March/April 2021

Technological Innovations in SNFs
By Zachary J. Palace, MD, CMD, FACP, and Moreen Donahue, DNP, RN, FAAN
Today’s Geriatric Medicine
Vol. 14 No. 2 P. 24

The Benefits of Contact-Free Continuous Patient Monitoring

Today’s health care environment is especially challenging for skilled nursing facilities (SNFs). Increasing clinical complexity and decreasing resources combined with industry pressure to improve safety and outcomes, efficiency, and patient satisfaction with care compel SNFs to explore innovative clinical strategies. The use of continuous monitoring in acute care settings is well documented. Significant improvement in the detection of patient deterioration and other adverse outcomes and earlier interventions to prevent further decline have been shown to be the result of continuous monitoring.

While continuous monitoring isn’t the standard of care for long term and postacute care residents, utilizing strategies such as contact-free continuous monitoring (CFCM) has tremendous potential to prevent adverse events such as falls and pressure ulcers and to detect changes in health status such as heart rate changes, respiratory depression, and sepsis. As a result, facility-based interventions could occur earlier and unnecessary hospitalizations could be avoided. Safety and improved outcomes will continue to be key issues in the provision of care. SNFs that embrace technologies such as CFCM to enhance care delivery and improve efficiency will have a competitive advantage in the evolving and challenging health care market for postacute and long term care (LTC).

Continuous Patient Monitoring Technologies
The use of continuous patient monitoring technologies to observe changes in vital signs is the standard of care in settings such as emergency departments and ICUs. These systems are in place to alert the clinical staff to real-time acute changes, which enhances the ability of health care professionals to deliver high-quality medical care. Recently, continuous patient care monitoring has been extended to general medical-surgical units. Research study outcomes indicate that the use of this technology promotes earlier detection of patient deterioration, decreased code events, decreased ICU days, and decreased lengths of stay.1 A natural extension of these positive outcomes is the implementation of continuous patient monitoring in postacute and LTC settings.

Vital signs monitoring is an essential component of physical assessment. The first skills taught to students in health care professions include how to accurately measure vital signs. Vital signs data such as heart rate, respiratory rate, body temperature, and blood pressure provide the first indications of abnormal physiological body changes.

Although there’s universal agreement on the importance of vital signs monitoring, there’s great variation in the recommended frequency of baseline vital signs measurement from one facility to another as well as from one clinician to another. This is based upon facility policies as well as clinicians’ orders, determined by current clinical status. Respiratory rate, a significant predictor of deterioration, has been found to be the most frequent vital sign to be omitted. Studies suggest that possible reasons might be the reliance on pulse oximetry as a substitute for respiratory rate monitoring or the lack of respiratory rate equipment.2

Evidence-Based Rationale for the Initiative
Evidence from multiple studies indicates that changes in baseline vital signs occur several hours before deterioration. Studies have suggested that altered respiratory rate was found to be the most significant predictor of decline. Due to variabilities in method, in ability to interpret findings, in frequency of vital signs monitoring, in recording, and in nurse interpretation, issues related to delays in instituting appropriate care can occur. Despite many studies that have indicated that abnormal respiratory rate is an indicator of serious cardiac events, it’s often the most neglected vital sign.3

Studies conducted by Brown and colleagues indicate that continuous monitoring of vital signs in nonintensive care settings can promote positive clinical and economic outcomes. One study conducted on a medical-surgical unit in a 316-bed community hospital included a population of 7,643 patients, of which 2,314 were placed under continuous monitoring. Significant findings included a reduction in length of stay, decreased number of ICU days for transfers to the ICU, and lower number of code blue events.4

The ECRI Institute, an organization dedicated to researching best practices for improving patient safety, recently published its top 10 patient safety concerns for 2019. Two concerns throughout the continuum of care on the 2019 list are detecting changes in a patient’s condition and detecting sepsis early in treatment.5 In March 2018, ECRI published its 2018 patient safety concerns; the first two were diagnostic errors and opioid safety across the continuum of care.6

The use of continuous monitoring in LTC facilities has the potential to address all four safety concerns by providing clinicians with aggregate, timely, trended vital signs data including real-time alerts to facilitate the diagnosis of conditions such as sepsis and respiratory depression. Clinicians and caregivers in LTC facilities are faced with caring for more medically complex patients with a wide variety of needs, the majority of whom previously would be treated in hospitals. Continuous monitoring provides the staff with a tool to potentially prevent rehospitalizations by detecting patient deterioration at the earliest indication. Evidence-based practice (EBP) in LTC settings has been the focus of much of the research conducted by Janet K. Specht, PhD, RN, FAAN, an emeritus professor and director of the University of Iowa John A Hartford Center for Geriatric Nursing Excellence. Results of her studies indicate that the adoption of EBP is slow and sporadic, despite clear evidence of efficacy and need. Limitations in resources, critical appraisal skills, and time are among the barriers to adopting EBP.7

The Canadian Agency for Drugs and Technology in Health conducted a literature search to determine the evidence-based guidelines regarding the optimal frequency and practice for the monitoring of vital signs for residents in LTC facilities. The search included the Cochrane Library, PubMed, Ovid Medline, ECRI, and major international technology agencies. The search was limited to English language documents published between January 1, 2011, and January 15, 2016. No health technology assessments, systematic reviews, meta-analyses, or evidence-based guidelines were identified regarding the optimal frequency or practice for the monitoring of vital signs for residents in LTC facilities.8

Frost and Sullivan, a growth consulting firm, monitors trends in the health care market. Its goal is to identify innovative technologies that support the Institute for Healthcare Improvement’s Triple Aim initiative of optimizing health system performance by providing high-quality care to patients, reducing costs, and improving population health. Organizations and communities that attain the Triple Aim will have healthier populations, in part because of new designs that better identify problems and solutions further upstream and outside of acute health care. Patients can expect less complex and much more coordinated care, and the burden of illness will decrease.9

With this in mind, Frost and Sullivan produced a whitepaper in 2017 that examined technology as a competitive edge for postacute providers. It studied the potential for CFCM to raise the standard of care while improving financial performance. The company believes that by utilizing CFCM, LTC facilities can improve the quality of care, reduce costs, increase reimbursement, and advance their position as a market leader.

In terms of increased reimbursement, Frost and Sullivan constructed a model that described the impact that a typical postacute facility could anticipate with the deployment of CFCM. Their model is based on a 106-bed postacute facility deploying CFCM to 21 medically complex beds. This model predicted that revenues would be increased by 22% and net profit margin by 13%, primarily resulting from the ability to care for more medically complex residents and thus higher reimbursement and overall decrease in rehospitalization.

Other benefits cited by Frost and Sullivan with regard to CFCM systems included the reduction in readmissions due to falls or pressure ulcers. The capability of these systems to detect resident deterioration and motion allows staff to respond and intervene before the resident becomes critical. All of these solutions were financially competitive with monthly costs comparable to other items such as fall prevention solutions. Frost and Sullivan concluded that postacute facilities that aim to retain and grow their competitive edge in the care continuum must adopt proven technologies that demonstrate improved outcomes and support financial sustainability. They envision a future where CFCM will become the standard of care for postacute facility beds.10

Low-Acuity Continuous Monitoring
Low-acuity continuous monitoring systems take continuous measurement of one or more of the basic vital signs such as heart rate, respiratory rate, noninvasive blood pressure, and arterial blood oxygen saturation as well as patient movement. These systems don’t display electrocardiogram wave forms. They generally include sensor devices, display units, and a central monitoring station. Central stations often are able to alert clinicians to changes in patient status through mobile devices. Types of continuous monitoring systems include bedside monitors, wearable monitors, and contact-free solutions.

Bedside monitors have sensors that are attached to the patient and are connected by cables or leads to a display unit near the bedside. Wearable sensors include those attached to the patient and a small, lightweight wearable device allowing the patient to be monitored while out of bed. CFCM systems don’t require sensors or devices to be attached to the patient. Heart rate, respiratory rate, and, in some cases, patient movement are monitored wirelessly through a sensor that’s placed under the mattress or within a chair cushion. Data are displayed at the bedside and at a central station. These technologies were designed with the front-line user in mind; all data are relayed directly to the care provider’s handheld device, so no additional staff is needed to oversee or tend to the system.

Clinical Initiative Using CFCM
A study to evaluate the effects of continuous monitoring in reducing rehospitalizations of postacute care residents in an SNF was conducted at two sites: Facility A, an 870-bed skilled nursing facility in Bronx, New York, and Facility B, a 374-bed facility in Netanya, Israel. The technology selected for this study was the EarlySense CFCM system that continuously transmitted real-time information of heart rate, respiratory rate, and level of activity in bed directly to the nursing staff and instantly alerted staff when values fell outside of preset parameters. A six-month monitoring period was compared with retrospective controls in a post–orthopedic surgery unit, and a nine-month comparison with control floors with no monitoring was used to study before vs after and concurrent outcomes. Data on falls, early diagnosis and treatment at the facility, and rehospitalization rates were collected. Contactless sensors that monitor heart and respiratory rates and in/out of bed status were utilized. All data were provided to caregivers on bedside monitors and at the nursing station. Alerts regarding changes in vital signs or bed exits were transmitted to nurses for further assessment and intervention. A total of 733 records at Facility A and 833 records at Facility B were reviewed. The falls rate decreased by 47% (p<0.05) at Facility A, and the transfer rate to the hospital decreased by 19% (p=0.06) at Facility B. Similar trends of improved outcomes were observed in other parameters at both sites. However, the numbers were too small for statistical significance.11

Potential Outcomes for the Standard Use of CFCM in LTC
The utilization of CFCM in LTC as the standard of care has many potential benefits. In terms of clinical outcomes, the ability to continuously monitor residents at increased risk for clinical deterioration, falls, and pressure ulcers provides a higher level of oversight and alerts staff to provide appropriate interventions. Many residents in LTC facilities have multiple comorbidities, including heart failure and COPD. The ability to recognize clinical decline and provide timely interventions can result in improved control of chronic conditions and reduced hospitalizations and readmissions. Other outcomes that could result from the standard use of CFCM in LTC facilities include increases in resident, family, and staff satisfaction; staff productivity; and referrals.

Conclusion
The use of CFCM as the standard of care for residents in LTC facilities is an innovative clinical strategy that has the potential to promote positive clinical, operational, and financial outcomes. Changing payment models are impacting SNFs as reimbursement changes from volume to value. Facilities that demonstrate the ability to accept higher-acuity patients while providing higher quality and more efficient care are more likely to succeed.

— Zachary J. Palace, MD, CMD, FACP, is a geriatrician and medical director of the Hebrew Home at Riverdale, located in Bronx, New York. He is board-certified in internal medicine and geriatric medicine.

References
1. Zimlichman E, Szyper-Kravitz M, Shinar Z, et al. Early recognition of acutely deteriorating patients in non-intensive care units: assessment of an innovative monitoring technology. J Hosp Med. 2012;7(8):628-633.

2. Mok WQ, Wang W, Liaw SY. Vital signs monitoring to detect patient deterioration: an integrative literature review. Int J Nurs Pract. 2015;21(Suppl 2):91-98.

3. Cretikos MA, Bellomo R, Hillman K, Chen J, Finfer S, Flabouris A. Respiratory rate: the neglected vital sign. Med J Aust. 2008;188(11):657-659.

4. Brown H, Terrence J, Vasquez P, Bates DW, Zimlichman E. Continuous monitoring in an inpatient medical-surgical unit: a controlled clinical trial. Am J Med. 2014;127(3):226-232.

5. ECRI Institute. Top 10 patient safety concerns for healthcare organizations 2019. https://www.ecri.org. Published March 2019. Accessed May 15, 2019.

6. ECRI Institute. Top 10 patient safety concerns for healthcare organizations 2018. https://www.ecri.org. Published March 2018. Accessed September 24, 2018.

7. Specht JK. Evidence based practice in long term care settings. J Korean Acad Nurs. 2013;43(2):145-153.

8. Canadian Agency for Drugs and Technologies in Health. Vital sign monitoring for residents in long-term care facilities: guidelines. https://www.cadth.ca/sites/default/files/pdf/htis/jan-2016/RB0955%20Monitoring%20of%20Vital%20Signs%20Final.pdf. Published January 21, 2016. Accessed September 24, 2018.

9. IHI Triple Aim initiative. Institute for Healthcare Improvement website. http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx. Accessed May 23, 2019.

10. Frost & Sullivan. Technology as a competitive edge for post-acute providers: contact-free continuous monitoring allows alternate care facilities to raise their standard of care while improving their financial performance. https://ww2.frost.com/research. Published 2017. Accessed September 24, 2018.

11. Palace ZJ, et al. American Geriatric Society Annual Meeting. May 2013.