Paramedics monitor patients in real-time, 24 hours a day.
By Adalberto Torres Jr., M.D., M.S., and Daniela Melendez, RN
Paramedics at the Clinical Logistics Center monitor patients across two facilities..
In the last six years, Nemours Health System has constructed two children's hospitals: Nemours Children's Hospital in Orlando in 2012; and Alfred I. duPont Hospital for Children in Wilmington, Delaware, opened a new tower in 2014. Both facilities have large, single-patient rooms designed with input from families, but they sacrifice providers' direct lines of sight of patients for more space and privacy.
To address potential patient safety issues created by this design, which is common in newer hospitals, all patient rooms are equipped with cardiorespiratory monitors, video cameras and audio communications systems.
This technology allows a paramedic to have real-time visualization of the patient, monitor vital signs and communicate with the care team. Despite the two institutions being almost 1,000 miles apart, paramedics at the Clinical Logistics Center (CLC) in Orlando remotely monitor patients at both facilities, 24/7.
To reduce alarm fatigue, paramedics monitor patients for no more than four consecutive hours at a time. They then spend the next two to four hours in a clinical department assisting with patient care. Every department that uses paramedics has its own job descriptions for them. For example, one of the acute care units uses the paramedics to obtain venous access and assist the care team with intra-hospital patient transport.
How the patient monitoring system works
At check in, parents and guardians are informed of the system with a statement incorporated into the consent paperwork. They are also informed the system is activated if an alarm is triggered that indicates potential risk to their child.
Paramedics view patients' vital signs on computers at their workstations and on large video screens in the CLC. When an alarm alerts paramedics a vital sign is outside the age-specific normal range, the system instructs the paramedics on specific protocols and actions to take.
If a patient's oxygen saturation of the blood drops below 90 percent, the system directs the paramedic to communicate using the audio system in the patient's room, establish direct visualization of the patient via camera, and establish the absence or presence of a health care provider.
If no team members verbally acknowledge they are with the patient, the paramedic establishes contact with the patient's assigned nurse. If the patient's condition requires the paramedic to take action, like if the patient is in respiratory distress, the paramedic activates a rapid response team.
Paramedics in the CLC can also establish audiovisual communication with patients during a code blue. The resuscitation leader can use the CLC to contact the attending physician or a subspecialist to come to the bedside. The paramedic can text a nearby nurse if the patient's nurse is occupied, call the nurses' station and ask the unit clerk to perform a task, or call the charge nurse to discuss the patient's alarms.
In addition to the use of software that delivers text alerts of the patient's alarms to the nurse's business cellphone, paramedics confirm the alarm signal quality is acceptable and confirm the patient's clinical appearance.
More than alarms
In addition to addressing patient alarms in real-time, the CLC performs automated surveillance of the electronic health record (EHR) using customizable messages to alert the care team of a potential medical emergency. For example, a clinical rule was created for central line-associated bloodstream infections (CLABSI).
Any inpatient with a tunneled or non-tunneled central line, port or peripherally inserted central line is assigned a score of "one" and automatically placed on the electronic watch list on one of the CLC screens. If the patient develops a fever or an elevated white blood cell count (WBC), he or she is immediately assigned a score of "two." If the patient develops a fever and an elevated WBC, a score of "three" is assigned, and the paramedic reviews the EHR for the prescription of an acceptable systemic antibiotic.
If an antibiotic is not prescribed to the patient, the paramedic sends a text to the attending physician notifying him or her of the risk factors present, and to consider prescribing a broad spectrum antibiotic. Other clinical rules the system tracks include neonatal sepsis and catheter-associated urinary tract infections. As part of CHA's Improving Pediatric Sepsis Outcomes Collaborative, the hospitals use the septic shock tool from the American Academy of Pediatrics. The CLC paramedics trigger huddles with clinical teams when the shock score reaches a predetermined value.
Other functions of the CLC include text reminders prior to the end of the shift, which enables nurses to complete documentation compliance in near real-time. Paramedics also surveil the patient abduction system, where the use of the video camera is critical.
Hospital leadership estimates the financial cost the CLC generates is at least $6 per occupied bed per inpatient day. This is based on the frequency of alarms, number of patients, time required to answer and determine false vs. true alarms, number of minutes to coordinate an appropriate clinical response and a nurse's hourly salary.
In the future, the system could be used for real-time tracking of patients with chronic conditions in their homes or community hospitals, or the coordination and facilitation of a patient's journey on a clinical pathway. To maximize the potential safety nets cast by using technology like the CLC only requires a combination of imagination and innovation.
Adalberto Torres Jr., M.D., M.S., is the chief of Critical Care, medical director of the Clinical Logistics Center; and Daniela Melendez, RN, is nurse manager at the Clinical Operations Center at Nemours Children's Hospital, in Orlando, Florida.
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