patients and staff and that staff recognise that when it's done well, it has a real ability to lift quality of care. So, Marco, I think, will talk a little bit more about some of the economic work that we've been involved in.

What we're now really trying to do is hone down on two elements. So, one is really proving that the outcomes that we all think are there and we've identified in retrospective analyses can really be borne out in real life. So, we're doing some work on the surgical floor to really try and measure and start to track that.

And then the other key element that we're looking at from a staffing perspective is the alarm burden and how staff can benefit from this technology and how they might interact with it in a way that actually improves workflow and staff experience rather than just becomes yet another system that we all think we have to do.

Desiree Chappell: It's really my pleasure to introduce our next guests and bring them into the conversation. We have Dr. Marco Luchetti. He's an anaesthesiologist and the Medical Director for Patient Care Solutions for GE HealthCare for Europe, the Middle East and Africa.

Marco, thank you so much for joining us here on Top Med Talk.

Marco Luchetti: Thank you. Thank you, Desiree, for your kind introduction. Yes, actually, I've been practicing as an anaesthesiologist and intensivist for nearly 25 years.

And then recently, seven years ago, I joined GE HealthCare as Clinical Manager first and then Medical Director. So, I have a large experience in the field of anaesthesia and intensive care to the point of, yeah, deterioration, I think, is one of the major, patient deterioration is one of the major challenges today in a hospital setting. Everyone who has been involved in this knows very well that when you get a call from the ward, a patient is deteriorating and you go there, you never know what you can find, what the situation is.

And it's always difficult to manage patients in that moment of crisis. So, what we need to do is to prevent patients from suddenly deteriorating. Actually, they are not suddenly deteriorating.

They are suddenly found to be deteriorated. That's the crucial point.

Desiree Chappell: My favorite quote recently has been, it's gradual until it's sudden, which was a quote about bankruptcy. But I think that it is very appropriate for our patients. Now, let me ask you a question because I think as team anaesthesia, as anaesthesiologists and intensivists, we have a lot of information to give us a better picture of what our patients look like in the OR, in the critical care unit.

I think it's hard for us to understand that the majority of our patients do not go to intensive care. They're going to the ward where they go from very intense monitoring to not much at all. Is that something that, I feel like that's a message we still have to get out there to our anesthesia colleagues.

Marco Luchetti: Yeah, you are right. Of course, the vast majority of patients don't need to go to the ICU. It's a routine surgery.

They have patients that don't have any underlying disease or comorbidities. So, surgery goes uneventful and there's no reason to go to the ICU for the patient to go to the ICU. But there's a small percentage of patients that usually needs to go to the ICU on one end because of the surgery.

So, the surgery is probably a major surgery and as the eye reads complications. On the other end, also patient conditions or comorbidities are the complicating situation. But in the end, those patients need some sort of high-level monitoring.

So, it can be also that they need mechanical ventilation. But in most cases, they just need some monitoring.

Desiree Chappell: Sadia, why don't you tell us about, talk to us a little bit more about some of the outcomes and things that you're looking at for surgical patients and the ones that really matter. Because one of the things I want to explore here in just a little bit is talking about, is it continuous beat to beat of every single patient or do we risk stratify? What are you finding are some of the problems that we need to make sure that we are getting enough information about?

Sadia Khan: I'm going to be honest, Desiree. Some of what I say is about what I've learned during my own work. And some of it, I think we've yet to determine and find out.

And that's part of the real joy of working in this space is just there's so much potential that technology can add for people. So to me, it's not about the technology. It's about the people, both in terms of process, but also in terms of those outcomes.

Because unless we can really say we made a meaningful difference, I'm not sure why we should bother. We shouldn't, should we? So to me, the issue of which patient, I think with my physicianly hat, I looked at it very differently when I first started this work.

And I've been doing work in this monitoring space in an inpatient setting, probably for almost close to a decade now. So quite a long time. My very first look at this was to say, well, let's just put it on everyone.

If we did almost everyone who walks in through the door, what's that going to look like? What I realized very early was it probably wasn't a good way for us to go forward. Although I recognize the arguments about waiting areas and emergency departments, but the way modern healthcare works, a lot of people are seen and assessed in an emergency room setting or an acute floor setting and discharged really quickly.

And if what we do is monitor all of those people, to be honest, in terms of the greatest yield from the technology, I'm not sure it's there. But if I look at it on the other side, if I look at those surgical floors and I look at those patients who are peri and post-operative, I think there's a huge potential gain because those are the areas that we see a lot of transfers to intensive care. We see a lot of what we would call rapid response teams.

I'm not sure what you would call them. Rapid response team activations. We see cardiac arrests from that floor disproportionately more than you might expect from the acuity and the demographics of the medical elements of those patients.

I'm not ignoring how much of a challenge the surgery is, but if you just thought about that patient from a physicianally medical hat, the level of risks that they'd carry should in theory be less than the outcomes that we're seeing. And it's definitely that that surgical period adds a whole load of other stresses.

Desiree Chappell: In the US, we talk a lot about the utilization of technology and integration into practice and how to do that. Talk to me a little bit more about that and really like this integration and making sure that it's right for, like you said, not necessarily just the patient, but the clinician as well.

Sadia Khan: So you were talking earlier about everything being gradual until it happens suddenly. And one of my favorite quotes is about it's the technology looking for a problem. What we actually need is a problem, a group, all the stakeholders are invested in that problem to come together to say, well, what is the way that we want to work this?

And I think one of the real challenges about integrating technology is certainly if you think about how UK hospitals work, and I guess it's the same world over, is often the clinicians on the front line are the last people to know or to be involved in how a process around something works. So I think one of the real things that I really loved doing throughout my work is the ability to work with frontline staff to decide how these things are going to go. And I think that has been a key measure of the success that we've had in terms of actually implementing and getting this work done.

Desiree Chappell: Yeah, I've had lots of conversations in the space of medical devices and pharmaceuticals about how we use it and what's important to us as the clinician and what do we need, not what does the company think that we need to do this better. And I think that's to your point, technology looking for a problem versus explaining what our problem is and what the solution is for it. So I think that's so very important.

In the next couple of days, I'm going to have another conversation with one of the authors of the COSMOS study talking about alarm fatigue and how we can reduce that because that is a true burden that I think is still, even though I feel like we talk about it a lot, it's still underappreciated about the burden of all of these alarms and all this information coming in. And with big data, you have a ton of information coming in to you as a clinician now. And it's like, how do I find out and hear the true signal versus all the noise?

So I don't want to dive into that too much. But one of the things we have to focus on when we are integrating new processes, but specifically new things that we have to spend money on to improve the process is that, you know, is this, does this make a difference for our patients? Yes or no?

If yes, how does that make sense? How is it? How do we show the value of that?

And this is not necessarily just for continuous monitoring, but this is just in general. And that's something that you guys are kind of looking at, isn't it?

Sadia Khan: Yeah, it is. And just coming back to that alarm fatigue. Yes, absolutely.

It's a real, real problem. And unless it's sort of thought through in a way that is considered for both patient and for staff, actually it causes problems on both sides. So I think that's a real key area in these technologies have to fix.

And that issue of decision fatigue, the amount of data that we're exposed to is exponentially increasing on a minute by minute basis. And you and I already touched on the acuity and the volume that's coming through. But we forget that as human beings, our ability to process and actually make good judgments wears out very quickly.

So that issue of alarms and how is data presented, we really have to be clear about when we implement, not just this technology, but any other technology. Yeah. In terms of the outcomes and the impacts, we're really looking at those patient facing things.

What matters to patients? What about outcomes in terms of how long you spend in hospital? Is your illness, your infection or whatever it is, picked up more quickly and treated more quickly for you?

And we're also looking at that staffing element, because if I were a finance manager and I know this because I've sat in enough finance meetings, a 10 person trying to be that clinician, trying to get whatever I want at that particular moment in time, they'd be asking, well, where's the saving? And for healthcare, saving traditionally comes out of headcount, but we don't have enough nurses already. So we have to be really mindful of how we're planning to use technologies like this and how we ensure that actually we lift the quality of care, not try to substitute.

Desiree Chappell: So when we talk about continuous monitoring for a ward patient, are we saying that this monitor stays on a patient 24-7, doesn't move, we never take it off and that is where the value comes from? Or is it kind of intermittent, continuous where it goes on for a couple hours at a time more frequently than just a blood pressure? Because that's a question that I've gotten recently and wondering about that.

Sadia Khan: So I'm going to be honest to say, I don't think we have the evidence base that tells us the clear difference between the two. I've always gone with the premise about if you think about my cardiology background, my cardiac background, telemetry is something I'm very well used to and remote device monitoring out in the community I'm very well used to. So our model is 24 hours.

Desiree Chappell: And that's where I think that, you know, looking at the value of this and saying this is continuous, the value to the provider is that we get all this data, but we don't have all the noise from all the alarms. It's filtering all of that out for us. I think it's going to be very, very important.

Well, as we wrap up here, Sade, talk to me about the work that you and Marco have been doing around and the team around the value of utilizing continuous monitoring, because this is something that you both presented a poster, had it abstract recently, yeah?

Sadia Khan: It is indeed. So you've already touched on the work that JW had done in the United States, and obviously healthcare systems are the same yet different. So one of the questions that came up, particularly as we had done a lot of the work on continuous patient monitoring in a UK setting, is would those cost benefits that were seen in the United States systems translate across into the National Health Service?

So I was really keen that actually we used our real world data. So we were looking at a whole year's worth of data of patients coming through what you would call, I think, med surge, and we would call the general ward areas in Chelsea or Westminster, which is a two site institution of roughly 6,000 staff, two emergency departments, and all the traditional general medical, general surgical specialties, plus a bit added on that you might expect. So we had roughly about 20, if I remember correctly, 23,000, 24,000 discharges from two hospital sites over a 12 month period.

What we basically did was took the elements of the model that they'd already published and re-ran that using our real world data, and we were actually able to evidence that we were likely to achieve significant cost savings driven by the things that we've already touched on, less rapid response team activations, less intensive care unit admissions, reduced length of stay. And that was actually fairly eye opening because on the one hand, with my research hat, I'd be like, yeah, this stuff's great. We've got to do this.

We've got to do this. But when I'd been challenged to say, where are your hard outcomes and how does this come out to the money? I wouldn't have been able to evidence that before we did this piece of work.

And when we did this piece of work, it's like, yes, it validates a lot of what we and others have been saying.

Desiree Chappell: Marco, it looks like from the work that you guys did, you kind of took that model and put that into what you're doing over in the UK. So from your perspective, why don't you tell us a little bit about that?

Marco Luchetti: Yeah, exactly. So we started from the study, the model study that the JW colleagues performed with data coming from the United States, a community hospital in the United States. We wanted to, let's say, replicate this model study in Europe first.

So we wanted to find data from as many countries as possible. But at the end of the day, we were able only to collect data, let's say relevant data and meaningful data from the UK. So what we did is basically use real world evidence from the Chelsea and Westminster Hospital, kindly provided by Sadia.

And we applied the model that we took from the United States study. So basically what we did is to use the reduction ratios. So how the implementation of continuous world monitoring was reducing, to what extent was reducing some, let's say, variables.

And so we applied those reduction ratios that was found described in that paper to the UK study. So basically, this was an easy way to model this for Europe. And let's say this is only UK, but at least for now.

And the results were absolutely comparable to those in the United States, even better in terms of costs in the end.

Desiree Chappell: All right. Well, we're definitely gonna signpost people to the paper that JW did. And then hopefully for the abstract.

Now, you guys are doing more work around this space and hoping to collect more data. Is that correct?

Marco Luchetti: Yes, that's correct. That's certainly correct. What you want to do now is collect more data from at least three or four major European countries and analyze those data using the same reduction ratios that we can extrapolate from the original study.

Actually, those reduction ratios come from the original study from Brown. So this is the original study where those reduction ratios were demonstrated for the first time. Then those were applied to the JW study and then transferred to the UK study.

But then we want to have at least more data encompassing more European countries because different realities, different experiences, different policies. So different countries may show different behaviors and different results in terms of main variables and in the end, in terms of costs. So this is the reason why we want to study as many countries as possible.

Yeah. Finding the good data, finding the data, the relevant data, meaningful data and complete data.

Desiree Chappell: Yeah. So Marco, why don't you tell us what were the big headlines from the study that JW did? What was the actual cost savings?

Marco Luchetti: Basically, what they found is that there were annual estimated cost savings for in-hospital stays around $3.4 million, 22 United States dollars, so for an adoption rate of 50%. And even, of course, even more, $6.8 million with an adoption rate of 100%. So this is really a huge savings in terms of dollars.

And what's interesting to remark here is that the largest contribution to cost savings in that study was provided by the reduction in length of stay for patients that were not admitted to the ICU. So patients that avoided ICU admission because of early detection of deterioration. So this was accounting for approximately 50% of the savings.

So this is in interesting result. So meaning that if we are able to prevent patients from going to the ICU because of deterioration, then we can save, of course, we can improve outcomes, patient outcomes, but we can also save a lot of money.

Desiree Chappell: Yeah, absolutely. Well, Marco, thank you.

Marco Luchetti: Of course, justifies the investment, the return on investment for the implementation of continuous monitoring.

Desiree Chappell: It sounds promising. So hopefully we will be able to catch up with you guys in another year or so. And here's some interesting results.

Thanks so much, guys.

Marco Luchetti: Yeah, hopefully, yes, yes.

Desiree Chappell: Yeah, all right. Well, thank you for being so generous with your time here. I know, Sade, you are sitting in your ward, it looks like now, or in the office.

So I appreciate that. And Marco, I do appreciate all the time that you could give us today here on TopMedTalk talking about this very important topic. Again, it's something that we have done series on.

So if you want to learn more about specific types of continuous ward monitoring and things like that, you can go on topmedtalk.com and find more information. Listen to our previous conversation we had or conversations we've had with Sadia about some of this work. And again, like I said, I hope we can catch up soon to hear more about it and what you are finding out now as you guys get into the surgical wards and find out more information.

So thank you all very much. Thanks, Desiree. Yeah, thank you.I appreciate you. Thank you, yes. 

 

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