More than 20 years after the publication of the Institute of Medicine's seminal report "To Err is Human" — which sought to cut preventable medical mistakes by half — progress toward safer care has been slow. The Agency for Healthcare Research and Quality reports that public and private efforts reduced hospital-acquired conditions by 13 percent from 2014-17, helping to prevent more than 20,000 deaths and saving $7.7 billion in healthcare costs. That's welcome news, but given that there are as many as 400,000 preventable deaths from medical mistakes each year, we wonder why more health systems aren't rushing to implement proven safety and quality solutions.
Health policy experts have warned for far too long that healthcare must adopt systemic safety procedures that are routine in high-reliability industries such as airlines and nuclear power. There certainly have been many efforts at improvement, notably the Partnership for Patients initiatives and improvement bundles and toolkits from various patient safety organizations, but these efforts have lacked the proven systemic approach, and often fall by the wayside as other staff and budget priorities emerge. Nor has the government truly prioritized this problem; federal funding for safety and quality research has actually dropped in the past decade. Meanwhile, too much effort has been spent by providers on compliance with quality measures that may or may not reflect true improvement in safety.
The fact is that there are a number of new, technology-based solutions to safety, quality, and cost challenges. Some have strong clinical evidence of efficacy while paying for themselves through avoided costs from fewer adverse events and reengineered healthcare delivery. Yet, most of those are deployed in just a small segment of health systems.
A great example is remote safety monitoring. Although it was designed a decade ago to solve patient falls — while also reducing spending on 1:1 "sitters" — this continuous virtual care solution has since evolved into an application that is helping to resolve a wide range of previously intractable patient and staff safety problems. A trained staff member watches as many as 16 of the most at-risk patients simultaneously via video from a central location, and is able to intervene directly via audio communication to the patient or signaling a validated alarm for point-of-care staff response.
Where properly deployed, remote safety monitoring nearly eliminates adverse events such as falls, workplace violence, patient suicide, self-injury (pulling out lines, drains and tubes), illicit drug use and hospital elopement. Even at 6 percent of patient census under observation, house-wide reduction in rates of adverse events of at least 50 percent have been observed. It is when census coverage rises to 10 percent or greater that we see rates of error fall to near zero.
A recent article reviewed 39,270 patient days of monitoring data for remote monitoring. These patients were selected due to high risk for falls or other adverse events based on nursing judgment. It found:
- The overall fall rate was 1.5 per 1,000 days of surveillance, and the unassisted rate was 1.12 per 1,000 days of surveillance — rates far lower than national averages.
- The oldest and most frail patients, those over 85, had an extremely low fall rate of 0.38/1,000 surveillance days. No patient fell more than once.
Another recently published study found that remote monitor technicians intervened to avoid 40 workplace violence events for every one that occurred — a 97 percent reduction. Still other peer-reviewed studies have found zero adverse events among suicide ideation patients using this solution and dramatically lower rates of elopement and dislodging of lines, tubes and drains.
This system replaces most in-room patient sitters, at a cost of approximately $2 per patient hour versus an average of $20 per hour for a sitter. That 90 percent reduction enables health systems to dramatically expand the universe of patients under observation while still saving operational dollars, more than enough to quickly recoup the upfront capital cost of the hardware and software. Across the nation, at any given time, approximately 3 percent of patients have one-to-one sitters, typically certified nursing assistants reassigned to sit with one patient. The cost of sitters in the United States is $3 billion annually. Factoring in the direct annual costs of inpatient falls with injury, estimated to be another $3 billion, as well as the undocumented costs of litigation, and you see why falls are an expensive national problem.
Proper deployment of such a service requires that a systematic approach be embraced; other industries with proven safety ratings would consider this to be standard operating procedure. Clinical staff need protocols for identifying patients who need video monitoring and decision trees to determine when and where to deploy monitoring and when to remove patients from continuous observation. There needs to be effective, standardized training of monitor techs.
Perhaps even more importantly, healthcare organizations need to use a solution across a sufficient volume of the patient census to produce meaningful improvement in reducing adverse events. Remote safety monitoring is currently deployed in about 15 percent of hospitals, but in those hospitals it averages just 6 percent of staffed beds under surveillance.
At the current rate of growth, by 2022 35 percent of all hospitals will have this technology, but given past results and the net zero cost of this solution, patients, hospitals, our national healthcare system, and taxpayers would benefit by greater penetration and average census coverage that is at least twice what it is today. We know that won't come without some sort of market intervention. We believe that government policy, including safety measures, value-based purchasing and ongoing implementation of bundles and toolkits, ought to advocate for the use of remote safety monitoring as a national standard of care. Patient advocates need to be much more aggressively involved.
To ACT is also human. Healthcare organizations must invest in technology that supports the healthcare workforce in accelerating better patient care and safety outcomes for both patients and staff.
Melanie Creagan Dreher, PhD, is the immediate past Chair of the Board of Trinity Health System, and Dean emeritus, Rush University College of Nursing. Patricia Quigley, PhD, is one of the nation's leading patient safety researchers. Catherine Rick, MSN, is on the Faculty for Executive Fellowship in Innovation Health Leadership at Arizona State University and former Chief Nursing Officer of the United States Department of Veterans Affairs. Marla Weston, PhD, is the immediate past CEO of the American Nurses Association.