Deterioration can go slow...

Transcription

1 Deterioration can go slow... My name is Dave, I m 67 year old. I m a retired train driver and live at home with wife & two dogs. I have COPD, the most common chronic lung disease and this is my story. EMERGENCY DEPARTMENT GENERAL WARD Emergency Department (ED) with severe breathlessness New chest infection Dave has had a cough and fevers for nearly a week. He arrives at the Emergency Department (ED) with severe breathlessness. Dave s improves with treatment. Test show a new chest infection. He needs antibiotics and is admitted to the ED short-stay ward. Antibiotics on general ward Not reviewed by doctor Developing a fever Developed sepsis and admitted to ICU Dave s vital signs are a little worse and he s developed a fever. The nurses give him increasing levels of oxygen and a fan for his fever. The doctor will come see him but must attend to an emergency elsewhere first. Dave developed sepsis. His blood pressure is low and his breathing is much worse. He is admitted to the ICU for artificial support of his lungs and circulation due to overwhelming infection; he has a 40% chance of dying. Dave is admitted to a general ward. He is given antibiotics, and will be seen once a day by a doctor and vital signs every 6-8 hours. When a patient is too well for hospital admittance but has a risk of complication, the Nightingale system would allow the patient to go home and receive the required attention when required. Resulting in better care at home and in the hospital. ICU Dave is not feeling much better. He gets oxygen and this helps his symptoms, so the busy junior doctor is reassured and choses not to review him. Change in vital signs Dave has a Nightingale system attached, is admitted to the Virtual Ward and is discharged with antibiotics. The helps Dave to take his medication give feedback on his progress. Nightingale recognizes a combination of vital sign changes. The ED Nightingale Doctor is prompted to call Dave at home; his treatment plan is changed and he is to start the steroids he was provided and take his inhalers more regularly The wrong antibiotic Dave is discharged from Nightingale Nightingale recognizes an ongoing early trend towards deterioration. This prompts the hospital team to review his laboratory results. The microbiology samples show that Dave is on the wrong antibiotic. Dave has to come back to the hospital to start new antoniotics. Dave can go home with remote monitoring. As he improved the Nightingale team decides he no longer needs remote monitoring.

2 If everything starts failing My name is Henrik. I am 71 and a proud grandfather of 6 grandchildren. I have been diagnosed cancer. This is my story PRE-OPERATIVE CLINIC RECOVERY ROOM SURGICAL WARD NIGHT 1 Henrik is transferred to the general surgical ward. His vitals signs are taken once per 6 8 hrs. Planned overnight Transferred to observation high care surgical ward Henrik is seen in the pre-op clinic. He is scheduled for fast-track surgery. A routine ECG shows a slight heart rhythm abnormality (long QTc-interval). Severe nausea and vomiting No action on lab results Henrik suffers from severe nausea and vomiting; he is prescribed drugs to treat nausea. Routine lab results shows that Henrik has a low blood potassium value. Henrik is not responding Henrik does not respond to calling his name and looks ash grey. The nurse cannot feel a pulse and starts CPR. After several electric shocks and i.v. medications, the normal heart rhythm returns. It can be hard to keep track of the large amount of patient data in case of a complex medical history. A clinical decision support system could potentially save lives for patients receiving medication for multiple conditions or have pre-existing conditions. Transferred to ICU Surgical planning with oesophageal Severe nausea and vomiting Urgent alert after lab results Henrik suffers from severe nausea and vomiting; he is prescribed drugs to treat nausea; while prescribing the anti-nausea drugs, doctor Lars Jensen receives an alert: it suggests checking the patient's blood potassium level carefully, because of the pre-existing heart rhythm abnormalities. The lab results shows that Henrik has developed a low blood potassium value. The Nightingale generates an urgent alert, explaining the risk has gone up and advised to check the ECG again. It also advises treating the low blood potassium to prevent potentially dangerous heart rhythm abnormalities. Bleeding in the chest Multi-organ failure Henrik does not do well. There is bleeding in the chest; there are problems with the stitches, possibly due to CPR. Henrik develops multi-organ failure and dies on day 7 after surgery. 3 Dangerous heart rhythm abnormalities Henrik feels much better The Nightingale sensor detects a further increase in the ECG QTc-interval and frequent extra beats and generates an allert. Henrik recieves potassium. The blood levels and the heart rhythm are normal again. Henrik feels much better. In the following days, he gradually recovers from the major surgery. On day 13 Henrik is discharged home.

3 It s all in the detail I am Amelia, known as Amy, 91 years old. I used to work as a nurse. I ve been on my own since my husband died, but enjoy watching cooking programmes and seeing my grandchildren and great-grandchildren from time to time. This is my story. A broken hip My carer finds me on the bathroom floor, and calls an ambulance which takes me to the Emergency Department. She tells the doctor that I can be forgetful and a little confused, and that I take tablets for an abnormal heart rhythm, for high blood pressure, and to help me pass water. The doctor says I have broken my hip. GENERAL WARD Hip replacement surgery Kidney failure Raised pulse Cardiac arrest My daughter says that I am much more confused than normal. One of my blood tests indicates that my kidneys may not be working properly. The ward nurse is told that the blood test should be repeated to make sure that I am alright. However, this does not happen. The ward nurses are very busy. My nurse takes my vital signs four times. On one occasion, she phones a doctor to say my pulse is 140. He says that it is probably a temporary thing, because of the heart rhythm but to call again if she is really worried. My pulse is now high most of the time. I am not producing much urine. At 11:00 I have a cardiac arrest. A whole team comes but cannot resuscitate me. Afterwards, they say that my latest blood tests show that I had acute kidney injury developing over the past few days. I have a hemi-arthroplasty (a type of hip replacement) and then go to the post-operative care unit for overnight observation. HOME An intelligent system could highlight such abnormalities, alert the relevant clinician, prompt repeat blood tests and alarm if this did not happen in an appropriate time. The proposed Nightingale system would monitor essential vital signs regularly irrespective of ward nurses workload, alerting clinicians and requiring a response if abnormalities persisted. Improving patient safety and quality of care. Feeling better Very high-risk patient Kidney failure Abnormal heart rate and blood pressure The Nightingale system ensures that all members of the surgical and post-operative teams are aware that I am a very high-risk patient. The Nightingale system shows that my confusion is worse than normal. The Nightingale system also automatically alerts the ward doctor that she will need to repeat my blood tests. When these turn out to be abnormal, the system suggests I may have acute kidney injury and gives a link to the hospital AKI management protocol. The Nightingale system monitors my vital signs throughout the day, and alerts the ward team when my heart rate and blood pressure are significantly abnormal. The doctor then repeats my bloods tests once more, which means she is alerted to the abnormal values and can prescribe fluids to correct these. The Nightingale system shows that my vital signs and blood chemistry are returning to normal, and that I am less confused. I am able to walk a short distance. The team and my daughter say that I am looking good.

4 Just one loose stitch I am William, 57 years old; I have a wife and two daughters; I work as an accountant and love to run for a hobby (I did two marathons!); I have pancreatic cancer. Fortunately it had been discovered early. This is my story. HOME AM William is operated, and the procedure is a success. Not feeling well After a week he is discharged home in good condition. When a patient is recovering well, there is no need to stay in the hospital. However, even after multiple days, complications could occur, resulting in an internal bleeding. Therefore remote monitoring could save lives, because of early detection PM 6.05 PM 4.50 PM 8.25 PM Concerned but not calling In ambulance to the hopital Emergency surgery William dies William is now drowsy; a little while later he is unresponsive. The ambulance is called and he is immediately taken to the hospital. Emergency surgical procedure: the surgeons find a large bleeding artery in the abdomen, due to a loose stitch. William dies from the effects of prolonged and severe blood loss. William does not feel Elaine, William s wife, is very well. concerned, but William does not want her to call the General Practitioner or the hospital AM 8.30 AM 3 Deterioration in vital signs He can be discharged home in good condition with a Nightingale wearable monitoring system. The nurse who is remotely monitoring William receives an alert from the Nightingale system. She sees on her screen that William has a high heart rate and rapid breathing. Blood pressure is low. In ambulance to the hopital William says he does not feel well. After consulting with the surgeon, she sends an ambulance and William is readmitted to the hospital. Henrik feels much better emergency surgical William recovers fully and procedure: the surgeons is discharged home after find a large bleeding artery in 5 days in hospital. the abdomen, which is successfully treated. He receives 4 units of blood.

5 When a patient stops breathing My name is Lara, I m 46 yr old. I work as a management consultant.. I m recently diagnosed with a painful benign liver tumor. This is my story. Epidural anaesthesia fails The anaesthetist has chosen to combine general anaesthesia with an epidural catheter to better control postoperative pain. Unfortunately, on the day of surgery, inserting the epidural is not successful. SURGICAL WARD 8:30 11:05 AM 1 PM Severe postoperative pain Transferred to the ward is uneventful. The tumor is completely removed. Blood loss is small. After surgery Lara is in immense pain which is hard to control. She receives morphine via an infusion pump and many other analgesics. Lara is disconnected from the monitoring system and transferred to a single room on the surgical ward. She remains in pain, despite all efforts and a lot of pain medication. Deterioration can be easily missed, especially at night in a dark patient room. The Nightingale system could potentially save lives, because it monitors the patient 24/7. Therefore deterioration can be detected earlier. RECOVERY ROOM 8 AM 5 PM 1 AM 6 PM PRE-OPERATIVE CLINIC something to help ther sleep Lara is not breathing and blue Finally the pain seems slightly less. She still has severe headache and is very sweaty. Her husband asks the nurse if Lara can have a sleeping pill to help her get some sleep. A junior doctor prescribes a sedative. The night nurse finds Lara unresponsive in bed; she is not breathing and blue. The nurse starts CPR and the resuscitation team is called. CPR is not successful. At 6:10 AM she is pronounced dead 6 PM 8.05 PM 1:30 AM Lara is transferred to the ward something to help her sleep Slowing down of respiratory rate Lara is transferred to a single room on the surgical ward. She wears a small sensor wirelessly connected with the Nightingale system. This allows the medical team to monitor her vital signs 24/7. Finally the pain seems slightly less. She still has severe headache and is very sweaty. Her husband asks the nurse if she may have a sleeping pill to help her get some sleep. A junior doctor prescribes a sedative. The Nightingale system has detected a suspect vital signs pattern: progressive slowing of respiratory rate followed by a slight decrease in oxygen saturation. The system notifies the nurse and junior doctor on call and suggests to check Lara for opioid respiratory depression, a known side-effect of morphine. Lara recovers well The nurse finds Lara quite sedated. The doctor gives her naloxone, an antidote for morphine. Within minute she is clearheaded again. Respiratory rate and saturation are back to normal. She recovers fully and is discharged home in good condition on day 6.