Wireless device slips under a mattress; a push to track patients on narcotic medications
Healthcare professionals monitor patients’ status at Houston Methodist Hospital by using a score known the Rothman Index.
Healthcare professionals monitor patients’ status at Houston Methodist Hospital by using a score known the Rothman Index.

Hospitals are trying new early-warning systems to monitor patients for subtle but dangerous signs of a worsening condition.

After surgery or during hospitalization for illness, patients are at risk for complications that can quickly turn fatal, such as a depressed breathing rate that can lead to cardiac arrest caused by over-sedation or an adverse reaction to narcotic pain medications. Patients can show signs of deterioration—known in medical terms as “decompensation”—as many as six to eight hours ahead of a cardiac or respiratory arrest, studies show.

But the signs aren’t always picked up or acted upon by staff. Patients on general medical and surgical floors are usually not monitored 24/7 unlike patients in intensive care units, who are hooked up to multiple machines and monitors.

Among the strategies hospitals are adopting is a wireless monitor that slips under a mattress and alerts nurses to changes in breathing and heart rate. Another approach rates a patient’s risk of serious deterioration in real time based on lab results, vital signs and nurses’ assessments gathered from electronic medical records.

“We have to be able to profile patients according to their risk, and then manage the high-risk group,” says David Westfall Bates, chief quality officer and chief of general internal medicine at Brigham and Women’s Hospital in Boston and a professor at Harvard Medical School.

The Rothman Index in use on a mobile phone. Children’s Hospital of Pittsburgh of UPMC has integrated PeraHealth’s Pediatric Rothman Index with their medical emergency response team to deliver alerts to doctors and nurses when a patient is in critical condition, anywhere in the hospital, at anytime. ENLARGE
The Rothman Index in use on a mobile phone. Children’s Hospital of Pittsburgh of UPMC has integrated PeraHealth’s Pediatric Rothman Index with their medical emergency response team to deliver alerts to doctors and nurses when a patient is in critical condition, anywhere in the hospital, at anytime. PHOTO: CHILDREN’S HOSPITAL OF PITTSBURGH OF UPMC
A study of 7,643 patient charts Dr. Bates co-authored last year in the American Journal of Medicine found that wireless monitors slipped under the mattress at Dignity Health’s California Hospital Medical Center in Los Angeles were linked to shorter hospital stays and a lower rate of “code blue” events (hospital lingo for a patient in immediate need of resuscitation or emergency medical attention), compared with units without the technology.

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The monitors, developed by EarlySense, based in Ramat Gan, Israel, also send alerts to nurses if patients get out of bed, and when it is time to turn them to avoid skin breakdown. Gladys Castro, nurse manager at California Hospital Medical Center, says that has helped prevent falls and bed sores.

Newton-Wellesley Hospital in Newton, Mass., uses EarlySense monitors throughout the hospital after starting a pilot program five years ago, says Perry An, chief operating officer of the division of hospital medicine. Dr. An says that they have helped warn staffers about issues that might otherwise have been missed. One alert revealed a low heart rate on a patient who turned out to have a blockage and subsequently had a pacemaker installed. In another case, an alert identified a patient on painkillers who was slipping into respiratory depression and was given medication to counter the effects.

The cost of EarlySense varies depending on hospital size, and how many features it includes. It can range from $80,000 to $200,000 for a 30-bed unit.

Pressure is mounting for hospitals to better identify patterns or changes before they get out of control. There is a national coalition of patient safety groups that is promoting continuous electronic monitoring of patients on narcotic pain medicines. The Centers for Medicare and Medicaid Services last year called for postoperative monitoring of patients on IV narcotics, regardless of where they are in the hospital, and said staff should educate patients and families to alert them if they notice any breathing problems.

Lenore Alexander, center, above, started a nonprofit organization to advocate for continuous electronic monitoring of patients on narcotics in the hospital. ENLARGE
Lenore Alexander, center, above, started a nonprofit organization to advocate for continuous electronic monitoring of patients on narcotics in the hospital. PHOTO: ROGER WU
According to the Joint Commission, a nonprofit organization that accredits hospitals and collects data on adverse events, 29% of narcotic-related adverse drug events including deaths, reported from 2004 to 2011 were from improper monitoring of patients. Recommended approaches to avoid such errors include finger sensors that measure oxygen levels in the blood and equipment that measures ventilation through patient’s exhaled breath, which are common in the ICU but not always used continuously on other units.

About 70 hospitals and health-care facilities are using a software program known as the Rothman Index, which costs about $150,000 for a medium-size 300-bed hospital. It was developed by brothers Michael and Steven Rothman after their mother, Florence, died in 2003 at age 87 after signs of deterioration were noticed too late following a routine heart procedure. Using information from 26 variables in medical records, it calculates a score from 1 to 100 and regularly updates it on a graph. Lower scores indicate closer monitoring or immediate help is needed.

The University of Pittsburgh Medical Center’s children’s hospital will roll out a pediatric version of the Rothman Index next month, after a study of the system published last month in Pediatric Critical Care Medicine found it could be a useful addition to staff evaluations. The aim is to update each child’s condition every 15 minutes and fire off an electronic page to a rapid response team of doctors and nurses if a patient’s condition falls below a certain level.

“Every child we admit is potentially vulnerable and we want to keep an electronic eye on every patient in the hospital,” says Robert Clark, chief of pediatric critical care medicine at Children’s Hospital of Pittsburgh of UPMC and a co-author of the study.

Houston Methodist Hospital in Texas started using the Rothman Index last July in two units and has since expanded it to nine additional units. In one three-month period the index identified 25 patients with deterioration so subtle that it wasn’t recognized by a doctor or nurse, says Katherine Walsh, a nurse and vice president of operations.

“This is not ever meant to replace good nursing care but it is a supplement that tells you there may be something you need to investigate,” Ms. Walsh says. The index also helps staffers determine when it is time to have discussions with patients and families about end-of-life care if a patient’s condition is declining irreversibly, Ms. Walsh says.

Yale-New Haven Hospital in Connecticut began adopting the Rothman Index in 2011, and is also partnering with Rothman Index owner PeraHealth Inc., based in Charlotte, N.C., to develop new applications. The hospital’s research has shown that the Rothman Index is a good predictor of which patients at discharge are at highest risk of having to come back to the hospital. It could be used to drive down readmissions, says Yale-New Haven Chief Medical Officer Thomas Balcezak.
Lenore Alexander started a nonprofit organization, LeahsLegacy, in 2013, to advocate for continuous electronic monitoring of patients on narcotics in the hospital. Her 11-year old daughter, Leah Coufal, died 12 years ago at Cedars-Sinai Medical Center in Los Angeles, after undetected respiratory arrest when she was on narcotic painkillers following surgery. A court case related to the death was settled.

“Monitoring is something we already have available to us that we could be using to save lives,” says Ms. Alexander, who is working with other nonprofit patient safety groups. While she doesn’t advocate for any particular company or equipment, she advises patients and families in the hospital to “ask how you will be monitored, how often and by whom.”

A Cedars-Sinai spokeswoman says patient privacy laws prevent discussion of specific cases but that all patients on narcotic pain medications are closely monitored, and patients at high risk for respiratory problems receive additional evaluation and care. “We are committed to helping our patients manage their pain while ensuring their safety,” she says.