Real-Time 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, and resolve.

PDA Technologies Provide Realtime Information Flow

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 providers.

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 well.

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 methods.

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 care.

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 it happen.

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
Suzanne Jamieson, Freelance Writer

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