Monitoring Patients from the OR to Rehab
What's new in the OR?When cardiac anesthesiologist Benjamin A. Kohl, MD, steps into the operating room (OR) at the Hospital of the University of Pennsylvania in Philadelphia, he is greeted by a phalanx of patient monitoring devices. Along with the perfusionist, surgeons, nurses, techs and other staff, Kohl keeps his eyes and ears attuned to the visual and audible cues of the patient's physiologic and hemodynamic status delivered by the various monitors.
Heart rate, ECG, oxygen saturation, blood pressure, central venous pressure, cardiac output and more—all these parameters must be carefully monitored while surgeons treat the heart, the perfusionist oxygenates the blood and the anesthesiologist medicates the patient. While these metrics are fairly standard in the OR, newer monitoring devices are emerging as important ways to increase patient safety and improve outcomes.
Kohl and his colleagues now utilize cerebral oxygen saturation monitors. Two stickers affixed to each of the patient's temporal regions of the head give the OR team a measure of the balance in oxygen saturation between the left and right hemispheres. "One of the morbidities that can occur with cardiac surgery is stroke," says Kohl, who is the director of the division of critical care. "We want to identify patients who are at risk or who suffer a stroke as soon as possible, so we can change therapy to minimize the injury." Regional differences in oxygen saturation would imply a lack of oxygen going to one side of the brain, potentially caused by an embolus impeding blood flow.
For some surgeries, the OR team will monitor the electroencephalogram (EEG), looking for electrical activity that signals a stroke. They also will enlist the EEG, somatosensory evoked potentials or motor evoked potentials to monitor the spinal cord. "One of the complicating factors during surgery on the descending thoracic aorta is paraplegia from the lack of blood flow to the spinal cord," Kohl says.
To remedy this complication, the team can improve blood flow to the spinal cord by increasing blood pressure, which is continually monitored via an intra-arterial catheter. A second option involves the use of a lumbar drain that surrounds the spinal cord. "If we see a decrease in blood flow to the spinal cord, we can decrease the pressure around the cord by allowing the fluid to drain, which increases perfusion pressure," Kohl says.
Sounding the alarmsMost monitors have the ability to be programmed with audible alarms that sound when a particular value is breached. For example, the ECG monitor can be programmed to go off if the heart rate is too slow or too fast; the peripheral and cerebral saturation monitors can be programmed to elicit alarms for drops in oxygen levels; and the spinal cord pressure monitor has an alarm. The EEG has no alarm but it is continuously monitored by a neurologist, Kohl says.
"We customize the alarms for each patient," he says. "Some patients might have a higher resting heart rate, such as 115 bpm, and we may not want the alarm to go off at 110 bpm, so we'll set it to 130, for example."
Kohl emphasizes that the technology is only one part of patient care in the surgical OR. Teamwork, constant communication and standardized protocols and processes also are integral. "All of this technology would mean little without the dedicated teams of people who care for patients," he says.
He also stressed the importance of standardizing monitors as much as possible so that each room has the same type of monitor. "The key aspect with monitors is trust," he says. "You have to know what it is telling you and how to respond. We find that by having as few vendors as possible, it makes it easier to gain comfort and trust with the devices."
Moving to the ICUWhen patients leave the surgical table, they need to remain under constant surveillance. Today's monitors allow for "plug-and-play" operation, meaning they can easily be disconnected from the OR and reconnected for transport to the intensive care unit (ICU), with the process repeated for bedside transfer. But it wasn't always this way.
In 2002, when Edward Hospital and Health Services in Naperville, Ill., opened the Edward Heart Hospital, as a beta site for certain product development, nurses and other staff had the opportunity to "engage with engineers and make recommendations from the clinical side to make monitoring easier," says Lynn Cochran, RN, administrative director of inpatient services at Edward.
One of the earliest requests from Cochran and her colleagues was to make it easier for patients in critical care to walk around while nurses could still visualize the patient's hemodynamic status. "The first iteration included an adaptor cable that looked like a garden hose," Cochran says. "It was effective in that it allowed patients to walk around a little, but we asked the engineers to make it even better."
Today, when patients want to walk around or when they need to be transported, the nurse merely dislodges a portable unit from the bedside monitor—with all electrodes intact—and hands the unit to the patient to carry or hooks it onto a pole for transport. "There is no downtime in terms of patient monitoring," Cochran says.
Historically, in the critical care and OR environment, patients were hardwired to monitors. On telemetry floors, however, patients had the ability to wear telemetry monitor "packs" around their neck and their rhythms could be viewed remotely at a central nurses station. "We wanted to merge the technologies. We liked the complexity that is possible through bedside monitoring, but we also wanted to integrate telemetry concepts into the critical care environment."
|“Clinical alarm hazards” have been named by the ECRI Institute in Plymouth Meeting, Pa., as the No. 2 technology hazard for 2011, particularly alarm problems involved with physiologic monitoring systems and ventilators. |
Many facilities have designed triage systems so alarms are routed to specific caretakers depending on their severity. At Edward Heart Hospital in Naperville, Ill., life threatening “red alerts” go to every nurse on the critical care floor. Less threatening alerts go out to the patient’s nurses, says Lynn Cochran, RN, administrative director of inpatient services at Edward. Battery warnings and other low-level alerts are sent to a care tech. “It’s very helpful with the division of labor,” she says.
Such triage systems also could help with “alarm fatigue,” which could overtake healthcare workers who daily hear the incessant sound of alarms, as many as 1,000 per day in a major hospital, many of them categorized as critical alarms.
The Boston Globe (Feb. 13, 2010) detailed how several patients died because staff did not respond to alarms, whether they were for low batteries or arrhythmias, or because modifications (resetting) essentially disabled the alarms.
Linda Hoke, PhD, RN, clinical nurse specialist in the cardiac intermediate care unit at the Hospital of the University of Pennsylvania in Philadelphia, has new nurses answer telemetry alarms for several hours. “It helps them become familiar with the various alarms and diminishes their anxiety associated with them,” she says.
Finding the balance between false positives and false negatives can be tricky. Hoke calls it “titrating the alarms.” For example, a patient was having “short runs” of ventricular tachycardia, but he was clinically fine. Without a modification in the alarm threshold, nurses could miss a true emergency. They changed the number of beats from seven to 10 before the alarm would sound.
The CICU consists of a 30-bed unit (Founders 10) and an 18-bed unit (Founders 11) on two floors. Founders 10 was renovated in 2004 and has telemetry-only monitors, while Founders 11 opened in March 2009 and has telemetry and bedside monitors. There are tradeoffs regarding telemetry-only versus having both types of monitors.
The newer unit offers 12-lead ECG telemetry, whereas the older unit has only two-lead ECG capability. Therefore, if a patient has a ventricular tachycardia red alert, the 12-lead ECG will help determine what precipitated the alert, which helps nurses make quicker decisions about care. Rather than upgrade the older unit, which would be costly, the admitting staff ensures that patients with arrhythmia problems are assigned to the newer unit.
In Founders 10, with telemetry-only monitors, nurses have to go to the central station to view patients' rhythms. In Founders 11, with both telemetry and bedside monitors, patients' values can be viewed at the central nurses station as well as in the room. "In Founders 11, we can walk around with the patient in the room, he or she can get some exercise and [we] see the rhythms on the bedside monitor, which is important for this patient population," Hoke says.
"It's a slight disadvantage not being able to read values in the rooms, but it's more costly to have both telemetry and a bedside monitor. The hospital has to decide which patients need to have bedside monitoring vs. just telemetry," she says.
In addition, patients in the newer wing tend to have a higher acuity of illness, with arterial lines that need to be pulled, for example. The bedside monitors allow real-time access to patient rhythm and blood pressure readings during catheter pulls.
The newer unit also has portable monitors that can slip into waterproof pouches, allowing patients to take showers. "Our philosophy is if patients are sick enough to be here on a monitor, they can't be taken off the monitor. Patients in the older unit cannot take showers."
Admitting and discharging is typically time-consuming, but in the newer CICU, nurses have to turn off the bedside monitor alarms and the telemetry alarms at the nurses station at discharge. In the older unit, only the telemetry monitor at the nurses station needs to be turned off. "It's a small disadvantage," Hoke says, "but at the end of a day, the extra processes can add up."
Wired in rehabWhen patients at Edward Heart Hospital venture to the rehab center, they are continuously monitored. The room is wired for telemetry. Patients can exercise with peace of mind knowing that if they exert themselves too much, healthcare professionals at the nurses station are evaluating their vital signs.
"We want the patients to adopt a lifestyle of exercise and integrate it into their overall recovery phase and into their lives post-discharge," says Cochran. "Many patients are apprehensive to exercise and it is comforting for them to know they can safely discover what they are capable of."
In the rehab center, a number of alerts could sound. Patients are monitored for heart rhythms, blood pressure and sometimes pulse oximetry. Oxygen levels can drop with increased physical activity, especially in patients with lung dysfunction. Patients could have a rhythm disturbance or a significant drop or rise in blood pressure.
"It is very beneficial to be able to see in real time the patient's response to increased activity," says Cochran. "You want to know how well he or she is tolerating the exercise. You want the patient to realize, for example, that he or she can walk on a treadmill or ride a bike and the heart rate and blood pressure will remain stable. It builds confidence for the patient to continue the routine at home."