Communication for Post-Surgical Cardiac Care Team
Technology Arrives in Home Healthcare
(Reprinted With Permission By The
Remington Report 1-800-247-4781)
Healthcare has been woefully slow to adapt technology for the benefit
of its caregivers. While professions ranging from accounting to
interior decorating to car mechanics have been positively impacted
by the rise of technology, healthcare workers can still find themselves
drowning in increasing loads of mandated manual paperwork while
being given few modern tools to deal with their patient load effectively.
But technology has finally arrived in healthcare. Burgeoning applications
offer long term potential for improving patient care and for making
the optimum use of critically short clinical human resources. The
current task has become finding and adapting the best uses as quickly
as they can be evaluated and assimilated.
VNA Home Health
Systems (VNAHHS), a non-profit organization serving Orange County,
California with over 150 clinicians and an active patient census
over 1100, provides intermittent home care for homebound and critically
ill patients. Innovative use of emerging and existing personal digital
assistant (PDA) technologies has catapulted VNAHHS into the international
spotlight as institutions worldwide scramble for advice on how to
adapt technology for healthcare.
The June 2001 FDA approval of ActiveECG,
the first pocket-sized cardiac monitor made this powerful diagnostic
tool economically available for home healthcare. In an atmosphere
of emphasizing the highest use of each healthcare dollar, the little
six ounce cardiac monitor offers a higher level of care and a new
measure of safety for newly released cardiac surgical patients that
could allow for more safe early hospital releases. It is easy to
set up, easy to use. It's potential is enormous.
Adopting the pocket-sized cardiac monitor was a good match for
VNAHHS's already technically adept clinicians and their search for
the best in patient care. Capturing the benefits of cutting-edge
technologies like the ActiveECG across the complex network of caregivers
in a particular locality is a separate challenge of education, equipment,
PDA Technologies Provide Realtime Information
All VNAHHS clinicians already use a PDA for clinical documentation
and decision support information such as a comprehensive database
of drug incompatibilities and human growth charts. Many emerging
healthcare technologies, like the pocket-sized cardiac monitor,
are based on the PDA, which has quickly gained momentum as the tool
of choice from nursing programs to hospitals and other healthcare
VNAHHS uses an enterprise wide proprietary software application
developed for our specific needs. Scheduling, patient charting,
and team communication are all performed through the pda or the
clinician's home pc. Interdisciplinary communication logs are synchronized
bi-directionally each day and provide a means of information flow
never before available to field staff in home health. Problems attributable
to poor or slow communication patterns are eliminated by providing
realtime updates and decision support information that is revolutionizing
the effectiveness of homecare treatment and optimizes the use of
scarce nursing resources.
Each clinician enters patient data into the same electronic patient
chart, synchronized daily so that no member of the team is making
decisions based on incomplete or out-of-date information. In the
case of cardiac patients, this team consists of the cardiologist,
the cardiac surgeon, the home health clinician, and any other involved
caregiver. The pocket-sized cardiac monitor gives a higher standard
of data for the team to evaluate the patient and his progress without
waiting for an in-office visit. The quality of patient care takes
a quantum leap because all members of the team contribute feedback
and test results to the same synchronized database.
Implementing a New System
VNAHHS teamed with William Thibault, MD, a respected Orange County
cardiac surgeon with a large South County practice, to implement
and evaluate the pocket-sized cardiac monitor. Thibault and his
assistant, Sue Archibald, RN, wanted a way to more closely monitor
their post-surgical patients prior to their first doctor visit.
More closely monitoring particularly fast track patients as their
medications took effect offerred the opportunity to identify those
who need adjustments or further care not apparent at their release
from the hospital. The benefits of fast tracking selected patients
including accelerated recovery and reduced costs could be further
enhanced with better information in that first critical period.
Typically, a home health clinician visits a post-surgical cardiac
patient in each of their first two days back at home to assess their
condition and offer support and advice to the family caregivers.
Additional visits are determined by need and by available insurance
coverage. Many patients are now released two to three days post-surgically
and the additional monitoring offerred by the pocket-sized cardiac
monitor allows a new level of care for these patients. Some can
comfortably be discharged a day earlier than previously with a written
order for home cardiac monitoring.
Debbie Beesley, RN, a 24-year nursing veteran who covers the South
Orange County territory surrounding Dr. Thibault's office for VNAHHS,
was chosen to be the lead nurse on the new program. In October 2001,
she was given a pocket-sized cardiac monitor, and along with her
supervisor Cathy McCabe, RN, and a few back-up nurses, was trained
to use it.
The six ounce pocket sized cardiac monitor performs the same basic
tasks as a 19 pound EKG. Developed by husband and wife emergency
medical technicians who saw the need for a portable cardiac monitor
first hand, the device is powered through the pda and also has a
viewer for use on a personal computer.
To use the portable cardiac monitor, the clinician attaches three
electrodes to the patient's chest, types in the patient's name,
activates the monitor, clicks the command to make a reading, and
the familiar graph of the heart rhythm is displayed. The file is
then saved and can be sent electronically to the other members of
the care team. The file shows the patient's name, the date the reading
was recorded, the length/time of the reading, the operator, and
a printout of the ECG strip showing the results.
Dr. Thibault's office faced a few challenges getting the system
operational: they had to upgrade their computer in order to use
the pc-side of the software and to get their e-mail working properly
for the efficient exchange of information with Beesley. The software
is easy to install and use, but its hardware requirements differed
from those of their existing medical back-office software. Setting
up the modem and e-mail to communicate easily with the outside world
also posed challenges that were worth the eventual payoff.
Initial Results Impressive
Familiarizing herself with the system, Beesley tried
it on two patients her first weekend after training with the device.
Pre-ventricular contractions (PVCs) were detected in one of those
first patients who was referred back to Thibault for further treatment.
Beesley, whose experience includes hospital care of post-surgical
cardiac patients, is well equipped to identify problems requiring
immediate attention. Archibald and Beesley communicate by telephone
at the end of each patient visit, and again at the end of the day
when Beesley sends the data to Archibald via e-mail. A visual examination
of each readout is made by the doctor, and the readout is forwarded
to the cardiologist as needed.
In the next ten patients monitored by Beesley, two others were identified
for a change in medication after slow rhythms were detected. Neither
situation was serious, but the ability to adjust the medication
prior to the next doctor visit provided a valuable benefit for both
patient and doctor.
In December 2001, a 75 year-old male patient was discharged from
the hospital after cardiac surgery only to be re-admitted days later
when a doctor's visit revealed rapid atrial fibrillations. Beesley
observes, "That scare could have been prevented with the use
of a cardiac monitor, but they had a different service without the
cardiac monitor." After the patient's second hospital stay,
Beesley was specifically requested so she could monitor the man
more closely with her pocket-sized cardiac monitor, and he is doing
Thibault's office requests Beesley on higher risk cases and she
cares for their patients when possible. This depends on variables
such as where the patient lives and what kind of insurance coverage
they have. Archibald continues her enthusiasm for the cardiac monitoring
and anticipates its expanded use among their patients. Past experience
has found one in 20 to 30 patients who develop an arrythmia after
discharge. Some patients are kept in the hospital primarily so they
can be monitored as their medications kick in.
The early results using the handheld cardiac monitor at the first
two in home visits indicate the possibility of identifying additional
patients who could be assisted by earlier changes of medications.
Easily and immediately sharing current heart rhythm data between
the surgeon and the cardiologist offers another substantial benefit
not previously available to post-surgical patients. These impressive
results with the first dozen patients have fueled even more enthusiasm
to eventually expand the project.
Thibault's practice would like to see all two day discharges monitored
with the pocket-sized cardiac monitor as the two to three day period
is when arrythmias are most common. "The ability to monitor
our newly released patients more closely is an exciting advance
in our field. We anticipate it becoming a routine part of the high
standards of care we offer to our patients," says Archibald.
Developing Community Systems
Capitalizing on the full potential of new technologies like the
pocket-sized cardiac monitor and synchronizing databases of healthcare
teams requires education, acceptance, and cooperation within the
larger medical community.
The hardware needed is not extensive or overally expensive. Personal
digital assistants have become virtual handheld computers with powerful
memory and peripheral attachments like a keyboard that make using
them easy. Ultimately, medical professionals with different roles
and sponsoring organizations will need to work together to make
it happen for the benefit of everyone.
Healthcare teams cannot synchronize communications without first
purchasing and installing the necessary equipment and making the
initial investment of time necessary to learn and adapt new systems.
Most medical offices already use personal computers for some tasks,
but many have not needed a connection to the Internet. Medical professionals
can now simply plug in to the existing infrastructure and become
connected with diverse caregivers and resources. This has become
a straightforward process, which it was not even as recently as
five years ago.
Teams need to coordinate protocols and processes within their existing
work flow. Compromises are needed to get diverse systems working
together and to overcome frustrations. A willingness to respond
to real life experiences with flexibility and concrete solutions
can make the difference for success.
The biggest hurdles to creating a community network of caregivers
are human frailties we can overcome. People resist change. It takes
a commitment to think in new ways and an even bigger commitment
to put those new ways of thinking into action.
Healthcare professionals need to be adept at using computer hardware
and software, and to work with colleagues from other organizations
overcoming technical difficulties and discovering new solutions
for patients and caregivers. Clinicians can no longer be burdened
with non-clinical tasks and obsolete data collection and communication
As we accept not only the inevitability of the changes that technology
can bring, but also its ability to effectively tackle and solve
past problems, we will finally join the legions of professionals
who already reap the benefits that technology offers. We will step
into a world where we can focus on the true issue of improving patient
Patient care is radically improved by realtime information flow
to and from clinical team members. The tremendous gains in patient
safety and improved quality of decision making in the field far
outshadow the time and effort that needs to be invested to make
Future World Solutions
Home health clinicians are part of a healthcare team supervised
by the attending physician and a critical cog in the larger community
healthcare network. Striking advances are being achieved in the
uses of technology to improve overall patient care and to make the
best use of each healthcare team member's expertise. The home health
care clinician does not have to be in the field alone notwithstanding
his or her wits and extensive training.
Technological tools are available and in use today that allow in
the field clinicians realtime access to sophisticated medical resources
like the pocket-sized cardiac monitor and the ability to communicate
effectively with other members of the healthcare team. This gives
the attending physician accurate and timely data for making the
best possible care decisions. These kinds of future world patient
care solutions have already arrived, but they require commitment,
education, and action to succeed.
Jeneane Brian, CEO, VNAHHS