Perception versus reality
An analysis that featured interviews with more than 30 clinical informatics executives uncovered a common perception that because patients in critical care units were attached to bedside monitoring devices, clinical surveillance was an established standard of care.3 However, Giuliano notes that “[s]urveillance and monitoring each represent a distinct process within patient care. Monitoring involves observation, measurement, and recording of physiological parameters, while surveillance is a systematic, goal-directed process based on early detection of signs of change, interpretation of the clinical implications of such changes, and initiation of rapid, appropriate interventions.”4 This author takes Giuliano’s definition a giant step further, evidenced by the seven clinical surveillance attributes (listed in the previous section) that must be present within a clinical scenario in order to label it as true clinical surveillance.
Adversely, when characterizing what clinical surveillance is not, we examine what patient monitoring actually is. Patient monitoring is both fragmented and episodic, capturing a patient’s condition in ways that are potentially dangerously narrow and incomplete. Most patient monitoring practices involve vital sign spot checks and responses to notifications sent from individual physiologic devices. Malkary notes that within a “MED-SURG environment, nurses conduct episodic monitoring several times per day or on an as-needed basis. This represents a gross under-sampling of what is going on with the patient, which could result in missing subtle changes in the patient’s condition.”5
Additionally, patient monitoring inherently assumes that an HAI, such as opioid-induced respiratory depression (OIRD), will be caught during the narrow windows of time that a clinician is visually observing a patient; in truth, spots checks can leave patients unmonitored 96% of the time.6 Even if a clinical team member (or patient) were to catch deterioration, the danger is active, present and likely requires emergency rescue or escalation to an intensive care unit.
A review of 357 claims from the Anesthesia Closed Claims Project database involving incidents which occurred between 1990 and 2009 revealed that in 42% of confrmed OIRD events, “the interval between the last nursing assessment and the detection of respiratory depression was less than two hours, and in 16 [%] of the cases, it was within 15 minutes.”7