Wide variety of technology brings care directly to the patient
From testing to telemetry, patient care is being brought to the bedside of a growing number of patients across the country. Engendered by constantly evolving and improving technology, patient-focused care is demonstrating a significant potential for improving patient safety while bolstering satisfaction.
"Rather than having the patient go through the pain and suffering of being moved around, we now bring the treatment or testing to them through patient-focused care," says Patrice L. Spath, a consultant with Brown-Spath & Associates in Forest Grove, OR. "They become the center of the wheel."
The centerpiece of patient-focused care is a growing array of services known as point-of-care (POC) services. Among these is POC testing. "In general, [POC] has a number of advantages," says James Nichols, PhD, associate professor of pathology at Tufts University School of Medicine in Boston, and medical director of clinical chemistry for Baystate Health System in Springfield, MA, where he supervises POC testing. "It requires a smaller amount of blood and is minimally invasive, which is very useful for neonates, who do not have much blood. And you can do the test right there and go on with the treatment, which maintains continuity of care."
Marc T. Zubrow, MD, director of critical care for Christiana Care Health System in Newark, DE, says he is reaping benefits in both patient safety and satisfaction from his recently installed Flexible Monitoring system (manufactured by Welch Allyn Inc. based in Skaneateles Falls, NY), which uses wireless telemetry to monitor patient heart rhythms.
"Patients can literally go anywhere, and people will know what’s going on [with them]; and they can be easily found in case of emergency," he notes. "Also, I had observed that in regular step-down units, the monitor watchers really weren’t watching; nurses had many other duties and were often called away. Plus, the cacophony of alarms in traditional step-down units is disturbing, especially when a patient is trying to sleep."
Spath agrees that patient-focused care can enhance patient safety. "There’s a significant patient safety aspect, in that any time a patient is handed off from one caregiver to another, there is a chance for an event,. Not only does the patient have to be handed off, but information relevant to that patient has to be handed off as well."
In addition, POC enhances patient safety through improved identification technology, she adds. "If you are right at the bedside and get a drop of blood to test, you don’t have to worry about the vial being mislabeled, getting mixed up, and having the wrong report coming back," Spath notes. "It definitely does minimize the patient ID problem."
The number of applications for POC services is nearly as wide as the applications a health care professional can envision. In testing alone, for example, it can include:
- blood gases
- electrolytes
- Ca++
- Na+
- K
- Mg++
- hematocrit
- glucose
- creatinine
- blood urea nitrogen
"There is an advantage to performing the top 10 most popular tests at the patient bedside since it is expensive to package, transport, unpackage, relabel, and rack the specimens for analysis. Furthermore, bottlenecks are created in the central laboratory when large numbers of specimens queue up for labeling, aliquoting, and centrifugation,"1 wrote Robin A. Felder, PhD, of the Uni-versity of Virginia, Charlottesville.
Christiana already is contemplating the expansion of its monitoring program beyond cardiovascular data. For example, implementation of wireless multiparameter monitoring, including noninvasive blood pressure and SpO2 (blood oxygen saturation) are being considered.
Radiology is another area where POC applications are numerous, including picture archiving and communications systems; medical imaging displays and display controllers; and POC workstations. Interventional radiology, fluoroscopy, digitized X-rays, and ultrasound are just a few of the specific areas of application.
Primarily, the major benefit [of POC radiology] is having images directly at the patient’s bedside for referral or consultation," says David Hebert, marketing manager in the medical business unit for Planar Systems of Beaverton, OR, a major manufacturer of flat display panels and other POC products.
"Under the old model, you had to print the exam results in radiology, then walk over to the patient’s bedside and then use it in conjunction with whatever procedure was planned. This affords a tremendous time savings."
Planar produces a wide range of diagnostic or referral quality displays for radiology, including the recently introduced Invitium POC workstation. This involves either a "normal" CPU or a thin-client CPU that actually is embedded into the display panel on a card, so it is mobile and available to any clinical informatic.
What is the future of POC radiology? "In an ideal world, as we advance, we will be integratable into CPOE [computerized physician order entry], drug administration programs — ideally, any and all patient data that can be accessed at the bedside," Hebert says. "This will allow the opportunity for increases in quality of care, but distributing critical information as widely and as quickly as possible."
Zubrow initiated his project in response to the constant challenge of finding enough step-down beds for patients coming out of intensive care. "I noted that most patients being observed in the step-down environment could be monitored from a remote site, and in that way, multiple areas of a hospital could all be monitored from the same site," he recalls. "The same thing is true in upgrading; if a patient requires monitoring, you can do that remotely rather than having the domino of bed transfers to make beds available."
The system being used by Christiana, which was developed by Welch Allyn, "is a superior system," Zubrow says. "It was the first on the market that had a screening ion, which enabled us to visualize the patient’s heart rhythm on their body." In other systems, he explains, when a patient has an acute problem, the health care professional usually has to push a button to get more specific information. "With this system, you walk in, and if you think you hear something you’re not used to hearing in the rhythm, you have instant information."
Patients who are being monitored have leads on their bodies, which send information to a small box that also is on their person. The box, in turn, sends information to an antenna on the ceiling, which then sends the data through a land line to the monitoring room, staffed by monitor technicians, who are responsible for arrhythmia detection of all patients being monitored by the system.
"Before, we had to move patients to specific [hard-wired] rooms," Zubrow says. "This also meant a new set of nurses. This was a huge patient dissatisfaction issue." At the same time, Christiana implemented a STAT (stabilization-transport-administration-teaching) nurse program to support the changes of added monitoring to multiple nursing units. The STAT nurse is a medical intensive care nurse available 24/7 to help provide critical care for patients. "The STAT nurse responds to changing status," he explains. "If a patient’s condition changes, there is immediate response."
There are two hospitals in the Christiana system. At Christiana, where the system has been in use since 2001, there are three central stations in use, each monitoring 44 patients. At Wilmington, there are four such stations.
"I think this has been a huge advance; I believe we are on the cutting edge, and the rest of the country will be doing this in short order," he says. "We’ve had a number of wonderful resuscitated patients who might not have been found that easily. Our survival rate for cardiac arrest is just as good [as for patients monitored in the more traditional fashion]. One of the concerns had been that we would not find these patients in time, but our data on in-hospital codes show we’re doing every bit as well as step-down patients. This is a safety net we know is saving lives."
This is just the beginning for Christiana when it comes to remote monitoring, Zubrow says. "Pretty soon, we will be monitoring pulse-ox’ [pulse oximetry] — perhaps within the next six months — and we will also be doing noninvasive monitoring of vital signs," he says. "Now, for example, if a patient on the floor requires medications through an intravenous drip, the pharmacy rules require they be in a certain location. In the future, we may not have to move the patient; this will improve patient care without increasing the need for personnel. In view of the current nursing shortage, this improvement in nurse productivity is very important."
Many testing applications
As director of all clinical chemistry and, therefore, responsible for POC testing, Nichols has numerous opportunities to employ such technology in the three-hospital Baystate system, which includes some 40 outpatient clinics, several nursing homes, and a Visiting Nurse Association. A number of simple tests are performed regularly, including urine dip strips, glucose, occult blood, pH, pregnancy, rapid "strep" tests, blood gases, electrolytes, and creatinine at POC. "A sample is taken, usually by finger stick or via the urine, then put onto either a dip strip or onto a kit," he adds.
There is a computer inside the hand-held device. Before the test is performed, the operator is asked for the patient’s ID number. "This way, the computer knows the patient and the lot number and links them to the result," Nichols explains. "Then we put the device into a docking station linked to our intranet, and it automatically sends it to our lab information system, then refers it back to the patient care system."
The time savings are significant; the whole blood does not have to be processed, spun, and separated. "You just put the whole blood on the device — it’s faster; you don’t have to draw it, wait for it to clot, spin it in the centrifuge, and then get the result to the clinician," he says.
Other applications for POC testing include infectious diseases. "We’ve had some requests for HIV testing," says Nichols. "We also do coagulation, prothrombin time, coumadin levels, and ACT testing in cardiac cath areas."
Nichols sees several advantages to POC testing. Moving these tests to the bedside improves patient satisfaction and makes the care more patient-focused, he says. "I think it’s more convenient. It brings analysis to the bedside, where the physician is as well, so it all works within the flow of patient care." This is not to say that the impact is totally positive, however. For example, staff sometimes can complain about the additional responsibility. "There is a general feeling that nursing is being dumped on, but we are all doing more," Nichols explains. "It’s narrow-minded to not think of this as part of patient care — as much as taking a temperature, weighing the patient, taking vital signs, or giving drugs."
Still, there can be drawbacks to POC testing, he says. "You take lab testing, which is a well-defined, structured process. With point-of-care testing, you are outside of an environment you can control. That leads to problems. In a lab, you have controlled temperature and highly trained people whose sole function is to analyze specimens. They are just focused on turning out results. If you take this outside the lab, you can start to get errors and problems."
For Nichols, the issue of whether to use POC is not cut and dried; rather, it is a question of weighing pros and cons. "You really have to balance everything," he advises. "In the patient care setting, is this effective and is it going to lead to a better outcome? Does the work of keeping quality up outweigh the benefit of the increase in quality? What am I doing for that patient, and am I doing it frequently enough? Do I have well-trained people who do this on a daily basis so I can trust the results?"
If the results you get are "just numbers," Nichols explains, that can be dangerous. "Make sure you pick devices that have foolproof checks and balances, so you get a number that is meaningful. Plus, a lot of what you do is manual, so the documentation is not always there. Without a computerized system in all POC devices, we lose much of its potential."
Spath agrees. "It has to be tied into your information system; otherwise, the nurse has to write it down." There are challenges involved in hooking into the rest of the electronic information system. A lot of labs are electronic, she says. "But if all you have is a hand-held pulse ox, it never becomes [part of the electronic] record."
Assuming you determine the benefits will outweigh any potential problems, just how difficult is it to do, for example, what Christiana did?
"There is a substantial financial outlay on the front end," Zubrow concedes. "But you can cost justify it if you extrapolate the cost of a nurse reader vs. a monitor reader, then the cost of transferring a patient — say, $200 or so. And who can put a cost on the reduced medical legal risk?"
In the final analysis, Nichols appears to agree. "In many instances, I see this as a wonderful technology for patient care and for improving what we do," he says.
Reference
1. Feder RA. "The Distributed Laboratory: Point-of-Care Services With Core Laboratory Management." In: Price CP, Hicks J, eds. Point of Care Testing, Washington, DC: The American Association for Clinical Chemistry; 1999.
Need More Information?
For more information, contact:
• James Nichols, PhD, Associate Professor of Pathology, Tufts University School of Medicine and Medical Director of Clinical Chemistry, Baystate Health System, Springfield, MA. Telephone: (413) 794-1206. E-mail: [email protected].
• Patrice L. Spath, Consultant, Brown-Spath & Associates, P.O. Box 721, Forest Grove, OR 97116. Telephone: (503) 357-9185. E-mail: [email protected].
• David Hebert, Marketing Manager, Planar Business Systems, 400 Fifth Ave., Waltham, MA 02451. Telephone: (781) 895-1155. Fax: (781) 895-1133. E-mail: [email protected].
From testing to telemetry, patient care is being brought to the bedside of a growing number of patients across the country. Engendered by constantly evolving and improving technology, patient-focused care is demonstrating a significant potential for improving patient safety while bolstering satisfaction.
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