Pro-Con Debate: Universal Versus Selective Continuous Monitoring of Postoperative Patients.

In this Pro-Con commentary article, we discuss use of continuous physiologic monitoring for clinical deterioration, specifically respiratory depression in the postoperative population. The Pro position advocates for 24/7 continuous surveillance monitoring of all patients starting in the postanesthesia care unit until discharge from the hospital. The strongest arguments for universal monitoring relate to inadequate assessment and algorithms for patient risk. We argue that the need for hospitalization in and of itself is a sufficient predictor of an individual's risk for unexpected respiratory deterioration. In addition, general care units carry the added risk that even the most severe respiratory events will not be recognized in a timely fashion, largely due to higher patient to nurse staffing ratios and limited intermittent vital signs assessments (e.g., every 4 hours). Continuous monitoring configured properly using a "surveillance model" can adequately detect patients' respiratory deterioration while minimizing alarm fatigue and the costs of the surveillance systems. The Con position advocates for a mixed approach of time-limited continuous pulse oximetry monitoring for all patients receiving opioids, with additional remote pulse oximetry monitoring for patients identified as having a high risk of respiratory depression. Alarm fatigue, clinical resource limitations, and cost are the strongest arguments for selective monitoring, which is a more targeted approach. The proponents of the con position acknowledge that postoperative respiratory monitoring is certainly indicated for all patients, but not all patients need the same level of monitoring. The analysis and discussion of each point of view describes who, when, where, and how continuous monitoring should be implemented. Consideration of various system-level factors are addressed, including clinical resource availability, alarm design, system costs, patient and staff acceptance, risk-assessment algorithms, and respiratory event detection. Literature is reviewed, findings are described, and recommendations for design of monitoring systems and implementation of monitoring are described for the pro and con positions.

Improvement of sepsis identification through multi-year comparison of sepsis and early warning scores.

BACKGROUND: Sepsis remains a leading cause of death among inpatients. Scoring systems designed to identify inpatients with sepsis currently have limited effectiveness. This single institution, retrospective, case-control study aims to improve sepsis decision support tool performance using temporal analyses of sepsis-specific and general deterioration scoring systems. METHODS: Sequential Organ Failure Assessment, National Early Warning Scores (NEWS), and Modified Early Warning Scores were calculated using four years of inpatient data. Sensitivity and specificity analyses compared performance of each score, calculated as a function of both various score cut-off values and time before sepsis diagnosis using established proxies for identifying clinical suspicion for sepsis. RESULTS: NEWS had the best sensitivity-specificity performance (AUROC 82.7) when examining various score cutoffs and time intervals during which diagnosis criteria were met. Comparison of false positives/negatives with various score thresholds showed a low rate of false positives with a NEWS of 7. Score trends in the hours leading up to sepsis criteria being met showed a marked increase for the sepsis group while for the cases there was a decrease during a comparable period. CONCLUSIONS: Temporal analyses of scores for patients coded as having sepsis provides novel insights into patterns of deterioration. The methods and results provide practical details demonstrating how general deterioration algorithms can be used to alert trained responders to potential cases of sepsis to improve sepsis recognition and treatment opportunities.

Characterizing rescue performance in a tertiary care medical center: a systems approach to provide management decision support.

BACKGROUND: Allocation of limited resources to improve quality, patient safety, and outcomes is a decision-making challenge health care leaders face every day. While much valuable health care management research has concentrated on administrative data analysis, this approach often falls short of providing actionable information essential for effective management of specific system implementations and complex systems. This comprehensive performance analysis of a hospital-wide system illustrates application of various analysis approaches to support understanding specific system behaviors and identify leverage points for improvement. The study focuses on performance of a hospital rescue system supporting early recognition and response to patient deterioration, which is essential to reduce preventable inpatient deaths. METHODS: Retrospective analysis of tertiary care hospital inpatient and rescue data was conducted using a systems analysis approach to characterize: patient demographics; rescue activation types and locations; temporal patterns of activation; and associations of patient factors, including complications, with post-rescue care disposition and outcomes. RESULTS: Increases in bedside consultations (20% per year) were found with increased rescue activations during periods of resource limitations and changes (e.g., shift changes, weekends). Cardiac arrest, respiratory failure, and sepsis complications present the highest risk for rescue and death. Distributions of incidence of rescue and death by day of patient stay may suggest opportunities for earlier recognition. CONCLUSIONS: Specific findings highlight the potential of using rescue-related risk and targeted resource deployment strategies to improve early detection of deterioration. The approach and methods applied can be used by other institutions to understand performance and allow rational incremental improvements to complex care delivery systems.

Patterns in continuous pulse oximetry data prior to pulseless electrical activity arrest in the general care setting.

The study objective was to understand if features derived from continuous pulse oximetry data can provide advanced warning of pulseless electrical activity arrest in the general care inpatient setting. Retrospective analysis of SpO2 and pulse rate data derived from continuous pulse oximetry was performed for pulseless electrical activity (n = 38) and control (n = 42) patient cohorts. Measures of central tendency and variation over time intervals ranging from 1 min to 1 h were used for inter- and intra-group comparisons. Logistic regression was applied to understand ability of features to predict pulseless electrical activity in future time intervals. Overall, the pulseless electrical activity arrest group tended to have lower mean SpO2 and higher mean pulse rate values than the control group. SpO2 and pulse rate variability was higher in the pulseless electrical activity arrest cohort. Changes in variability were observed beginning several hours prior to the rescue event. Up to 20 min before rescue events, pulse rate features were significantly different from feature values for the preceding 30-min interval (> 10% difference in mean, > 46% difference in range). Similar results were found for SpO2 features 10 min before the event (> 4% difference in mean, > 60% difference in range). There is a significant difference in SpO2 and pulse rate features derived from continuous pulse oximetry between pulseless electrical activity and control groups. Integration of automated feature calculation and clinician notification into clinical monitoring and information systems may increase patient safety by supporting early detection of such events.

The Osteogenic Potential of Brown Seaweed Extracts.

Marine drugs hold significantly more promise than their terrestrial counterparts, which could help to solve the current shortfall in treatments for osteoporosis and other bone related diseases. Fucoxanthin is the main carotenoid found in brown seaweed, and has many perceived health benefits, including potential bone therapeutic properties. This study assessed the osteogenic potential of pure fucoxanthin and crude extracts containing both fucoxanthin and phenolic fractions (also cited to have osteogenic potential) isolated from two intertidal species of brown seaweed, Laminaria digitata and Ascophyllum nodosum. In vitro studies were performed using a human foetal osteoblast cell line (hFOBs) and primary human bone marrow stromal cells (hBMSCs). The results found pure fucoxanthin inhibitory to cell proliferation in hFOBs at higher concentrations, whereas, the crude extracts containing both polyphenols and fucoxanthin showed the ability to scavenge free radicals, which masked this effect. None of the extracts tested showed strong pro-osteogenic effects in either cell type tested, failing to support previously reported positive effects.

Characteristics of Desaturation and Respiratory Rate in Postoperative Patients Breathing Room Air Versus Supplemental Oxygen: Are They Different?

BACKGROUND: Routine monitoring of postoperative patients with pulse oximetry-based surveillance monitoring has been shown to reduce adverse events. However, there is some concern that pulse oximetry is limited in its ability to detect deterioration quickly enough to allow for intervention in patients receiving supplemental oxygen. To address such concerns, this study expands on the current limited knowledge of differences in desaturation and respiratory rate characteristics between patients breathing room air and those receiving supplemental oxygen. METHODS: Pulse oximetry-derived data and patient characteristics were used to examine overnight desaturation patterns of 67 postoperative patients who were receiving either supplemental oxygen or breathing room air. The 2 modalities with respect to the speed of desaturation, in addition to magnitude and duration of desaturation events, are compared. Night-time pulse rate, oxygen saturation, respiratory rate, and the transition times from normal oxygen saturation levels to desaturated states are also compared. The behavior of respiratory rate in proximity to desaturation events is described. Statistical methods included multivariable regression and inverse probability of treatment weighted to adjust for any imbalance in patient characteristics between the oxygen and room air patients and linear mixed effect models to account for clustering by patient. RESULTS: The study included 33 patients on room air and 34 receiving supplemental oxygen. The speed of desaturation was not different for room air versus oxygen for 2 types of desaturation (adjusted % difference, 95% confidence interval [CI]: type I; 22.4%, -51.5% to 209%; P = .67, type II; -17.3%, -53.8% to 47.6%; P = .52). Patients receiving supplemental oxygen had a higher mean oxygen saturation (adjusted difference, 95% CI, 2.4 [0.7-4.0]; P = .006). No differences were found for the average overnight respiratory or pulse rate, or proportion of time in desaturation states between the 2 groups.The time to transition from a normal oxygen saturation (92%) to 88% or below was not longer for supplemental oxygen patients (P = .42, adjusted difference 26.1%: 95% CI, -28.1% to 121%). Respiratory rates did not differ between the overall mean and desaturation or recovery phases or between the oxygen and room air group. CONCLUSIONS: In this study, desaturation characteristics did not differ between patients receiving supplemental oxygen and breathing room air with regard to speed, depth, or duration of desaturation. Transition time for desaturations to reach low oxygen saturation alarms was not different, while respiratory rate remained in the normal range during these events. These findings suggest that pulse oximetry-based surveillance monitoring for deterioration detection can be used equally effectively for patients on supplemental oxygen and for those on room air.

Assessment of continuous acoustic respiratory rate monitoring as an addition to a pulse oximetry-based patient surveillance system.

Technology advances make it possible to consider continuous acoustic respiratory rate monitoring as an integral component of physiologic surveillance systems. This study explores technical and logistical aspects of augmenting pulse oximetry-based patient surveillance systems with continuous respiratory rate monitoring and offers some insight into the impact on patient deterioration detection that may result. Acoustic respiratory rate sensors were introduced to a general care pulse oximetry-based surveillance system with respiratory rate alarms deactivated. Simulation was used after 4324 patient days to determine appropriate alarm thresholds for respiratory rate, which were then activated. Data were collected for an additional 4382 patient days. Physiologic parameters, alarm data, sensor utilization and patient/staff feedback were collected throughout the study and analyzed. No notable technical or workflow issues were observed. Sensor utilization was 57 %, with patient refusal leading reasons for nonuse (22.7 %). With respiratory rate alarm thresholds set to 6 and 40 breaths/min., the majority of nurse pager clinical notifications were triggered by low oxygen saturation values (43 %), followed by low respiratory rate values (21 %) and low pulse rate values (13 %). Mean respiratory rate collected was 16.6 ± 3.8 breaths/min. The vast majority (82 %) of low oxygen saturation states coincided with normal respiration rates of 12-20 breaths/min. Continuous respiratory rate monitoring can be successfully added to a pulse oximetry-based surveillance system without significant technical, logistical or workflow issues and is moderately well-tolerated by patients. Respiratory rate sensor alarms did not significantly impact overall system alarm burden. Respiratory rate and oxygen saturation distributions suggest adding continuous respiratory rate monitoring to a pulse oximetry-based surveillance system may not significantly improve patient deterioration detection.

Surveillance Monitoring Management for General Care Units: Strategy, Design, and Implementation.

BACKGROUND: The growing number of monitoring devices, combined with suboptimal patient monitoring and alarm management strategies, has increased "alarm fatigue," which have led to serious consequences. Most reported alarm man- agement approaches have focused on the critical care setting. Since 2007 Dartmouth-Hitchcock (Lebanon, New Hamp- shire) has developed a generalizable and effective design, implementation, and performance evaluation approach to alarm systems for continuous monitoring in general care settings (that is, patient surveillance monitoring). METHODS: In late 2007, a patient surveillance monitoring system was piloted on the basis of a structured design and implementation approach in a 36-bed orthopedics unit. Beginning in early 2009, it was expanded to cover more than 200 inpatient beds in all medicine and surgical units, except for psychiatry and labor and delivery. RESULTS: Improvements in clinical outcomes (reduction of unplanned transfers by 50% and reduction of rescue events by more than 60% in 2008) and approximately two alarms per patient per 12-hour nursing shift in the original pilot unit have been sustained across most D-H general care units in spite of increasing patient acuity and unit occupancy. Sample analysis of pager notifications indicates that more than 85% of all alarm conditions are resolved within 30 seconds and that more than 99% are resolved before escalation is triggered. CONCLUSION: The D-H surveillance monitoring system employs several important, generalizable features to manage alarms in a general care setting: alarm delays, static thresholds set appropriately for the prevalence of events in this setting, directed alarm annunciation, and policy-driven customization of thresholds to allow clinicians to respond to needs of individual patients. The systematic approach to design, implementation, and performance management has been key to the success of the system.

Building a Foundation of Continuous Improvement in a Rapidly Changing Environment: The Dartmouth-Hitchcock Value Institute Experience.

BACKGROUND: A performance improvement competency development program, known as the Value Institute (VI), was established at Dartmouth-Hitchcock (D-H; Lebanon, New Hampshire) in 2011 to develop a performance improvement-focused workforce and systems capable of meeting the challenges of creating a sustainable health system. METHODS: A tiered competency development program that provides patient safety, health care quality, and improvement science education, and an execution support infrastructure that enables access to performance improvement tools for all employees, comprise the core of the VI. RESULTS: At 20 months after the launch of the first VI classes, more than 10% of all employees were trained to the Yellow Belt level, and approximately 1.5% of all employees became advanced practitioners (Green Belts or Black Belts). Improvement projects have focused on both clinical and business process optimization, as well as regulatory and accreditation compliance and patient safety. Project savings during the two years of operation have exceeded the investment of resources to establish this long-term performance improvement capability by 2.5 times. CONCLUSIONS: The D-H VI model promotes multidisciplinary team-based learning, incremental skill development, and access to a common continuous improvement vocabulary and method for all employees-all key to building the teams and momentum needed for successful execution of improvement work and to maintain outcomes. Initial outcomes, represented by organizational spread, project execution status, participants' feedback scores, and return on investment estimates, suggest that robust team-based learning combined with coaching provides sufficient depth and breadth of learning and effective opportunities to gain practical experience in continuous improvement.

A comparison of oxygen saturation data in inpatients with low oxygen saturation using automated continuous monitoring and intermittent manual data charting.

BACKGROUND: The manual collection and charting of traditional vital signs data in inpatient populations have been shown to be inaccurate when compared with true physiologic values. This issue has not been examined with respect to oxygen saturation data despite the increased use of this measurement in systems designed to assess the risk of patient deterioration. Of particular note are the lack of available data examining the accuracy of oxygen saturation charting in a particularly vulnerable group of patients who have prolonged oxygen desaturations (mean SpO2 <90% over at least 15 minutes). In addition, no data are currently available that investigate the often suspected "wake up" effect, resulting from a nurse entering a patient's room to obtain vital signs. METHODS: In this study, we compared oxygen saturation data recorded manually with data collected by an automated continuous monitoring system in 16 inpatients considered to be at high risk for deterioration (average SpO2 values <90% collected by the automated system in a 15-minute interval before a manual charting event). Data were sampled from the automatic collection system from 2 periods: over a 15-minute period that ended 5 minutes before the time of the manual data collection and charting, and over a 5-minute range before and after the time of the manual data collection and charting. Average saturations from prolonged baseline desaturations (15-minute period) were compared with both the manual and automated data sampled at the time of the nurse's visit to analyze for systematic change and to investigate the presence of an arousal effect. RESULTS: The manually charted data were higher than those recorded by the automated system. Manually recorded data were on average 6.5% (confidence interval, 4.0%-9.0%) higher in oxygen saturation. No significant arousal effect resulting from the nurse's visit to the patient's room was detected. CONCLUSIONS: In a cohort of patients with prolonged desaturations, manual recordings of SpO2 did not reflect physiologic patient state when compared with continuous automated sampling. Currently, early warning scores depend on manual vital sign recordings in many settings; the study data suggest that SpO2 ought to be added to the list of vital sign values that have been shown to be recorded inaccurately.

Developing a continuous monitoring infrastructure for detection of inpatient deterioration.

A physiologic database infrastructure, composed of a patient monitoring system and a data processing and storage system, enables the detection of deterioration in noncritical patients, thereby helping to prevent failure-to-rescue events.

Understanding the "alarm problem" associated with continuous physiologic monitoring of general care patients.

Study Aim: The aim of this study is to investigate the impact of alarm configuration tactics in general care settings. Methods: Retrospective analysis of over 150,000 hours of medical/surgical unit continuous SpO2 and pulse rate data were used to estimate alarm rates and impact on individual nurses. Results: Application of an SpO2 threshold of 80% vs 88% produced an 88% reduction in alarms. Addition of a 15 second annunciation delay reduced alarms by an additional 71% with an SpO2 threshold of 80%. Pulse rate alarms were reduced by 93% moving from a pulse rate high threshold of 120-140 bpm, and 95% by lowering the pulse rate low threshold from 60 to 50 bpm. A 15 second annunciation delay at thresholds of 140 bpm and 50 bpm resulted in additional reductions of 80% and 81%, respectively. Combined alarm frequency across all parameters for every 24 hours of actual monitored time yielded a rate of 4.2 alarms for the surveillance configuration, 83.0 alarms for critical care monitoring, and 320.6 alarms for condition monitoring. Total exposure time for an individual nurse during a single shift ranged from 3.6 min with surveillance monitoring, to 1.2 hours for critical care monitoring, and 5.3 hours for condition monitoring. Conclusions: Continuous monitoring can eliminate unwitnessed/unmonitored arrests associated with significant increased mortality in the general care setting. The "alarm problem" associated with these systems is manageable using alarm settings that signify severely abnormal physiology to alert responsible clinicians of urgent situations.

A Pragmatic Method for Measuring Inpatient Complications and Complication-Specific Mortality.

OBJECTIVES: The primary objective of this study was to develop hospital-level metrics of major complications associated with mortality that allows for the identification of opportunities for improvement. The secondary objective is to improve upon current metrics for failure to rescue (i.e., death from serious but treatable complications.). METHODS: Agency for Healthcare Research and Quality metrics served as the basis for identifying specific complications related to major organ system morbidity associated with death. Complication-specific occurrence rates, observed mortality, and risk-adjusted mortality indices were calculated for the study institution and 182 peer organizations using component International Classification of Disease, Tenth Revision codes. Data were included for adults over a 4-year period, with exclusion of hospice patients and complications present on admission. Temporal visualizations of each metric were used to compare past and recent performance at the study hospital and in comparison to peers. RESULTS: The complication-specific method showed statistically significant differences in the study hospital occurrence rates and associated mortality rates compared with peer institutions. The monthly control-chart presentation of these metrics provides assessment of hospital-level interventions to prevent complications and/or reduce failure to rescue deaths. CONCLUSIONS: The method described supplements existing metrics of serious complications that occur during the course of acute hospitalization allowing for enhanced visualization of opportunities to improve care delivery systems. This method leverages existing measure components to minimize reporting burden. Monthly time-series data allow interventions to prevent and/or rescue patients to be rapidly assessed for impact.

A review of current and emerging approaches to address failure-to-rescue.

Failure-to-Rescue, defined as hospital deaths after adverse events, is an established measure of patient safety and hospital quality. Until recently, approaches used to address failure-to-rescue have been focused primarily on improvement of response to a recognized patient crisis, with limited success in terms of patient outcomes. Less attention has been paid to improving the detection of the crisis. A wealth of retrospective data exist to support the observation that adverse events in general ward patients are preceded by a significant period (on the order of hours) of physiologic deterioration. Thus, the lack of early recognition of physiologic decline plays a major role in the failure-to-rescue problem.

Pulse oximeter plethysmographic waveform changes in awake, spontaneously breathing, hypovolemic volunteers.

BACKGROUND: The primary objective of this study was to determine whether alterations in the pulse oximeter waveform characteristics would track progressive reductions in central blood volume. We also assessed whether changes in the pulse oximeter waveform provide an indication of blood loss in the hemorrhaging patient before changes in standard vital signs. METHODS: Pulse oximeter data from finger, forehead, and ear pulse oximeter sensors were collected from 18 healthy subjects undergoing progressive reduction in central blood volume induced by lower body negative pressure (LBNP). Stroke volume measurements were simultaneously recorded using impedance cardiography. The study was conducted in a research laboratory setting where no interventions were performed. Pulse amplitude, width, and area under the curve (AUC) features were calculated from each pulse wave recording. Amalgamated correlation coefficients were calculated to determine the relationship between the changes in pulse oximeter waveform features and changes in stroke volume with LBNP. RESULTS: For pulse oximeter sensors on the ear and forehead, reductions in pulse amplitude, width, and area were strongly correlated with progressive reductions in stroke volume during LBNP (R(2) ≥ 0.59 for all features). Changes in pulse oximeter waveform features were observed before profound decreases in arterial blood pressure. The best correlations between pulse features and stroke volume were obtained from the forehead sensor area (R(2) = 0.97). Pulse oximeter waveform features returned to baseline levels when central blood volume was restored. CONCLUSIONS: These results support the use of pulse oximeter waveform analysis as a potential diagnostic tool to detect clinically significant hypovolemia before the onset of cardiovascular decompensation in spontaneously breathing patients.

Inpatient Respiratory Arrest Associated With Sedative and Analgesic Medications: Impact of Continuous Monitoring on Patient Mortality and Severe Morbidity.

OBJECTIVES: The primary study objective was to investigate the impact of surveillance monitoring (i.e., continuous monitoring optimized for deterioration detection) on mortality and severe morbidity associated with administration of sedative/analgesic medications in the general care setting. A second objective was consideration of the results in the context of previous investigations to establish practice recommendations for this approach to patient safety. METHODS: Retrospective review of available rescue event and patient safety data from a tertiary care hospital in a rural setting was performed for a 10-year period. Systematic analysis of all adult general care inpatient data followed by chart review for individual patients was used to identify patient death or permanent harm (i.e., ventilator dependency, hypoxic encephalopathy) related to administration of sedative/analgesics. RESULTS: Of 111,488 patients in units with surveillance monitoring available, none died or were harmed by opioid-induced respiratory depression when surveillance monitoring was in use. One patient died from opioid-induced respiratory depression in a unit where surveillance monitoring was available; however, the patient was not monitored at the time of the adverse event. In unmonitored units (15,209 patients during 29 months of incremental implementation), three patients died from opioid overdose (19.73 deaths per 100,000 at risk patients). The reduced death rate when surveillance monitoring was available (0.0009%) versus not available (0.02%) was significant (P = 0.03). CONCLUSIONS: For a 10-year period, the rescue system with continuous surveillance monitoring had a profound effect on death from sedative/analgesic administration in the general care setting. This approach to patient safety can help address the risk of sedative/analgesic-related respiratory arrests in hospitals.

Impact of pulse oximetry surveillance on rescue events and intensive care unit transfers: a before-and-after concurrence study.

BACKGROUND: Some preventable deaths in hospitalized patients are due to unrecognized deterioration. There are no publications of studies that have instituted routine patient monitoring postoperatively and analyzed impact on patient outcomes. METHODS: The authors implemented a patient surveillance system based on pulse oximetry with nursing notification of violation of alarm limits via wireless pager. Data were collected for 11 months before and 10 months after implementation of the system. Concurrently, matching outcome data were collected on two other postoperative units. The primary outcomes were rescue events and transfers to the intensive care unit compared before and after monitoring change. RESULTS: Rescue events decreased from 3.4 (1.89-4.85) to 1.2 (0.53-1.88) per 1,000 patient discharges and intensive care unit transfers from 5.6 (3.7-7.4) to 2.9 (1.4-4.3) per 1,000 patient days, whereas the comparison units had no change. CONCLUSIONS: Patient surveillance monitoring results in a reduced need for rescues and intensive care unit transfers.

A Systems Approach to Design and Implementation of Patient Assessment Tools in the Inpatient Setting.

Failure to rescue events, or events involving preventable deaths from complications, are a significant contributor to inpatient mortality. While many interventions have been designed and implemented over several decades, this patient safety issue remains at the forefront of concern for most hospitals. In the first part of this study, the development and implementation of one type of highly studied and widely adopted rescue intervention, algorithm-based patient assessment tools, is examined. The analysis summarizes how a lack of systems-oriented approaches in the design and implementation of these tools has resulted in suboptimal understanding of patient risk of mortality and complications and the early recognition of patient deterioration. The gaps identified impact several critical aspects of excellent patient care, including information-sharing across care settings, support for the development of shared mental models within care teams, and access to timely and accurate patient information. This chapter describes the use of several system-oriented design and implementation activities to establish design objectives, model clinical processes and workflows, and create an extensible information system model to maximize the benefits of patient state and risk assessment tools in the inpatient setting. A prototype based on the product of the design activities is discussed along with system-level considerations for implementation. This study also demonstrates the effectiveness and impact of applying systems design principles and practices to real-world clinical applications.

Improving Patient Safety and Clinician Workflow in the General Care Setting With Enhanced Surveillance Monitoring.

Clinical monitoring systems have been implemented in the inpatient hospital setting for decades, with little attention given to systems analysis or assessment of impact on clinician workflow or patient care. This study provides an example of how system-level design and analysis can be applied in this domain, with specific focus on early detection of patient deterioration to mitigate failure to rescue events. Wireless patient sensors and pulse oximetry-based surveillance system monitors with advanced display and information systems capabilities were introduced to 71 general care beds in two units. Nursing workflow was redesigned to integrate use of the new system and its features into patient assessment activities. Patient characteristics, vital sign documentation, monitor alarm, workflow, and system utilization data were collected and analyzed for the period five months before and five months after implementation. Comparison unit data were also collected and analyzed for the same periods. A survey pertaining to staff satisfaction and system performance was administered after implementation. Statistical analysis was performed to examine differences in the before and after data for the target and control units. The enhanced monitoring system received high staff satisfaction ratings and significantly improved key clinical elements related to early recognition of changes in patient state, including reducing average vital signs data collection time by 28%, increasing patient monitoring time (rate ratio 1.22), and availability and accuracy of patient information. Impact on clinical alarms was mixed, with no significant increase in clinical alarms per monitored hour.