How Barton Healthcare improved outcomes with improved respiratory monitoring


Postoperative respiratory compromise represents a significant health care burden in terms of increased morbidity and mortality along with increased length of hospital stay and cost of care. Respiratory compromise may be precipitated by a range of postoperative pulmonary complications (PPCs), the most common of which is often referred to as respiratory insufficiency, arrest and failure (RIAF).1,2 These complications have a complex and multifactorial etiology, including preoperative, intraoperative and postoperative risk factors.


While the overall incidence of pulmonary complications is influenced by the definition and criteria used for evaluation, evidence to date suggests that general PPCs are relatively common. With respect to respiratory depression and RIAF, studies suggest an incidence of approximately 1.5 percent to 7 percent.2,3,4,5,6 Despite this established clinical and monetary burden, evidence suggests that current patient monitoring strategies are not optimal for the rapid identification of postoperative respiratory compromise. The implementation of a rigorous and comprehensive patient monitoring system has the potential to improve patient outcomes and reduce the cost of care.

While hospitals can use monitoring tools like capnography to assess a patient's respiratory state, organizations are not always capable of maximizing this data collection to drive clinical improvements on their own.

Medical technology company Medtronic, based in Minneapolis, partners with acute care hospitals for a quality improvement program to reduce adverse respiratory events and patient length of stay by monitoring respiratory outcome metrics. During a Feb. 21 webinar with Becker's Hospital Review, Medtronic leaders and administrators from Barton Healthcare discussed the initiative and its success at the Lake Tahoe, Calif.-based health system.

Continuous capnography monitoring: How it works
First, the Medtronic program takes hospital billing data (ICD9/ICD10), as well as EMR or locally captured data and compares it to national benchmarks for several measures. Secondly, the program compares pre and post implementation of continuous monitoring data for a number of respiratory related intervention and outcomes measurements, including naloxone use and intensive care unit transfers due to respiratory failure. These metrics are then used to customize a report to provide the hospitals, in a means that allows them to understand how continuous monitoring has led to changes in respiratory metrics.

"The goal of our program is really to provide your own data back to assess how your respiratory metrics have changed pre- and post-continuous monitoring," Keith Morrison, senior global commercial marketing manager with Medtronic, said during the webinar. "We want to be able to help partner with facilities to provide your own data back and identify changes needed and how to improve the hospital's patient outcomes."

The ideal respiratory outcomes data sets are from one to two years before implementing the continuous capnography monitoring program and 6 to 12 months' worth of data after monitoring took effect.

After continuously monitoring respiratory outcomes for two years, administrators at Barton Healthcare examined the data to identify possible quality improvement opportunities. The team found their internal dataset to be limited in its capacity to drive action.

"We realized we had to partner with Medtronic to dig a little deeper and get more significant data out of the system," said Christine O'Farrell, director of quality management at Barton Healthcare.

Ms. O'Farrell found the Medtronic program beneficial for the system. Through the program, Barton Healthcare learned the rates of respiratory compromise among its patient population was slightly higher than the national benchmark, whereas the system's rate of postoperative respiratory events was significantly lower than the national average.

During the webinar, Dawn Evans, RN, patient safety officer with Barton Healthcare, said a key component of the program is using the data on patient outcomes to determine the patients at risk for respiratory failure and those most appropriate for capnography monitoring.

"With staff, it has been key to continually reinforce the use of the capnography," said Ms. Evans. "We've gotten to the point now where we are continually applying these [capnography monitors] to the correct patients."

Since implementing the program, Barton has submitted data on its improvement initiative and respiratory outcomes to the Joint Commission as a best practice. The submission has since been published in the commission's journal The Source.

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Alarm reduction and staff engagement
Individual hospital patients can generate dozens of alarms a day, not all of which are actionable. Previous research has suggested 90 percent of hospital alarms don't result in any action taken by hospital staff.

A reduction in alarms is one of the most noticeable changes at Barton since the implementation of the monitoring program. An overabundance of alarms can result in alarm fatigue. A daily environment with constant but unneeded ringing numbs providers to the shrill sounding devices, and patients can ultimately suffer from their corrupted attention spans.

Medtronic collected and analyzed data for 6 weeks, removing outliers to assess the typical medical surgical floor patient alarm behavior. After reporting results to Barton Health, adjustments were made and Medtronic analyzed the results a second time to determine the impact.

"They monitored it again and we lowered our low Co2 alarms by 39 percent and our low respiratory alarm rate by 52 percent," said Mary Kay Sennings, Barton's pulmonary services manager. "That made a significant impact with our alarm fatigue."

In addition to addressing alarm fatigue, Ms. Sennings said Barton makes consistent efforts to keep the staff engaged and educated on the importance of the improvement effort.

Finding a partner
While hospitals can continuously monitor respiratory outcomes unilaterally, strategic partnerships can improve the use of data to create a baseline for quality improvement efforts. Medtronic is currently working with individuals and organizations all over the globe on initiatives — including those related to continuous respiratory monitoring — to rethink healthcare and improve outcomes.

"We believe that our deep clinical, therapeutic and economic expertise can help adjust to complex challenges such as rising costs, aging populations and the burden of chronic disease faced by families and healthcare systems today," said Dave Giarracco, vice president of Medtronic market development.

To view the webinar, click here.

To view the webinar slides, click here.

To view past webinars, click here.

1. Shander A, Fleisher LA, Barie PS, Bigatello LM, Sladen RN, Watson CB. Clinical and economic burden of postoperative pulmonary complications: patient safety summit on definition, risk-reducing interventions, and preventive strategies. Crit Care Med. 2011;39(9):2163-2172.
2. Agarwal SJ, Erslon MG, Bloom JD. Projected incidence and cost of respiratory failure, insufficiency and arrest in Medicare population, 2019. Abstract presented at AcademyHealth Congress, June 2011
11. Agarwal SJ, Erslon MG, Seda J, Kelley SD. Large national database highlights significant risk factors for respiratory complications and mortality after abdominal surgery. Critical Care Med. 2011;39(12):162.
12. Kelley SD, Agarwal SJ, Erslon MG, Seda J, Lautz DB. Risk factors for respiratory insufficiency, arrest and failure among selected open and laparoscopic procedures - analysis of 90,000+ procedures. Surg Endosc. 2012;26(Suppl 1):P565
14. Linde-Zwirble WL, Bloom JD, Mecca RS, Hansell DM. Postoperative pulmonary complications in adult elective surgery patients in the US: severity, outcomes and resources use. Crit Care Med. 2010;14:P210
15. Bloom JD, Lu M, Sigl JC, Hansell DM. Postoperative naloxone rescue following parenteral opioids after abdominal surgery: incidence and cohort morbidity and mortality. ESICM Annual Congress. 2010:A0787.
16. Bloom JD, Agarwal SJ, Erslon MG, Mestek ML, Hansell DM. Incidence, economic impact and risk factors for respiratory failure after abdominal surgery. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). 2011:P441

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