Article

The Return on Investment of Implementing a Continuous Monitoring System in General Medical-Surgical Units

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Abstract

To evaluate the cost savings attributable to the implementation of a continuous monitoring system in a medical-surgical unit and to determine the return on investment associated with its implementation. Return on investment analysis. A 316-bed community hospital. Medicine, surgery, or trauma patients admitted or transferred to a 33-bed medical-surgical unit. Each bed was equipped with a monitoring unit, with data collected and compared in a 9-month preimplementation period to a 9-month postimplementation period. Two models were constructed: a base case model (A) in which we estimated the total cost savings of intervention effects and a conservative model (B) in which we only included the direct variable cost component for the final day of length of stay and treatment of pressure ulcers. In the 5-year return on investment model, the monitoring system saved between $3,268,000 (conservative model B) and $9,089,000 (base model A), given an 80% prospective reimbursement rate. A net benefit of between $2,687,000 ($658,000 annualized) and $8,508,000 ($2,085,000 annualized) was reported, with the hospital breaking even on the investment after 0.5 and 0.75 of a year, respectively. The average net benefit of implementing the system ranged from $224 per patient (model B) to $710 per patient (model A) per year. A multiway sensitivity analyses was performed using the most and least favorable conditions for all variables. In the case of the most favorable conditions, the analysis yielded a net benefit of $3,823,000 (model B) and $10,599,000 (model A), and for the least favorable conditions, a net benefit of $715,000 (model B) and $3,386,000 (model A). The return on investment for the sensitivity analysis ranged from 127.1% (25.4% annualized) (model B) to 601.7% (120.3% annualized) (model A) for the least favorable conditions and from 627.5% (125.5% annualized) (model B) to 1739.7% (347.9% annualized) (model A) for the most favorable conditions. Implementation of this monitoring system was associated with a highly positive return on investment. The magnitude and timing of these expected gains to the investment costs may justify the accelerated adoption of this system across remaining inpatient non-ICU wards of the community hospital.

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... Aside from effects on clinical outcomes, impacts on costs have rarely been included in studies evaluating the implementation of continuous vital sign monitoring devices. The few studies that did investigate financial outcomes found lower cost of patient stay in the hospital (attributed mostly to shortened length of stay and lower ICU costs) [20][21][22]. Together, these findings indicate a need for further investigation of the impact of wearable vital sign monitoring on clinical outcomes and costs. ...
... Our results further suggest a potential negative impact on in-hospital costs, specifically lower ICU costs (€622), after implementation of the wearable biosensor. The few previous studies that also looked at financial outcomes following the implementation of a wireless vital sign monitoring system also found lower cost of inpatient stay, attributed mostly to shortened length of stay and lower ICU costs [20][21][22]. Costs savings ranged between $224 and $710 saved per person, dependent on the type of prediction model used by Slight et al. [20] and $2,897 saved per person by Mohr et al. [22] Large differences in cost savings can potentially be explained by the incorporation of costs attributed to implementation of the system. ...
... The few previous studies that also looked at financial outcomes following the implementation of a wireless vital sign monitoring system also found lower cost of inpatient stay, attributed mostly to shortened length of stay and lower ICU costs [20][21][22]. Costs savings ranged between $224 and $710 saved per person, dependent on the type of prediction model used by Slight et al. [20] and $2,897 saved per person by Mohr et al. [22] Large differences in cost savings can potentially be explained by the incorporation of costs attributed to implementation of the system. ...
Article
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Aim: To assess changes in outcomes and costs upon implementation of continuous vital sign monitoring in postsurgical patients. Materials & methods: Retrospective analysis of clinical outcomes and in-hospital costs comparedwith a control period. Results: During the intervention period patients were less frequently admitted to the intensive care unit (ICU) (p = 0.004), had shorter length of stay (p < 0.001) and lower costs (p < 0.001). The intervention was associated with a lower odds of ICU admission (odds ratio: 0.422; p = 0.007) and ICU related costs (coefficient: -622.6; p = 0.083). Conclusion: Continuous vital sign monitoring may have contributed to fewer ICU admissions and lower ICU costs in postsurgical patients.
... Limited evidence exists estimating the costs or cost-effectiveness associated with implementing an EDDS. One study [10] estimates the costs pre-versus post-implementation of a continuous monitoring system at a single center in California. Although not the same as the EDDS in this study, the system does include monitoring of vital signs and notifying staff of patient deterioration. ...
... future science group10.2217/cer-2021-0222 ...
Article
Aim: This study estimates the costs and outcomes pre- versus post-implementation of an early deterioration detection solution (EDDS), which assists in identifying patients at risk of clinical decline. Materials & methods: A retrospective database analysis was conducted to assess average costs per discharge, length of stay (LOS), complications, in-hospital mortality and 30-day all-cause re-admissions pre- versus post-implementation of an EDDS. Results: Average costs per discharge were significantly reduced by 18% (US$16,201 vs $13,304; p = 0.007). Average LOS was also significantly reduced (6 vs 5 days; p = 0.033), driven by a reduction in general care LOS of 1 day (p = 0.042). Complications, in-hospital mortality and 30-day all-cause re-admissions were similar. Conclusion: Costs and LOS were lower after implementation of an EDDS for general care patients.
... Moreover, the societal costs of both transient and permanent severe complications may extend well beyond hospital discharge, for example the costs of life-long nursing care for permanent neurologic injury after a cardiac arrest. One study 58 investigated the economic impact of the implementation of a continuous monitoring system in the medical-surgical ward of a U.S. community hospital. Savings were estimated to range between $224 and $710 per patient, with a hospital breaking even on the investment after 6 to 9 months. ...
... Savings were estimated to range between $224 and $710 per patient, with a hospital breaking even on the investment after 6 to 9 months. 58 High-quality studies are warranted to assess the cost-effectiveness of continuous monitoring on the wards. ...
Article
Continuous and mobile monitoring of vital signs may soon become a reality on hospital wards. By enabling the early detection of clinical deterioration, it may improve quality of care and patient safety.
... Model A was a care-based model in which the estimated total cost savings of intervention effects were reviewed. Whilst model B was a conservative model in which only the direct variable cost component for the final day of the length of stay and treatment of pressure ulcers was included [56]. When evaluating the costs of the system both cost models found a positive return on investment when used in both surgical and medical wards [56]. ...
... Whilst model B was a conservative model in which only the direct variable cost component for the final day of the length of stay and treatment of pressure ulcers was included [56]. When evaluating the costs of the system both cost models found a positive return on investment when used in both surgical and medical wards [56]. ...
Article
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Introduction: Monitoring a patient’s vital signs forms a basic component of care, enabling the identification of deteriorating patients and increasing the likelihood of improving patient outcomes. Several paper-based track and trigger warning scores have been developed to allow clinical evaluation of a patient and guidance on escalation protocols and frequency of monitoring. However, evidence suggests that patient deterioration on hospital wards is still missed, and that patients are still falling through the safety net. Wearable sensor technology is currently undergoing huge growth, and the development of new light-weight wireless wearable sensors has enabled multiple vital signs monitoring of ward patients continuously and in real time. Areas covered: In this paper, we aim to closely examine the benefits of wearable monitoring applications that measure multiple vital signs; in the context of improving healthcare and delivery. A review of the literature was performed. Expert commentary: Findings suggest that several sensor designs are available with the potential to improve patient safety for both hospital patients and those at home. Larger clinical trials are required to ensure both diagnostic accuracy and usability.
... However, evidence on the effects of these CMVS systems on patient outcomes is scarce [17,18]. This may be related to the fact that the implementation of CMVS at scale remains challenging and requires considerable upfront financial investment by hospital administrations [19,20]. ...
Article
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Background Continuous monitoring of vital signs (CMVS) using wearable wireless sensors is increasingly available to patients in general wards and can improve outcomes and reduce nurse workload. To assess the potential impact of such systems, successful implementation is important. We developed a CMVS intervention and implementation strategy and evaluated its success in 2 general wards. Objective We aimed to assess and compare intervention fidelity in 2 wards (internal medicine and general surgery) of a large teaching hospital. MethodsA mixed methods sequential explanatory design was used. After thorough training and preparation, CMVS was implemented—in parallel with the standard intermittent manual measurements—and executed for 6 months in each ward. Heart rate and respiratory rate were measured using a chest-worn wearable sensor, and vital sign trends were visualized on a digital platform. Trends were routinely assessed and reported each nursing shift without automated alarms. The primary outcome was intervention fidelity, defined as the proportion of written reports and related nurse activities in case of deviating trends comparing early (months 1-2), mid- (months 3-4), and late (months 5-6) implementation periods. Explanatory interviews with nurses were conducted. ResultsThe implementation strategy was executed as planned. A total of 358 patients were included, resulting in 45,113 monitored hours during 6142 nurse shifts. In total, 10.3% (37/358) of the sensors were replaced prematurely because of technical failure. Mean intervention fidelity was 70.7% (SD 20.4%) and higher in the surgical ward (73.6%, SD 18.1% vs 64.1%, SD 23.7%; P
... These signals are obtained by wired sensors and help health care providers (HCP) detect changes in patient conditions, and guide treatment decisions. Implementation of continuous monitoring has been associated with better outcomes and lower mortality [3,4]. However, current monitoring technologies pose challenges associated with the use of multiple wires connecting the sensors to the monitors [5][6][7]. ...
Article
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The purpose of this study is to provide a structured overview of existing wireless monitoring technologies for hospitalized children. A systematic search of the literature published after 2010 was conducted in Medline, Embase, Scielo, Cochrane, and Web of Science. Two investigators independently reviewed articles to determine eligibility for inclusion. Information on study type, hospital setting, number of participants, use of a reference sensor, type and number of vital signs monitored, duration of monitoring, type of wireless information transfer, and outcomes of the wireless devices was extracted. A descriptive analysis was applied. Of the 1130 studies identified from our search, 42 met eligibility for subsequent analysis. Most included studies were observational studies with sample sizes of 50 or less published between 2019 and 2022. Common problems pertaining to study methodology and outcomes observed were short duration of monitoring, single focus on validity, and lack information on wireless transfer and data management. Conclusion: Research on the use of wireless monitoring for children in hospitals has been increasing in recent years but often limited by methodological problems. More rigorous studies are necessary to establish the safety and accuracy of novel wireless monitoring devices in hospitalized children.What is Known: • Continuous monitoring of vital signs using wired sensors is the standard of care for hospitalized pediatric patients. However, the use of wires may pose significant challenges to optimal care. What is New: • Interest in wireless monitoring for hospitalized pediatric patients has been rapidly growing in recent years. • However, most devices are in early stages of clinical testing and are limited by inconsistent clinical and technological reporting.
... We found components of the signature in the labs (white blood cell count), vital signs (BP), and from the bedside monitor (every-2second respiratory rate, variability of the SpO 2 ). We affirmed the importance of continuous cardiorespiratory monitoring data in discovering dynamic signatures of illness (38)(39)(40) excluding it reduced the AUC by 12%. This finding underscores the importance of using all available sources of information in bedside predictive analytics monitoring (41). ...
Article
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Acute respiratory failure requiring the initiation of invasive mechanical ventilation remains commonplace in the pediatric intensive care unit (PICU). Early recognition of patients at risk for respiratory failure may provide clinicians with the opportunity to intervene and potentially improve outcomes. Through the development of a random forest model to identify patients at risk for requiring unplanned intubation, we tested the hypothesis that subtle signatures of illness are present in physiological and biochemical time series of PICU patients in the early stages of respiratory decompensation. We included 116 unplanned intubation events as recorded in the National Emergency Airway Registry for Children in 92 PICU admissions over a 29-month period at our institution. We observed that children have a physiologic signature of illness preceding unplanned intubation in the PICU. Generally, it comprises younger age, and abnormalities in electrolyte, hematologic and vital sign parameters. Additionally, given the heterogeneity of the PICU patient population, we found differences in the presentation among the major patient groups – medical, cardiac surgical, and non-cardiac surgical. At four hours prior to the event, our random forest model demonstrated an area under the receiver operating characteristic curve of 0.766 (0.738 for medical, 0.755 for cardiac surgical, and 0.797 for non-cardiac surgical patients). The multivariable statistical models that captured the physiological and biochemical dynamics leading up to the event of urgent unplanned intubation in a PICU can be repurposed for bedside risk prediction.
... Another potential way to improve integration is to remove notification devices from individuals and instead promote a wardbased responsibility for CRM, by incorporating big screens at the nurses' station. 21,22 In the context of wards being divided into sections, each of which is the responsibility of a single nurse, the nurses may perceive the device as an individual burden, rather than as a collective responsibility, leading to disengagement from the system and decreased responsiveness to alerts. Allowing ward-based responsibility could help overcome another limitation of individual nurse responders: in the context of nursing staff only seeing the benefit of the CRM system on a patient-by-patient basis, or only in patients who have deteriorated, they may underestimate the global impact of the devices (response) with the outcome that their engagement with the CRM devices is impaired. ...
Article
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Rationale, aims and objectives: Continuous remote monitoring (CRM) provides a novel solution to the challenges of monitoring patients' vital signs in hospital, but the results of quantitative studies have been mixed. Acceptance by staff is a crucial determinant of the success of healthcare technologies and may explain these discrepancies. Drawing on the approach of realist evaluation, this paper aims to identify theories about how, why and in what conditions nursing staff perceptions vary regarding the CRM of patients' vital signs. Methods: Multiple methods were used to elicit theories about factors likely to facilitate or impede the successful implementation of continuous remote vital signs monitoring. This included a literature review, consultation with patients and observational work conducted during a randomized controlled trial (RCT) of CRM. In addition, a priori theories developed through informal interactions with patients and ward staff during the day-to-day set-up of the trial were included. Results: The findings suggest that the perceptions of nursing staff regarding remote monitoring can be influenced by the type of patients under their care and their previous experience of telemetry. Factors which may undermine the engagement of staff are perceived staff burden, which can be dependent on contextual factors such as staffing levels, time of day and senior staff attitudes. Staff attitudes are also likely to be influenced by patient perspectives and the utility of the devices associated with remote monitoring. The successful implementation of CRM may be dependent on staff training, research staff input and hospital culture. Conclusions: Theories regarding nursing staff engagement with remote monitoring are numerous, varied and contradictory. The theories elicited in this initial phase will be refined during interviews with the nursing staff involved with the RCT.
... Given the recent advances in monitoring technology, wearable and wireless continuous monitoring of vital signs is now available as a potential solution for earlier detection of clinical deterioration on general wards [15][16][17]. These wearables have shown to be reasonably accurate and also have the potential to improve patient outcomes and reduce cost [18,19]. Most of these systems come with conventional alarm strategies based on single parameter threshold values comparable with those in high care units for critically ill patients. ...
Article
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Background: Wireless continuous vital sign monitoring by wearable devices have recently become available for patients on general wards to promote timely detection of clinical deterioration. Many continuous monitoring systems use conventional threshold alarm settings to alert nurses in case of deviating vital signs. However, frequent false alarms often lead to alarm fatigue and inefficiencies in the workplace. The aim of this study was to determine the feasibility of continuous vital sign monitoring without the use of alarms, thereby exclusively relying on interval trend monitoring. Methods: This explanatory sequential mixed methods study was conducted at an abdominal surgical ward of a tertiary teaching hospital. Heart rate and respiratory rate of patients were measured every minute by a wearable sensor. Trends were visualized and assessed six times per day by nurses and once a day by doctors during morning rounds. Instead of using alarms we focused exclusively on regular vital sign trend analysis by nurses and doctors. Primary outcome was feasibility in terms of acceptability by professionals, assessed by the Usefulness, Satisfaction and Ease of Use questionnaire and further explored in two focus groups, as well as fidelity. Results: A total of 56 patients were monitored and in 80.5% (n = 536) of nurses' work shifts the trends assessments were documented. All deviating trends (n = 17) were recognized in time. Professionals (N = 46) considered continuous monitoring satisfying (4.8±1.0 on a 1-7 Likert-scale) and were willing to use the technology. Although insight into vital sign trends allowed faster anticipation and action upon changed patient status, professionals were neutral about usefulness (4.4±1.0). They found continuous monitoring easy to use (4.7±0.8) and easy to learn (5.3±1.0) but indicated the need for gaining practical experience. Nurses considered the use of alarms for deviating vital signs unnecessary, when trends were regularly assessed and reported. Conclusion: We demonstrated that continuous vital signs trend monitoring without using alarms was feasible in the general ward setting, thereby avoiding unnecessary alarms and preventing alarm fatigue. When monitoring in a general ward setting, the standard use of alarms may therefore be reconsidered.
... Examples of the return on investment being applied to specific technology-facilitated interventions include that of a mobile health clinic serving uninsured and underinsured people and being evaluated in terms of emergency visits avoided and quality of life gains (Oriol et al, 2009). Slight et al (2014) evaluated the return on investment of the introduction of a continuous monitoring system in general medical-surgical units, focusing solely on the financial costs, a point highlighted in an accompanying editorial (Halpern and Shaz, 2014). In some respects, these are narrower in focus, specifically targeting one or two stakeholders and do not necessarily address the dilemma faced by the hospital chief financial officer, as referred to above. ...
Article
Procuring and managing diagnostic services, such as laboratory medicine, is generally based on cost and activity. Improving productivity of laboratory services therefore tends to focus on reducing the cost per test. However, this approach fails to recognise the impact of the test result on the other stakeholders involved in delivering care to the patient across the care pathway. Any assessment of the return on investment from a diagnostic service therefore needs to be undertaken together with a value proposition established for the service. This will enable the clinical, process and economic impact for all stakeholders to be assessed, which can then be used to develop an implementation plan that ensures the expectations of all stakeholders can be addressed.
... Assuming a 5-year Return-of-Investment model, for a single hospital the authors calculated a cost reduction of 0.6 to 2.1 million US dollar per year, with a break even point as early as 0.5 to 0.75 years. 553 This calculation seems to be extremely optimistic, and we urgently need trustable data on the costeffectiveness of implementing of wireless ward monitoring to support physicians during negotiations with the hospital management. However, the only way to achieve such data are to implement and study remote monitoring systems in a controlled fashion in several hospitals simultaneously. ...
Article
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: Patient safety is an activity to mitigate preventable patient harm that may occur during the delivery of medical care. The European Board of Anaesthesiology (EBA)/European Union of Medical Specialists had previously published safety recommendations on minimal monitoring and postanaesthesia care, but with the growing public and professional interest it was decided to produce a much more encompassing document. The EBA and the European Society of Anaesthesiology (ESA) published a consensus on what needs to be done/achieved for improvement of peri-operative patient safety. During the Euroanaesthesia meeting in Helsinki/Finland in 2010, this vision was presented to anaesthesiologists, patients, industry and others involved in health care as the 'Helsinki Declaration on Patient Safety in Anaesthesiology'. In May/June 2020, ESA and EBA are celebrating the 10th anniversary of the Helsinki Declaration on Patient Safety in Anaesthesiology; a good opportunity to look back and forward evaluating what was achieved in the recent 10 years, and what needs to be done in the upcoming years. The Patient Safety and Quality Committee (PSQC) of ESA invited experts in their fields to contribute, and these experts addressed their topic in different ways; there are classical, narrative reviews, more systematic reviews, political statements, personal opinions and also original data presentation. With this publication we hope to further stimulate implementation of the Helsinki Declaration on Patient Safety in Anaesthesiology, as well as initiating relevant research in the future.
... Regarding costs, no outcomes were reported about the devices in the included studies. Such data may however be essential for preparing future business cases for large-scale implementation, considering the relatively high cost of such monitoring devices and platforms [85]. ...
Article
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Background: Continuous monitoring of vital signs using wearable, wireless devices may allow for timely detection of clinical deterioration in patients on general wards in comparison to the standard intermittent vital signs measurements. A large number of studies with many different wearable devices have been reported in recent years, but a systematic review is not available to date. Objective: The aim of this study was to provide a systematic review for healthcare professionals of the current evidence about validation, feasibility, clinical and cost outcomes of wireless wearable devices for continuous vital signs monitoring. Methods: A systematic and comprehensive search was performed using PubMed/MEDLINE, EMBASE, and CENTRAL from 2009 to September 2019 for studies that evaluated wearable, wireless, devices for continuous monitoring of vital signs in adults. Outcomes were structured by validation, feasibility, clinical and costs. Risk of bias was determined by Mixed Methods Appraisal Tool, QUADAS-2 or Quality of Health Economic Studies tool. Results: Twenty-seven studies were included which evaluated thirteen different wearable devices. Studies predominantly evaluated validation or feasibility outcomes of these devices. Only a few studies reported clinical outcomes and they did not report a significant effect. Cost outcomes were not reported in any study. The quality of included studies was predominantly rated as low or moderate. Conclusions: Wireless wearable continuous monitoring devices are mostly still in the clinical validation and feasibility testing phases. As yet there are no high quality large well controlled studies of wireless wearable devices available that show a significant clinical benefit or cost-effectiveness. Such studies are needed to help healthcare professionals and administrators in their decision-making regarding implementation of these devices on a larger scale in clinical practice or in-home monitoring. Clinicaltrial:
... According to the authors, this likely resulted from increased vigilance of the nurses. In the return on investment study (9), which was conducted on a 316-bed community hospital with mainly medical, surgical, and trauma patients, showed savings of between $3,268,000 (conservative model) and $9,089,000 within a 5-year period. These savings were mainly driven by reduced LoS, reduced ICU LoS and reduced pressure ulcers. ...
Article
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Background: Complications after surgical procedures are common and can lead to a prolonged hospital stay, increased rates of postoperative hospital readmission, and increased mortality. Monitoring vital signs is an effective way to identify patients who are experiencing a deterioration in health. SensiumVitals is wireless system that includes a lightweight, digital patch that monitors vital signs at two minute intervals, and has shown promise in the early identification of patients at high risk of deterioration. Objective: To evaluate the cost-utility of continuous monitoring of vital signs with SensiumVitals in addition to intermittent monitoring compared to the usual care of patients admitted to surgical wards. Methods: A de novo decision analytic model, based on current treatment pathways, was developed to estimate the costs and outcomes. Results from randomised clinical trials and national standard sources were used to inform the model. Costs were estimated from the NHS and PSS perspective. Deterministic and probabilistic sensitivity analyses (PSA) were conducted to explore uncertainty surrounding input parameters. Results: Over a 30-day time horizon, intermittent monitoring in addition to continuous monitoring of vital signs with SensiumVitals was less costly than intermittent vital signs monitoring alone. The total cost per patient was £6,329 versus £5,863 for the comparator and intervention groups respectively and the total effectiveness per patient was 0.057 QALYs in each group. Results from the PSA showed that use of SensiumVitals in addition to intermittent monitoring has 73% probability of being cost-effective at a £20,000 willingness-to-pay threshold and 73% probability of being cost-saving compared to the comparator. Cost savings were driven by reduced costs of hospital readmissions and length of stays in hospital. Conclusions: Use of SensiumVitals as a postoperative intervention for patients on surgical wards is a cost-saving and cost-effective strategy, yielding improvements in recovery with decreased health resource use. • Key Points for Decision Makers • SensiumVitals has the potential to reduce the length of postoperative hospital stay, readmission rates, and associated costs in postoperative patients. • In this study, SensiumVitals has been found to be a cost-saving (dominant) and cost-effective (dominant) intervention for monitoring the vital signs of surgical patients postoperatively.
... 38 Though continuous monitoring systems are expensive, the return on investment may be favorable. 39 However, level 1 evidence to support continuous monitoring is lacking. 40 Potential disadvantages of continuous monitoring include distracting false-positive alarms, patient discomfort, and impaired mobility. ...
Article
Background Delayed recognition of decompensation and failure-to-rescue on surgical wards are major sources of preventable harm. This review assimilates and critically evaluates available evidence and identifies opportunities to improve surgical ward safety. Data sources Fifty-eight articles from Cochrane Library, EMBASE, and PubMed databases were included. Conclusions Only 15–20% of patients suffering ward arrest survive. In most cases, subtle signs of instability often occur prior to critical illness and arrest, and underlying pathology is reversible. Coarse risk assessments lead to under-triage of high-risk patients to wards, where surveillance for complications depends on time-consuming manual review of health records, infrequent patient assessments, prediction models that lack accuracy and autonomy, and biased, error-prone decision-making. Streaming electronic heath record data, wearable continuous monitors, and recent advances in deep learning and reinforcement learning can promote efficient and accurate risk assessments, earlier recognition of instability, and better decisions regarding diagnosis and treatment of reversible underlying pathology.
... In recent years, the industry has provided physicians and nurses with different techniques for continuously measuring vital parameters including respiratory rate on the ward [12,25], but technical, organisational and financial arguments still withhold us from using these systems [26][27][28]. Most monitoring systems still use cables and may lead to unwanted immobilization of the respective patients [29]. Manually assessment of vital parameters might take up to 10 mins, meaning that even if vital functions are measured every 4 h (6 times a day), this will result in only 60 min of direct surveillance of the ward patient within 24 h, leaving the post-operative ward patient un-monitored for 96% of the time. ...
Article
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Change of respiratory rate (RespR) is the most powerful predictor of clinical deterioration. Brady- (RespR ≤ 8) and tachypnea (RespR ≥ 31) are associated with serious adverse events. Simultaneously, RespR is the least accurately measured vital parameter. We investigated the feasibility of continuously measuring RespR on the ward using wireless monitoring equipment, without impeding mobilization. Continuous monitoring of vital parameters using a wireless SensiumVitals® patch was installed and RespR was measured every 2 mins. We defined feasibility of adequate RespR monitoring if the system reports valid RespR measurements in at least 50% of time-points in more than 80% of patients during day- and night-time, respectively. Data from 119 patients were analysed. The patch detected in 171,151 of 227,587 measurements valid data for RespR (75.2%). During postoperative day and night four, the system still registered 68% and 78% valid measurements, respectively. 88% of the patients had more than 67% of valid RespR measurements. The RespR’s most frequently measured were 13–15; median RespR was 15 (mean 16, 25th- and 75th percentile 13 and 19). No serious complications or side effects were observed. We successfully measured electronically RespR on a surgical ward in postoperative patients continuously for up to 4 days post-operatively using a wireless monitoring system. While previous studies mentioned a digit preference of 18–22 for RespR, the most frequently measured RespR were 13–16. However, in the present study we did not validate the measurements against a reference method. Rather, we attempted to demonstrate the feasibility of achieving continuous wireless measurement in patients on surgical postoperative wards. As the technology used is based on impedance pneumography, obstructive apnoea might have been missed, namely in those patients receiving opioids post-operatively.
... Earlier identification of clinical deterioration with continuous monitoring may prevent serious adverse events and reduce mortality at the general ward and during transport 38 and hospital costs. 6,39 Continuous monitoring may improve patient wellbeing by reducing sleep disturbances due to nurse measurements. [40][41][42] Further studies should focus on the clinical and socioeconomic outcomes of continuous monitoring with these wearable devices and the reduction of nurse workload. ...
Article
Background: Clinical deterioration regularly occurs in hospitalized patients potentially resulting in life threatening events. Early warning scores (EWS), like the Modified Early Warning Score (MEWS), assist care givers in assessing patients' clinical situation, but cannot alert for deterioration between measurements. New devices, like the ViSi Mobile (VM) and HealthPatch (HP) allow for continuous monitoring and can alert deterioration in an earlier phase. VM and HP were tested regarding MEWS calculation compared to nurse measurements, and detection of high MEWS in periods between nurse observations. Methods: This quantitative study was part of a randomized controlled trial. Sixty patients of the surgical and internal medicine ward with a minimal expected hospitalization time of three days were randomized to VM or HP continuous monitoring in addition to regular nurse MEWS measurements for 24-72 h. Results: Median VM and HP MEWS were higher than nurse measurements (2.7 vs. 1.9 and 1.9 vs. 1.3, respectively), predominantly due to respiratory rate measurement differences. During 1282 h VM and 1886 h HP monitoring, 71 (14 patients) and 32 (7 patients) high MEWS periods were detected during the non-observed periods. Time between VM or HP based high MEWS and next regular nurse measurement ranged from 0 to 9 (HP) and 10 (VM) hours. Conclusions: Both VM and HP are promising for continuous vital sign monitoring and may be more accurate than nurses. High MEWS can be detected in hospitalized patients around the clock and clinical deterioration at an earlier phase during unobserved periods.
... The emergence of e-health has also triggered the demand for data processing in medical data sources and ehealth processes. The digitization of medical information or behavior has not only enriched the doctor's diagnosis and treatment, but more importantly, he shared the medical information of the whole society ,and it is convenient to store, use and transfer [15][16][17].At the same time, the comprehensive construction of a smart campus is inseparable from the soundness of medical institutions. To ensure campus safety, it is especially important to implement a medical data monitoring system among high-quality people. ...
Article
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With the continuous development of information technology,people are gradually moving from the digital age to the intelligent era. As one of the most representative emerging technologies in this era, the artificial intelligence is quietly changing our lives at an unprecedented rate. At present,the Internet of Things has been formally included the five emerging strategic industries in the country. Its development route is from safe city, digital city to perception of China. As an important part of a safe city, the medical and health field is also moving towards to the intelligent era. Therefore, it is imperative to construct a Smart Campus hospital environment monitoring system based on Internet of Things technology. The most core part of home environment intelligent monitoring system is the design of data acquisition and display methods. This paper mainly designs and implements the system client, system data format conversion and system data transmission. The main technical points involved are HL7 protocol, AMQP protocol and RabbitMQ framework, besides, and the cache technology is applied to the server. Information is cached to provide data assembly for different clients. Finally, real-time monitoring and alarming of the environment are implemented in the PC client and the Android client.The paper monitors the Smart Campus hospital environment,then carries out real-time transmission, storage, display, and finally analyzes the data to intelligently identify the Smart Campus hospital environment.
... On the other hand, continuous monitoring can help to identify the risks of impending clinical crisis with aberrations in vital signs, improve the clinical outcomes in hospitalized patients and reduce overall cost [1]. Implementation of continuous monitoring in a 33-bed medical surgical unit led to savings of over $9 million in 5 years [3]. ...
Conference Paper
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Continuous remote monitoring with convenient wireless sensors is attractive for early detection of patient deterioration, preventing adverse events and leading to better patient care. This article presents an innovative sensor design of VitalPatch, a fully disposable wireless biosensor, for remote continuous monitoring, and details the performance assessments from bench testing and laboratory validation in 57 subjects. The bench testing results reveal that VitalPatch's QRS detection had a positive predictive value of $> 99$% from testing with ECG databases. The accuracies of HR, BR and skin temp (in mean absolute error, MAE) from bench testing were $< 5$ bpm, $< 1$ brpm, $< 1 ^{ \circ}C$ respectively. The laboratory testing in 57 subjects revealed the accuracy of HR and BR to be $2.2 \pm 1.5$ bpm and $1.7 \pm 0.7$ brpm respectively for stationary periods. The absolute percent error in detecting steps was $4.7 \pm 4.6$%, and the accuracy in detecting posture was $96.4 \pm 3.1$%. Meanwhile, the specificity and sensitivity of fall detection $( \mathrm {n}=20)$ was found to be 100% and 93.8%, respectively. In conclusion, VitalPatch biosensor demonstrated clinically acceptable accuracies for its vital signs and actigraphy metrics applicable for continuous unobtrusive patient monitoring.
... Slight et al. [9] equipped a community hospital with a monitoring unit that measures mechanical vibrations of the heart cardio ballistic motion effect, respiratory and patient motion. "Average net benefit of implementing the system ranged from $224 per patient […] to $710 per patient." ...
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... Evidence of cost-effectiveness in the use of con- tinuous monitoring technology as compared with standard care (manual or electronic) is still sparse [53]. A return on investment (ROI) model devel- oped for the single-center community hospital in Los Angeles trial [44] has shown a ROI with a breakeven of 0.5-1.5 years. ...
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This chapter reviews some of the common suggestions for adoption of higher monitoring frequency in CGUs; characteristics of recent continuous monitoring technology and systems; their potential advantages and disadvantages; emerging evidence for effectiveness and cost benefit; and likely impact on patient safety.
... Moreover, it appeared highly cost-effective. 18 The results of the study by Schmidt et al 12 have a number of implications. Before the approach is implemented widely, it would be helpful if the results could be validated prospectively in at least a few more hospitals. ...
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Background Several continuous monitoring solutions, including wireless wearable sensors, are available or being developed to improve patient surveillance on surgical wards. We designed a survey to understand the current perception and expectations of anaesthesiologists who, as perioperative physicians, are increasingly involved in postoperative care. Methods The survey was shared in 40 university hospitals from Western Europe and the USA. Results From 5744 anaesthesiologists who received the survey link, there were 1158 valid questionnaires available for analysis. Current postoperative surveillance was mainly based on intermittent spot-checks of vital signs every 4–6 h in the USA (72%) and every 8–12 h in Europe (53%). A majority of respondents (91%) considered that continuous monitoring of vital signs should be available on surgical wards and that wireless sensors are preferable to tethered systems (86%). Most respondents indicated that oxygen saturation (93%), heart rate (80%), and blood pressure (71%) should be continuously monitored with wrist devices (71%) or skin adhesive patches (54%). They believed it may help detect clinical deterioration earlier (90%), decrease rescue interventions (59%), and decrease hospital mortality (54%). Opinions diverged regarding the impact on nurse workload (increase 46%, decrease 39%), and most respondents considered that the biggest implementation challenges are economic (79%) and connectivity issues (64%). Conclusion Continuous monitoring of vital signs with wireless sensors is wanted by most anaesthesiologists from university hospitals in Western Europe and in the USA. They believe it may improve patient safety and outcome, but may also be challenging to implement because of cost and connectivity issues.
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To assist in the early warning of deterioration in hospitalised children we studied the feasibility of collecting continuous wireless physiological data using Lifetouch (ECG-derived heart and respiratory rate) and WristOx2 (pulse-oximetry and derived pulse rate) sensors. We compared our bedside paediatric early warning (PEW) score and a machine learning automated approach: a Real-time Adaptive Predictive Indicator of Deterioration (RAPID) to identify children experiencing significant clinical deterioration. 982 patients contributed 7,073,486 min during 1,263 monitoring sessions. The proportion of intended monitoring time was 93% for Lifetouch and 55% for WristOx2. Valid clinical data was 63% of intended monitoring time for Lifetouch and 50% WristOx2. 29 patients experienced 36 clinically significant deteriorations. The RAPID Index detected significant deterioration more frequently (77% to 97%) and earlier than the PEW score ≥ 9/26. High sensitivity and negative predictive value for the RAPID Index was associated with low specificity and low positive predictive value. We conclude that it is feasible to collect clinically valid physiological data wirelessly for 50% of intended monitoring time. The RAPID Index identified more deterioration, before the PEW score, but has a low specificity. By using the RAPID Index with a PEW system some life-threatening events may be averted.
Chapter
Critical care is undergoing a sea change as intensivist access is inadequate to meet current and future demand for specialist services, while the amount of data involved in critical care plans continues to increase markedly. Heralded by similar changes in nonmedical industries due to increased digital computing power and secure data storage capability, healthcare (and critical care in particular) is rapidly becoming influenced by the rise of remote proactive physiologic monitoring (RPM) technologies that provide enhanced remote specialist access and clinical decision support through a variety of hardware devices and analytic software platforms. While still relatively early in development, RPM technologies are already radically changing the landscape of critical care delivery through individual use cases as well as collective, integrated platforms. Centralized monitoring tele-ICU systems are enterprise-level, end-to-end platforms offering improved clinical outcomes through use of robust clinical information systems that allow early recognition of disease and proactive intervention. Downsides include a high investment of resources and extended time to implementation. Decentralized tele-ICU systems are versatile and relatively inexpensive systems that mirror the bedside experience at the expense of an integrated analytics platform. Artificial intelligence, data science, and related disciplines continue to provide advances in predictive analytics by leveraging the power of machine learning algorithms such that critical care delivery through RPM technologies has made an “Internet of ICU Things” a realistic possibility. Institutions looking to utilize RPM technologies and/or a full tele-ICU program should be keenly aware of impacts upon remote and bedside clinicians and seek to integrate such technologies with legacy systems and minimize interdepartmental technology variations. A strong emphasis on interoperability and compatibility within new and existing technologies and together with clinical operations and workflows is crucial for success.
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The problem of resolution enhancement for speckle patterns analysis-based movement estimation is considered. In our previous publications we showed that this movement represents the corresponding tilt vibrations of the illuminated object and can be measured as a relative spatial shift between time adjacent images of the speckle pattern. In this paper we show how to overcome the resolution limitation obtained when using an optical sensor available in an optical mouse and which measures the Cartesian coordinates of the shift as an integer number of pixels. To overcome such a resolution limitation, it is proposed here to use simultaneous measurements from the same illuminated spot by a few cameras (sensors) each having imaging lenses with different amounts of defocusing. The amount of defocusing defines the proportion ratio between actual changes in the tilt plane and measured shift between speckle images. To utilize the diversity of such ratios we apply a beam-forming signal processing approach that makes it possible to achieve different design criteria and improve the measurement accuracy, respectively. The validity and properties of the proposed solution are demonstrated by a few examples of in-vivo touchless measurements of human heart beat sounds.
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Purpose of project: The purpose of this article is to demonstrate the effectiveness of the Cumulative Complexity Model as a framework to build an Excel tool and a Pareto tool that will enable inpatient case managers to predict the increased risk for and prevent repeat falls. The Excel tool is based on work explained in a previous article by and uses a macro to analyze the factors causing the repeat falls and then calculate the probability of it happening again. This enables the case manager to identify trends in how the patient is transitioning toward goals of care and identify problems before they become barriers to the smooth transition to other levels of care. Thus, the case manager will save the facility money by avoiding unneeded days of care and avoiding the costs that result from rendering medical care for the patient who has fallen. Primary practice settings: In July 2015, a group of nurses at a small Veterans Health Administration Hospital in the Northwest collaborated to find ways to reverse a trend of increasing falls and repeat falls. Methodology and sample: A retrospective chart review of all falls and repeat falls (N = 73) that happened between January 2013 and July 2015 was used to generate a list of top 11 contributing variables that enabled evaluation of the data. A bundle of 3 interventions was instituted in October 2015: (1) development of a dedicated charge nurse/resource nurse, (2) use of a standardized method of rounding, and (3) use of a noncontact patient monitoring system ("virtual nurses"). Falls pre- and postimplementation (N = 109) were analyzed using linear and logistic regression analyses. Data were entered into an Excel sheet and analyzed to identify the major contributing factors to falls and repeat falls and to identify trends. These data were also evaluated to find out whether length of stay and nurse workload contributed to falls. Results: Fifteen months after implementation of the aforementioned interventions, falls on the unit went down from 30 aggregate falls in 2015 to 17 aggregate falls in 2016. Repeat falls in 2015 went from 9 repeat falls after admission to the unit down to 2 repeat falls in 2016. Each additional extrinsic variable that was present added an additional 1.43 to the odds ratio (OR) for a fall. Similarly, each additional intrinsic variable present added 2.08 to the OR for a fall. The linear regression of length of stay and falls demonstrated that 17.5% of falls correlated with length of stay, F(1,36) = 7.63, p = .009, R = .175, adjusted R = .152. Workload correlated with work 17% of the time, as measured by using ward days of care, F(1,100) = 20.84, p = .00001, R = .17, adjusted R = .16. Implications for case managers: Two examples of the how to use these tools are located in the "Discussion" section of the article.
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Background Continuous vital signs monitoring on general hospital wards may allow earlier detection of patient deterioration and improve patient outcomes. This systematic review will assess if continuous monitoring is practical outside of the critical care setting, and whether it confers any clinical benefit to patients. Methods MEDLINE®, MEDLINE® In-Process, EMBASE, CINAHL and The Cochrane Library were searched for articles that evaluated the clinical or non-clinical outcomes of continuous vital signs monitoring in adults outside of the critical care setting. The protocol was registered with PROSPERO (CRD42017058098). Findings Twenty-four studies met the inclusion criteria and reported outcomes on a total of 40,274 patients and 59 ward staff in nine countries. The majority of studies showed benefits in terms of critical care use and length of hospital stay. Larger studies were more likely to demonstrate clinical benefit, particularly critical care use and length of hospital stay. Three studies showed cost-effectiveness. Barriers to implementation included nursing and patient satisfaction and the burden of false alerts. Conclusions Continuous vital signs monitoring outside the critical care setting is feasible and may provide a benefit in terms of improved patient outcomes and cost efficiency. Large, well-controlled studies in high-risk populations are required to evaluate the clinical benefit of continuous monitoring systems.
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Background: Death and anoxic brain injury from unrecognized postoperative respiratory depression (PORD) is a serious concern for patient safety. The American Patient Safety Foundation has called for continuous electronic monitoring for all patients receiving opioids in the postoperative period. These recommendations are based largely on consensus opinion with currently limited evidence. The objective of this study is to review the current state of knowledge on the effectiveness of continuous pulse oximetry (CPOX) versus routine nursing care and the effectiveness of continuous capnography monitoring with or without pulse oximetry for detecting PORD and preventing postoperative adverse events in the surgical ward. Methods: We performed a systematic search of the literature databases published between 1946 and May 2017. We selected the studies that included the following: (1) adult surgical patients (>18 years old); (2) prescribed opioids during the postoperative period; (3) monitored with CPOX and/or capnography; (4) primary outcome measures were oxygen desaturation, bradypnea, hypercarbia, rescue team activation, intensive care unit (ICU) admission, or mortality; and (5) studies published in the English language. Meta-analysis was performed using Cochrane Review Manager 5.3. Results: In total, 9 studies (4 examining CPOX and 5 examining continuous capnography) were included in this systematic review. In the literature on CPOX, 1 randomized controlled trial showed no difference in ICU transfers (6.7% vs 8.5%; P = .33) or mortality (2.3% vs 2.2%). A prospective historical controlled trial demonstrated a significant reduction in ICU transfers (5.6-1.2 per 1000 patient days; P = .01) and rescue team activation (3.4-1.2 per 1000 patient days; P = .02) when CPOX was used. Overall, comparing the CPOX group versus the standard monitoring group, there was 34% risk reduction in ICU transfer (P = .06) and odds of recognizing desaturation (oxygen saturation [SpO2] <90% >1 hour) was 15 times higher (P < .00001). Pooled data from 3 capnography studies showed that continuous capnography group identified 8.6% more PORD events versus pulse oximetry monitoring group (CO2 group versus SpO2 group: 11.5% vs 2.8%; P < .00001). The odds of recognizing PORD was almost 6 times higher in the capnography versus the pulse oximetry group (odds ratio: 5.83, 95% confidence interval, 3.54-9.63; P < .00001). No studies examined the impact of continuous capnography on reducing rescue team activation, ICU transfers, or mortality. Conclusions: The use of CPOX on the surgical ward is associated with significant improvement in the detection of oxygen desaturation versus intermittent nursing spot-checks. There is a trend toward less ICU transfers with CPOX versus standard monitoring. The evidence on whether the detection of oxygen desaturation leads to less rescue team activation and mortality is inconclusive. Capnography provides an early warning of PORD before oxygen desaturation, especially when supplemental oxygen is administered. Improved education regarding monitoring and further research with high-quality randomized controlled trials is needed.
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IntroductionThe term rapid response system (RRS) describes a hospital-wide approach to (a) improve the detection of deteriorating patients and (b) provide a responding team who commence treatment aimed at preventing serious adverse events including cardiac arrest and unexpected death [1]. Ward staff are alerted to clinical deterioration when patients fulfil predefined criteria based on vital sign derangement and other important changes in the patient’s clinical status (Table 1).Rapid response team (RRT) staff have the required skills and knowledge to assess and manage critically ill patients. As such, they are often based in the intensive care unit (ICU). An essential underlying tenant of the RRS model is that early intervention in the course of deterioration improves patient outcome [1].Improving detection of deteriorationResearch in the era prior to RRS implementation suggested that hospital wards may not reliably detect and/or recognise clinical deterioration [1]. Escalation of care ...
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To perform initial validation of a continuous motion monitoring technology that can potentially be used as a risk assessment tool to determine risk for developing pressure ulcers (PUs). We have used the EverOn system (Earlysense LTD, Ramat Gan, Israel) as a bed movement and activity monitor. The EverOn is a contactless continuous measurement system based on a piezoelectric sensor that is placed under the patient's mattress. The study was a noninterventional study performed in 2 medical departments in 2 medical centers. Recorded movement data from enrolled patients were retrospectively analyzed, and patients were assigned a motion level score. Motion scores for the first night of hospitalization were correlated with the Norton scale as calculated per patient on admission. Overall, 116 patients were included in the study from the 2 sites. Motion score was significantly different between the PU risk groups as determined by the Norton scale (10.7 ± 6.2 for low, 5.4 ± 4.9 for intermediate, and 1.6 ± 3.2 for high risk; P < 0.001). Using the Norton scale as a gold standard to define high risk for developing PU (≤14), the sensitivity of the motion score was 85%, and the specificity was 93%. With regard to individual risk components, we found that activity, mobility, physical condition, and incontinence correlated highly with motion level. The high correlation between the EverOn motion score and the calculated Norton scale indicates the potential of this technology to serve as a risk assessment tool for the development of PUs.
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Pressure ulcers are painful sores that arise from prolonged exposure to high pressure points, which restricts blood flow and leads to tissue necrosis. This is a common occurrence among patients with impaired mobility, diabetics and the elderly. In this work, a flexible pressure monitoring system for pressure ulcer prevention has been developed. The prototype consists of 99 capacitive pressure sensors on a 17-cm x 22-cm sheet which is flexible in two dimensions. Due to its low cost, the sensor sheet can be disconnected from the reusable electronics and be disposed of after use, suitable for a clinical setting. Each sensor has a resolution of better than 2-mmHg and a range of 50-mmHg and offset is calibrated in software. Realtime pressure data is displayed on a computer. A maximum sampling rate of 12-Hz allows for continuous monitoring of pressure points.
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Bar coding can reduce hospital pharmacy dispensing errors, but it is unclear if the benefits of this technology justify its costs. The purpose of this study was to assess the costs and benefits and determine the return on investment at the institutional level for implementing a pharmacy bar code system. We performed a cost-benefit analysis of a bar code-assisted medication-dispensing system within a large, academic, nonprofit tertiary care hospital pharmacy. We took the implementing hospital's perspective for a 5-year horizon. The primary outcome was the net financial cost and benefit after 5 years. The secondary outcome was the time until total benefits equaled total costs. Single-variable, 2-variable, and multiple-variable Monte Carlo sensitivity analyses were performed to test the stability of the outcomes. In inflation- and time value-adjusted 2005 dollars, total costs during 5 years were $2.24 million ($1.31 million in 1-time costs during the initial 3.5 years and $342 000 per year in recurring costs starting in year 3). The primary benefit was a decrease in adverse drug events from dispensing errors (517 events annually), resulting in an annual savings of $2.20 million. The net benefit after 5 years was $3.49 million. The break-even point for the hospital's investment occurred within 1 year after becoming fully operational. A net benefit was achieved within 10 years under almost all sensitivity scenarios. In the Monte Carlo simulation, the net benefit during 5 years was $3.2 million (95% confidence interval, -$1.2 million to $12.1 million), and the break-even point for return on investment occurred after 51 months (95% confidence interval, 30 to 180 months). Implementation of a bar code-assisted medication-dispensing system in hospital pharmacies can result in a positive financial return on investment for the health care organization.
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For hospitalized patients with unexpected clinical deterioration delayed or suboptimal intervention is associated with increased morbidity and mortality. Lack of continuous monitoring for average risk patients has been suggested as a contributing factor for unexpected in-hospital mortality. Our objective was to assess the effects of continuous heart rate and respiration rate monitoring in a medical-surgical unit on unplanned transfers and length of stay at the intensive care unit and length of stay at the medical-surgical unit. In a controlled study we have compared a 33-beds medical-surgical unit (intervention unit) to a "sister" control unit for a 9-month pre and a 9-month post implementation period. Following the intervention, all beds in the intervention unit were equipped with monitors that allowed for continuous assessment of heart and respiration rate. We reviewed 7643 patient charts, 2314 that were continuously monitored in the intervention arm and 5329 in the control arms. Comparing the average length of stay of patients hospitalized in the intervention unit following the implementation of the monitors to that prior to the implementation and to that in the control unit we have observed a significant decrease (from 4.0 to 3.6 and 3.6 days respectively; p=<0.01). Total Intensive Care Unit days were significantly lower in the intervention unit post implementation (63.5 versus. 120.1 and 85.36 days/1000 patients respectively; p=0.04). The rate of transfer to the Intensive Care Unit did not change comparing before and after implementation and to the control unit (p=0.19). Rate of code blue events decreased following the intervention from 6.3 to 0.9 and 2.1 respectively per 1000 patients (p=0.02). Continuous monitoring on a medical-surgical unit was associated with a significant decrease in total length of stay in the hospital and in intensive care unit days for transferred patients, as well as lower code blue rates.
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Background: Hospital cost containment, cost reduction, and alternative care delivery systems continue to preoccupy health care providers, payers, employers, and policy makers throughout the United States. The universal metric for gauging the success of these efforts is hospital length of stay (LOS). Reducing the LOS purportedly yields large cost savings. The purpose of this study is to assess precisely how much hospitals save by shortening LOS.Study Design: We reviewed the cost-accounting records of all surviving patients (n = 12,365) discharged from our academic medical center during fiscal year 1998 with LOS of 4 days or more. Actual costs were identified through the University of Michigan cost-accounting system. Individual patient costs were broken out on a daily basis and then decomposed further into variable direct, fixed direct, and indirect categories. The population was analyzed by determining the incremental resource cost of the last full day of stay versus the total cost for the entire stay. The data were also stratified by LOS and by surgical costs. An analysis of all trauma patients was then performed on all patients discharged from the hospital’s adult level I trauma center (n = 665). Costs were determined on specific days, including admission day, each ICU day, day of discharge from the ICU, and each of the last 2 days before the discharge day.Results: The incremental costs incurred by patients on their last full day of hospital stay were $420 per day on average, or just 2.4% of the $17,734 mean total cost of stay for all 12,365 patients. Mean end-of-stay costs represented only a slightly higher percentage of total costs when LOS was short (eg, 6.8% for patients with LOS of 4 days). Even when the data were stratified to focus on patients without major operations, the $432 average last-day variable direct cost was only 3.4% of the $12,631 average total cost of care. A focus on the trauma center helps to explain this phenomenon. For our trauma center, variable direct costs accounted for 42% of the mean total cost per patient of $22,067. The remaining 58% was hospital overhead (fixed and indirect costs). The median variable direct cost on the first day of admission is $1,246, and the median variable direct cost on discharge is $304. Approximately 40% of the variable costs are incurred during the first 3 days of admission.Conclusions: For most patients, the costs directly attributable to the last day of a hospital stay are an economically insignificant component of total costs. Reducing LOS by as much as 1 full day reduces the total cost of care on average by 3% or less. Going forward, physicians and administrators must deemphasize LOS and focus instead on process changes that better use capacity and alter care delivery during the early stages of admission, when resource consumption is most intense.
Article
Continuous vital sign monitoring has the potential to detect early clinical deterioration. While commonly employed in the intensive care unit (ICU), accurate and noninvasive monitoring technology suitable for floor patients has yet to be used reliably. To establish the accuracy of the Earlysense continuous monitoring system in predicting clinical deterioration. Noninterventional prospective study with retrospective data analysis. Two medical wards in 2 academic medical centers. Patients admitted to a medical ward with a diagnosis of an acute respiratory condition. Enrolled patients were monitored for heart rate (HR) and respiration rate (RR) by the Earlysense monitor with the alerts turned off. Retrospective analysis of vital sign data was performed on a derivation cohort to identify optimal cutoffs for threshold and 24-hour trend alerts. This was internally validated through correlation with clinical events recognized through chart review. Of 113 patients included in the study, 9 suffered major clinical deterioration. Alerts were found to be infrequent (2.7 and 0.2 alerts per patient-day for threshold and trend alert, respectively). For the threshold alerts, sensitivity and specificity in predicting deterioration was found to be 82% and 67%, respectively, for HR and 64% and 81%, respectively, for RR. For trend alerts, sensitivity and specificity were 78% and 90% for HR, and 100% and 64% for RR, respectively. The Earlysense monitor was able to continuously measure RR and HR, providing low alert frequency. The current study provides data supporting the ability of this system to accurately predict patient deterioration. Journal of Hospital Medicine 2012; © 2012 Society of Hospital Medicine.
Article
We have developed a non-contact heart rate monitoring system for elderly people In bed using two radars placed on the bed base. The system is designed to increase accuracy despite body motion noise and change of body position and sleeping posture In bed. In order to achieve this, we combined an automatic gaIn control (AGC) method with a real-time radar-output channel selection method which is based on a spectrum shape analysis (SSA). Field tests were carried out with elderly subjects at a nursing home. The accuracy was maintained because the system successfully avoided the null detection point (NDP) problem, respiratory harmonic interference and intermodulation problems. The heart rate accuracy (r = 0.703) was higher than that of the conventional method. The system was proved to be effective In monitoring vital signs without the need for any physical contact with the subjects.
Chapter
This Statistical Brief presents data from the Healthcare Cost and Utilization Project (HCUP) on patterns of utilization and costs for adult hospital stays involving the treatment of pressure ulcers in 2006. Variation in the characteristics of stays principally for pressure ulcers and hospitalizations with a secondary diagnosis of pressure ulcers are compared to stays for all other conditions. Differences in utilization are illustrated according to patient age, expected primary payer, and related conditions. All differences between estimates noted in the text are statistically significant at the 0.05 level or better.
Article
Cardiorespiratory instability may be undetected in monitored step-down unit patients. We explored whether using an integrated monitoring system that continuously amalgamates single noninvasive monitoring parameters (heart rate, respiratory rate, blood pressure, and peripheral oxygen saturation) into AN instability index value (INDEX) correlated with our single-parameter cardiorespiratory instability concern criteria, and whether nurse response to INDEX alert for patient attention was associated with instability reduction. Prospective, longitudinal evaluation in sequential 8-, 16-, and 8-wk phases (phase I, phase II, and phase III, respectively). A 24-bed trauma step-down unit in single urban tertiary care center. All monitored patients. Phase I: Patients received continuous single-channel monitoring (heart rate, respiratory rate, blood pressure, and peripheral oxygen saturation) and standard care; INDEX background was recorded but not displayed. Phase II: INDEX was background-recorded; staff was educated on use. Phase III: Staff used a clinical response algorithm for INDEX alerts. Any monitored parameters even transiently beyond local cardiorespiratory instability concern triggers (heart rate of <40 or >140 beats/min, respiratory rate of <8 or >36 breaths/min, systolic blood pressure of <80 or >200 mm Hg, diastolic blood pressure of >110 mm Hg, and peripheral oxygen saturation of <85%) defined INSTABILITYmin. INSTABILITYmin further judged as both persistent and serious defined INSTABILITYfull. The INDEX alert states were defined as INDEXmin and INDEXfull by using same classification. Phase I and phase III admissions (323 vs. 308) and monitoring (18,258 vs. 18,314 hrs) were similar. INDEXmin and INDEXfull correlated significantly with INSTABILITYmin and INSTABILITYfull (r = .713 and r = .815, respectively, p < .0001). INDEXmin occurred before INSTABILITYmin in 80% of cases (mean advance time 9.4 ± 9.2 mins). Phase I and phase III admissions were similarly likely to develop INSTABILITYmin (35% vs. 33%), but INSTABILITYmin duration/admission decreased from phase I to phase III (p = .018). Both INSTABILITYfull episodes/admission (p = .03) and INSTABILITYfull duration/admission (p = .05) decreased in phase III. The integrated monitoring system INDEX correlated significantly with cardiorespiratory instability concern criteria, usually occurred before overt instability, and when coupled with a nursing alert was associated with decreased cardiorespiratory instability concern criteria in step-down unit patients.
Article
To assess the accuracy of the EverOn™ piezoelectric sensor based contactless heart rate and respiration rate monitoring system. Measurements of the EverOn™ and reference devices were performed in a sleep lab and an intensive care unit (ICU) setting. One minute measurements by both the reference device and the EverOn™ were averaged and compared. Accuracy was defined in accordance with industry criteria. Respiration rate (RR) accuracy in the 41 children and 16 adults evaluated in the sleep lab was 93.1% and 90.6% respectively, and heart rate (HR) accuracy was 94.4% and 91.5% respectively. For the 42 ICU patients RR accuracy was 82.0% and 75% (versus end-tidal CO(2) and manual respectively), while accuracy of HR was 94.0%. The EverOn™ was found to be superior to the impedance technique in measuring RR. The system described was found to be accurate in accordance with regulatory and industry criteria.
Article
Although rapid response teams (RRTs) increasingly have been adopted by hospitals, their effectiveness in reducing hospital mortality remains uncertain. We conducted a meta-analysis to assess the effect of RRTs on reducing cardiopulmonary arrest and hospital mortality rates. We conducted a systematic review of studies published from January 1, 1950, through November 31, 2008, using PubMed, EMBASE, Web of Knowledge, CINAHL, and all Evidence-Based Medicine Reviews. Randomized clinical trials and prospective studies of RRTs that reported data on changes in the primary outcome of hospital mortality or the secondary outcome of cardiopulmonary arrest cases were included. Eighteen studies from 17 publications (with 1 treated as 2 separate studies) were identified, involving nearly 1.3 million hospital admissions. Implementation of an RRT in adults was associated with a 33.8% reduction in rates of cardiopulmonary arrest outside the intensive care unit (ICU) (relative risk [RR], 0.66; 95% confidence interval [CI], 0.54-0.80) but was not associated with lower hospital mortality rates (RR, 0.96; 95% CI, 0.84-1.09). In children, implementation of an RRT was associated with a 37.7% reduction in rates of cardiopulmonary arrest outside the ICU (RR, 0.62; 95% CI, 0.46-0.84) and a 21.4% reduction in hospital mortality rates (RR, 0.79; 95% CI, 0.63-0.98). The pooled mortality estimate in children, however, was not robust to sensitivity analyses. Moreover, studies frequently found evidence that deaths were prevented out of proportion to reductions in cases of cardiopulmonary arrest, raising questions about mechanisms of improvement. Although RRTs have broad appeal, robust evidence to support their effectiveness in reducing hospital mortality is lacking.
Article
The past 10-15 yrs brought significant changes in the United States healthcare system. Effects on Medicare intensive care unit use and costs are unknown. Intensive care unit costs are estimated using the Russell equation with a ratio of intensive care unit to floor cost per day, or "R value," of 3, which may no longer be valid. We sought to determine contemporary Medicare intensive care unit resource use, costs, and R values; whether these vary by patient and hospital characteristics; and the impact of updated values on estimated intensive care unit costs. Retrospective analysis of Medicare Inpatient Prospective Payment System hospitalizations from 1994 to 2004 using Medicare Provider Analysis and Review files. All nonfederal acute care US hospitals paid through the Inpatient Prospective Payment System. Inpatient prospective payment system hospitalizations from 1994 to 2004 (n = 121,747, 260). None. We examined resource use and costs (adjusted to y2004$), calculating intensive care unit and floor costs directly and using these to generate year-specific R values. By 2004, 33% of Medicare hospitalizations had intensive care unit or coronary care unit care, with more than half of the increase in total hospitalizations because of additional intensive care unit hospitalizations. Adjusted intensive care unit cost per day remained stable ($2,616 vs. $2,575; 1994 vs 2004), yet adjusted floor cost per day rose substantially ($1,027 vs. $1,488) driven by decreased floor length of stay. Annual adjusted Medicare intensive care unit costs increased 36% to $32.3B, largely because of increased utilization. R values decreased progressively from 2.55 to 1.73, were lower for surgical vs. medical admissions and survivors vs. nonsurvivors, but varied little by hospital characteristics. An R value of 3 overestimated Medicare intensive care unit costs by 17.6% ($5.7 billion) in 2004. Medicare intensive care unit use is rising rapidly and will likely continue to do so. Despite significant healthcare system changes, adjusted daily critical care costs remained stable, yet care outside the intensive care unit became more expensive. To track intensive care unit cost over time, year-specific R values should be used.
Article
To determine whether or not the development of a Stage II or greater pressure ulcer in-hospital is associated with increased hospital costs and length of stay after adjusting for admission severity of illness, comorbidities, nosocomial infections, and other hospital complications. Prospective, inception cohort study. Tertiary care, urban, university teaching hospital. 286 patients identified within 3 days of admission to a tertiary care, urban teaching hospital were enrolled in a prospective, inception cohort study. Patients were age 55 or greater; expected to be confined to bed or chair or with a hip fracture; and expected to remain in hospital at least 5 days. Baseline data were collected within 3 days of admission. Weekly skin assessments were performed by study nurses to document the development of pressure ulcers. Medical record reviews, patient exams, and physician and nurse interviews were used to obtain baseline demographic, medical, functional, nutritional, and global measures of disease severity. The incidence of nosocomial infections and the number of other hospital complications were monitored by medical record reviews. Hospital costs were estimated using category-specific cost-to-charge ratios. Diagnostic-related group (DRG) adjusted length of stay was calculated by subtracting the mean length of stay for assigned DRGs from actual stays. Incident pressure ulcers were associated with significantly higher mean unadjusted hospital costs ($37,288 vs $13,924, P = 0.0001) and length of stay (30.4 vs 12.8 days, P = 0.0001). In addition to pressure ulcers, other independent predictors of hospital costs and length of stay after multivariable analyses included: admission to an intensive care unit or surgical service, younger age, nosocomial infection, the physician assessment of disease severity, and the number of other hospital complications. Compared with those who did not develop pressure ulcers, patients who developed pressure ulcers also were more likely to develop nosocomial infections (45.9% [17/37] vs 20.1% [50/249], P = 0.001) and other hospital complications (86.5% [32/37] vs 43.0% [107/249], P < 0.001). After adjusting for only the admission predictors of costs and length of stay by multivariable analyses, hospital costs, and length of stay for those who developed pressure ulcers remained significantly greater than for those who did not develop pressure ulcers ($14,260 vs $12,382, P = 0.03, and 16.9 vs 12.9 days, P = 0.02, respectively). The differences in costs and length of stay for those with and without incident pressure ulcers were even greater when adjusted for admission predictors and also the occurrence of nosocomial infections and other complications ($29,048 vs $13,819, P = 0.002, and 20.9 vs 12.7 days, P = 0.0001, respectively). Incident pressure ulcers are associated with substantial and significant increases in hospital costs and length of stay. Nosocomial infections and other hospital complications are additional significant independent predictors of health care utilization among patients at risk for pressure ulcers.
Article
Physiological values and interventions in the 24 h before entry to intensive care were collected for admissions from hospital wards. In a 13-month period, there were 79 admissions in 76 patients who had been in hospital for at least 24 h and had not undergone surgery within 24 h of admission to intensive care. Thirty-four per cent of patients underwent cardiopulmonary resuscitation before intensive care admission. Using Acute Physiology and Chronic Health Evaluation II scoring to quantify abnormal physiology in the group as a whole, a significant deterioration in respiratory function before admission was found. During the 6-h period immediately before intensive care admission, 75% of patients received oxygen, 37% underwent arterial blood gas sampling, and oxygen saturation was measured in 61% of patients, 63% of whom had an oxygen saturation of less than 90%. Overall hospital mortality in the study group was 58%. Information collected on the wards identified seriously ill patients who may have benefited from earlier expert treatment.
Article
This review examined the impact of different payment systems on primary care physician behaviour. Three payment systems were included: capitation (payment is made for every patient for whom care is provided), salary, and fee for service (payment is made for every item of care provided). There was some evidence that primary care physicians provide a greater quantity of primary care services under fee for service payment compared with capitation and salary, although long-term effects are unclear. There was no evidence, however, concerning other important outcomes such as patient health status, or comparing the relative impact of salary versus capitation payment.
Article
Hospital cost containment, cost reduction, and alternative care delivery systems continue to preoccupy health care providers, payers, employers, and policy makers throughout the United States. The universal metric for gauging the success of these efforts is hospital length of stay (LOS). Reducing the LOS purportedly yields large cost savings. The purpose of this study is to assess precisely how much hospitals save by shortening LOS. We reviewed the cost-accounting records of all surviving patients (n = 12,365) discharged from our academic medical center during fiscal year 1998 with LOS of 4 days or more. Actual costs were identified through the University of Michigan cost-accounting system. Individual patient costs were broken out on a daily basis and then decomposed further into variable direct, fixed direct, and indirect categories. The population was analyzed by determining the incremental resource cost of the last full day of stay versus the total cost for the entire stay. The data were also stratified by LOS and by surgical costs. An analysis of all trauma patients was then performed on all patients discharged from the hospital's adult level I trauma center (n = 665). Costs were determined on specific days, including admission day, each ICU day, day of discharge from the ICU, and each of the last 2 days before the discharge day. The incremental costs incurred by patients on their last full day of hospital stay were $420 per day on average, or just 2.4% of the $17,734 mean total cost of stay for all 12,365 patients. Mean end-of-stay costs represented only a slightly higher percentage of total costs when LOS was short (e.g., 6.8% for patients with LOS of 4 days). Even when the data were stratified to focus on patients without major operations, the $432 average last-day variable direct cost was only 3.4% of the $12,631 average total cost of care. A focus on the trauma center helps to explain this phenomenon. For our trauma center, variable direct costs accounted for 42% of the mean total cost per patient of $22,067. The remaining 58% was hospital overhead (fixed and indirect costs). The median variable direct cost on the first day of admission is $1,246, and the median variable direct cost on discharge is $304. Approximately 40% of the variable costs are incurred during the first 3 days of admission. For most patients, the costs directly attributable to the last day of a hospital stay are an economically insignificant component of total costs. Reducing LOS by as much as 1 full day reduces the total cost of care on average by 3% or less. Going forward, physicians and administrators must deemphasize LOS and focus instead on process changes that better use capacity and alter care delivery during the early stages of admission, when resource consumption is most intense.
Article
To examine if delayed transfer to the intensive care unit (ICU) after physiologic deterioration is associated with increased morbidity and mortality. Inception cohort. Community hospital in Ogden, Utah. Ninety-one consecutive inpatients with noncardiac diagnoses at the time of emergent transfer to the ICU. We determined the time when each patient first met any of 11 pre-specified physiologic criteria. We classified patients as "slow transfer" when patients met a physiologic criterion 4 or more hours before transfer to the ICU. Patients were followed until discharge. None. In-hospital mortality, functional status at hospital discharge, hospital resources. At the time when the first physiologic criterion was met on the ward, slow- and rapid-transfer patients were similar in terms of age, gender, diagnosis, number of days in hospital prior to ICU transfer, prehospital functional status, and APACHE II scores. By the time slow-transfer patients were admitted to the ICU, they had significantly higher APACHE II scores (21.7 vs 16.2; P =.002) and were more likely to die in-hospital (41% vs 11%; relative risk [RR], 3.5; 95% confidence interval [95% CI], 1.4 to 9.5). Slow-transfer patients were less likely to have had their physician notified of deterioration within 2 hours of meeting physiologic criteria (59% vs 31%; P =.001) and less likely to have had a bedside physician evaluation within the first 3 hours after meeting criteria (23% vs 83%; P =.001). Slow transfer to the ICU of physiologically defined high-risk hospitalized patients was associated with increased risk of death. Slow response to physiologic deterioration may explain these findings.
Article
Electronic medical record systems improve the quality of patient care and decrease medical errors, but their financial effects have not been as well documented. The purpose of this study was to estimate the net financial benefit or cost of implementing electronic medical record systems in primary care. We performed a cost-benefit study to analyze the financial effects of electronic medical record systems in ambulatory primary care settings from the perspective of the health care organization. Data were obtained from studies at our institution and from the published literature. The reference strategy for comparisons was the traditional paper-based medical record. The primary outcome measure was the net financial benefit or cost per primary care physician for a 5-year period. The estimated net benefit from using an electronic medical record for a 5-year period was 86,400 US dollars per provider. Benefits accrue primarily from savings in drug expenditures, improved utilization of radiology tests, better capture of charges, and decreased billing errors. In one-way sensitivity analyses, the model was most sensitive to the proportion of patients whose care was capitated; the net benefit varied from a low of 8400 US dollars to a high of 140,100 US dollars . A five-way sensitivity analysis with the most pessimistic and optimistic assumptions showed results ranging from a 2300 US dollars net cost to a 330,900 US dollars net benefit. Implementation of an electronic medical record system in primary care can result in a positive financial return on investment to the health care organization. The magnitude of the return is sensitive to several key factors.
Article
To determine the incidence, cost, and payment for intensive care unit services among Medicare beneficiaries. Retrospective observational database cohort study. All nonfederal hospitals with intensive care unit beds (n = 5003) paid through the inpatient prospective payment system (IPPS). We used all fiscal year 2000 Medicare IPPS hospitalizations with consistent payment information (n = 10,657,587). None. We examined the distribution of cost and payments overall, by hospital type, and by diagnosis related group. Intensive care was used in 2,353,208 cases (21.1%). The overall incidence was 59.8 cases per thousand beneficiaries in the aged (65+) population, increasing with age from 36.2 (65-69) to 91.6 (85+). Intensive care unit patients cost nearly three times floor patients (4,135 dollars vs. 5,571 dollars), with two thirds of costs associated with the intensive care unit portion of the stay, 2,278 dollars per intensive care unit day. However, intensive care unit cases were paid at a rate only twice floor cases (11,704 dollars vs. 5,835 dollars). Only 83% of costs were paid for intensive care unit patients, compared with 105% for floor patients, generating a 5.8 billion dollars loss to hospitals when intensive care unit care is required. There was a linear association between the percent intensive care unit in a diagnosis related group and the percent paid, with payment >90% of cost only in diagnosis related groups with >/=60% intensive care unit cases. We found that teaching hospitals were better paid than nonteaching hospitals (87% vs. 78% of costs, respectively), but this was only due to indirect medical education payments. Intensive care is common, expensive, and poorly paid in the Medicare population. Few diagnosis related groups have a large enough intensive care unit population to ensure adequate payment. Additional diagnosis related groups for conditions common to the intensive care unit would improve payment and enable incentives for efficiency.
Article
A half decade has elapsed since the Institute of Medicine released 2 landmark reports on health care safety and quality, To Err Is Human1 and Crossing the Quality Chasm.2 Those studies helped articulate a broad agenda for quality improvement in health care, and examples of success on a small scale are numerous. However, the collective impact of improvement work has been far below the potential envisioned by the Institute of Medicine. Health care can benefit now from a new sense of urgency, with levels of discipline and pace akin to those of a political campaign.
Article
Although computerized physician order entry (CPOE) may decrease errors and improve quality, hospital adoption has been slow. The high costs and limited data on financial benefits of CPOE systems are a major barrier to adoption. The authors assessed the costs and financial benefits of the CPOE system at Brigham and Women's Hospital over ten years. Cost and benefit estimates of a hospital CPOE system at Brigham and Women's Hospital (BWH), a 720-adult bed, tertiary care, academic hospital in Boston. Institutional experts provided data about the costs of the CPOE system. Benefits were determined from published studies of the BWH CPOE system, interviews with hospital experts, and relevant internal documents. Net overall savings to the institution and operating budget savings were determined. All data are presented as value figures represented in 2002 dollars. Between 1993 and 2002, the BWH spent $11.8 million to develop, implement, and operate CPOE. Over ten years, the system saved BWH $28.5 million for cumulative net savings of $16.7 million and net operating budget savings of $9.5 million given the institutional 80% prospective reimbursement rate. The CPOE system elements that resulted in the greatest cumulative savings were renal dosing guidance, nursing time utilization, specific drug guidance, and adverse drug event prevention. The CPOE system at BWH has resulted in substantial savings, including operating budget savings, to the institution over ten years. Other hospitals may be able to save money and improve patient safety by investing in CPOE systems.
Article
Pressure ulcers are common in a variety of patient settings and are associated with adverse health outcomes and high treatment costs. To systematically review the evidence examining interventions to prevent pressure ulcers. MEDLINE, EMBASE, and CINAHL (from inception through June 2006) and Cochrane databases (through issue 1, 2006) were searched to identify relevant randomized controlled trials (RCTs). UMI Proquest Digital Dissertations, ISI Web of Science, and Cambridge Scientific Abstracts were also searched. All searches used the terms pressure ulcer, pressure sore, decubitus, bedsore, prevention, prophylactic, reduction, randomized, and clinical trials. Bibliographies of identified articles were further reviewed. Fifty-nine RCTs were selected. Interventions assessed in these studies were grouped into 3 categories, ie, those addressing impairments in mobility, nutrition, or skin health. Methodological quality for the RCTs was variable and generally suboptimal. Effective strategies that addressed impaired mobility included the use of support surfaces, mattress overlays on operating tables, and specialized foam and specialized sheepskin overlays. While repositioning is a mainstay in most pressure ulcer prevention protocols, there is insufficient evidence to recommend specific turning regimens for patients with impaired mobility. In patients with nutritional impairments, dietary supplements may be beneficial. The incremental benefit of specific topical agents over simple moisturizers for patients with impaired skin health is unclear. Given current evidence, using support surfaces, repositioning the patient, optimizing nutritional status, and moisturizing sacral skin are appropriate strategies to prevent pressure ulcers. Although a number of RCTs have evaluated preventive strategies for pressure ulcers, many of them had important methodological limitations. There is a need for well-designed RCTs that follow standard criteria for reporting nonpharmacological interventions and that provide data on cost-effectiveness for these interventions.
Article
A positive answer is given to the question intrigued by our previous work reported in EMBC 2005: whether it is possible for a non-contact physiological movement detector to detect vital signs from four sides of a human body. In addition to the proof from measured data, theoretical analysis confirms the surprising advantage of detection from the back of the body. Based on this observation, a non-contact system was set up to perform overnight monitoring of vital signs using low power radio waves. Measurement data is presented and analyzed. The challenges and key technologies that improved the performance of our system for overnight monitoring are discussed.
Article
Patient falls are a serious problem in hospitals, resulting in substantial morbidity, mortality, length of stay, and costs. The results of a small trial of a patient vigilance system in a post-neurosurgery unit of a large acute care hospital are reported. The system includes two components: (a) passive sensor array placed under the patient in a hospital bed, and (b) a bedside unit that connects to the nurse call system already in place at the hospital. This trial demonstrated the overall effectiveness of the vigilance system in reducing the rate of patient falls. The cost-effectiveness analysis found that use of this system was associated with somewhat higher measured costs. It is likely that the system was cost-saving, due to unmeasured costs.
impact on the cost of hospital admission
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Using Continuous Motion Sensing Technology as a Nursing Monitoring and Alerting Tool to Prevent In-Hospital Development of Pressure Ulcers
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