March 2019

HIT Happenings — Continuous Surveillance: The New Standard in Patient Safety
By Mary Jahrsdoerfer, PhD, RN
For The Record
Vol. 31 No. 3 P. 30

The prevention of hospital-acquired illnesses (HAIs) has come under greater regulatory scrutiny from the Centers for Medicare & Medicaid Services. Most notably, this has happened through the Hospital-Acquired Conditions Reduction Program, which penalizes hospitals for high rates of such HAIs as ventilator-associated injuries, preventable readmissions, and sepsis.

Enhancing the safety and outcomes of patients and avoiding costly penalties begins with comprehensive continuous clinical surveillance practices. Clinical leaders reading this may push back with an argument that, yes, some reforms could be made at the margins, but such practices already exist within their health systems. Let’s explore further.

Distinction
Here is where we get into an issue of semantics. In a concept analysis published by the HIMSS Online Journal of Nursing Informatics, it was argued that clinicians often use the terms “monitoring” and “surveillance” interchangeably, noting that, “In today’s acute-care environment, multiple internal and external factors give clinical surveillance characteristics distinct from those other terms and have changed how nurses apply critical thinking and decision-making to patient care and safety.”

The term surveillance embodies the following clinical attributes: attention, timeliness, recognition, intuition, analysis, action, and collaboration. While monitoring may have one or more of these attributes, clinical surveillance requires all seven. The core of surveillance is real-time attention, recognition, and analysis that allows for action and collaboration. It is a paradigm shift from a retrospective clinical response to prospective anticipation and planning.

This prospective shift may take one of two forms: artificial intelligence, where the machine (software capability of the monitor) learns the physiological trends for a particular patient and notifies the clinician when a trend takes a different trajectory, or rules-based phenomenon, where a human (clinical expert) sets the rules or combination of rules for which the clinician must be notified, therefore eliminating extraneous nonactionable alarms.

Understanding the distinctions between patient monitoring and continuous clinical surveillance is more than a matter of language. It represents the quintessential basis of good clinical practice, the foundation of comprehensive patient safety initiatives, and the ability to comply with—and even exceed—regulatory requirements.

Perception vs Reality
An analysis conducted by Spyglass Consulting Group that featured interviews with more than 30 clinical informatics executives uncovered a common perception that because patients in critical care units were attached to bedside monitoring devices, clinical surveillance was an established standard of care.

However, in the February 2017 issue of Biomedical Instrumentation & Technology, Karen K. Giuliano, RN, PhD, FAAN, notes that “[s]urveillance and monitoring each represent a distinct process in patient care. Monitoring involves observation, measurement, and recording of physiological parameters, while surveillance is a systematic, goal-directed process based on early detection of signs of change, interpretation of the clinical implications of such changes, and initiation of rapid, appropriate interventions.”

It’s possible to take Giuliano’s definition a giant step further by factoring in the seven clinical surveillance attributes that must be present within a clinical scenario in order to label it as true clinical surveillance.

Conversely, when characterizing what clinical surveillance is not, the exact nature of patient monitoring must be examined. Patient monitoring is both fragmented and episodic, capturing a patient’s condition in ways that are dangerously narrow and incomplete. Most patient monitoring practices involve vital sign spot-checks and responses to notifications sent from individual physiologic devices.

The Spyglass Consulting Group analysis notes that within a “MED-SURG environment, nurses conduct episodic monitoring several times per day or on an as-needed basis. This represents a gross undersampling of what is going on with the patient, which could result in missing subtle changes in the patient’s condition.”

Additionally, patient monitoring inherently assumes that an HAI, such as opioid-induced respiratory depression (OIRD), will be caught during the narrow windows of time that a clinician is visually observing a patient. In truth, spot checks can leave patients unmonitored 96% of the time, according to research conducted by Brian Rothman, MD, at Vanderbilt University.

Even if a clinical team member (and patient) were to catch deterioration, the danger is active, present, and likely requires emergency rescue or escalation to an ICU.

The 2017 American Journal of Nursing article “Monitoring Hospitalized Adult Patients for Opioid-Induced Sedation and Respiratory Depression” notes that in 42% of confirmed OIRD events, “the interval between the last nursing assessment and the detection of respiratory depression was less than two hours, and, in 16% of the cases, it was within 15 minutes.”

In contrast, continuous clinical surveillance allows the clinical team to stay informed through real-time, continuous data flow from multiple sources that can be filtered and intelligently analyzed for significant trends and prospective intervention. There also is growing evidence that continuous clinical surveillance facilitates interventions long before a life-threatening event occurs.

The significant difference is in the acquisition and analysis of essential patient data. Whereas patient monitoring is episodic and littered with potentially consequential gaps, continuous clinical surveillance is ongoing, comprehensive, and assimilated for prospective clinical decision-making.

The Power of Prediction
Patient monitoring depends on a team of clinicians, working as individuals, to observe the state of the patient’s health at a particular moment. It leans heavily on the (often technical) threshold violations of individual devices.

By contrast, clinical surveillance is team based, allowing multiple caregivers to assess holistic portraits of multiple patients from a centralized location or via mobile alarm notifications. Because continuous clinical surveillance relies on multivariate rules to correlate data; identify clinically relevant temporal trends, sustained conditions, reoccurrences, and combinatorial indications; and create new early warning alarms, clinical team members can quickly recognize and respond to signs of distress before the patient’s health is compromised.

According to an industry report from Bernoulli Health, “Data collection and analysis are further enhanced when including methods for disseminating, analyzing, and distributing these data. These features facilitate better patient care management and clinical workflow by allowing patients to be monitored remotely.”

What Does the Future Hold?
While health care leaders are beginning to conceptualize the professional meaning of clinical surveillance, a strong need to operationalize the technical aspect of surveillance into patient safety standards and outcomes still exists.

In a recent report, KLAS indicates that “Clinical surveillance tools hold the promise of giving caregivers clinically actionable insights that decrease mortality, reduce readmissions, and improve overall patient outcomes, and clinicians expect these alerts to be embedded directly within their workflow.”

In a study of two geographically disperse hospitals, the researchers conclude that continuous clinical surveillance “may have initiated nursing interventions that prevented failure-to-rescue events. Nurses surveyed unanimously agreed that continuous vital sign surveillance will help enhance patient safety.”

Advances in health care surveillance technology and distribution have made continuous clinical surveillance not just an achievable reality but also an increasingly essential patient care capability.

— Mary Jahrsdoerfer, PhD, RN, is chief nursing information officer at Bernoulli Health and director of graduate health informatics at Adelphi University.