Multi-site study tests virtual care for post-op patients

HAMILTON, ONT. – Researchers and clinicians at Hamilton Health Sciences are leading a multi-hospital study to determine if the numbers of discharged surgical patients who return to hospital in the first 30 days after discharge – a critical period for recoveries – can be significantly reduced through the use of remote monitoring technology.

The project is called PVC-RAM, short for “Post discharge after surgery Virtual Care with Remote Automated Monitoring” technology.

It launched in May, and it’s rapidly recruiting 900 patients at hospitals across Canada – including Hamilton General, the Juravinski Hospital, St. Joseph’s Health Care, London Health Sciences, Kingston General, the Ottawa Hospital, as well as facilities in Edmonton and Winnipeg.

Spurred on in large measure by the need to keep patients out of hospitals after surgery due to the COVID-19 pandemic, Hamilton Health Sciences wished to implement the project quickly. “It’s a trial on steroids, when it comes to the starting times and recruiting timelines,” said Dr. P.J. Devereaux, director of the Division of Perioperative Care at McMaster University and one of the project leaders.

“If we can reduce the numbers of re-admissions, we can increase our capacity to do more elective and urgent surgeries,” said Dr. Devereaux. “We may also reduce the spread of COVID-19 by keeping people out of hospital, whenever possible.”

Using advanced technologies, the researchers are confident that patients can be effectively cared for virtually, from hospital-to-home. The real question is determining how effective the system can be – how many patients will have better outcomes using remote monitoring, and how many won’t have to return to hospital.

“We know that 15 to 20 percent of post-op patients will come back to the emergency room or be re-admitted in the 30-day period after discharge,” said Dr. P.J. Devereaux. “But if we can reduce that, we can free up beds and increase the capacity of hospitals to do more elective and urgent surgeries. We can also reduce the risk of patients becoming infected with COVID-19.”

While just getting off the ground, the project has already helped patients at home through the use of technology. Dr. Devereaux cited the case of one cardiac patient who was discharged from hospital with the equipment. On just the second day at home, the monitoring equipment discovered a heart rate of only 32 beats per minute and low blood pressure – triggering an e-mail notification to a nurse.

The nurse followed up with a doctor, who asked the patient’s wife to show a view of her husband by using video on a tablet computer. “It was clear that the patient was in trouble,” said Dr. Devereaux. “The patient was brought back to hospital and was found to have had a complete heart block.”

Surgery was quickly performed, which likely saved the patient’s life.

Dr. Devereaux is working in tandem with Dr. Michael McGillion, assistant dean, Research, School of Nursing, McMaster University. The scope of PVC-RAM includes all types of urgent, semi-urgent and emergency care patients. Examples include oncology patients, as well as patients who have suffered hip fractures or aneurysms.

The team has received funding from Hamilton Health Sciences, along with pharmaceutical giant Roche, and it’s seeking additional funds from various sources.

The technology is being supplied by Cloud DX, an award-winning Canadian company with headquarters in Kitchener, Ont.

The system, called Cloud DX Connected Health, beams the data gathered by a suite of Health Canada-licensed, vital-sign devices through a tablet computer (supplied by Bell Canada) from the patient’s home back to monitoring stations at the various hospitals.

Software designed by Cloud DX, and customized for PVC-RAM, monitors the vital signs and notifies trained nurses if there are unusual readings, so that nurses can immediately get in touch with the patients or their families for rapid assessment.

If nurses believe the help of a physician is needed, they can escalate to an on-call doctor. In most cases, nurses with training in tele-health will be able to help the patients in the moment, thereby keeping them healthy at home.

The Cloud DX platform can send a survey to patients every day, and automatically scores the answers. A secure, medical-grade version of Zoom has been integrated into the Cloud DX platform, so that nurses can video-chat with patients every day for the first 15 days, and every two days for the following 15 days.

Secure two-way text messaging is also available on the tablet so that patients are able to contact the nurses 24 hours a day, seven days a week, if they feel unwell or need support or reassurance.

“When patients hear they can have 24-hour, around the clock access to nurses, it’s plain and simple – they want it,” said Dr. McGillion. “We really believe this is going to become part and parcel of healthcare in the future.”

The virtual care support, day and night, can help on many fronts. “There have been night-time issues which require immediate intervention,” said Dr. McGillion, “such as adverse drug reactions or the urgent need to adjust medications.” In many cases, nurses and physicians are able to resolve the issue remotely, keeping the patient healthy.

Dr. McGillion noted that six to 10 nurses will be managing patients at the majority of the hospital sites, and that 20 are already working on the project at the Hamilton General and Juravinski hospitals.

It should be noted that PVC-RAM is enrolling a total of 900 patients, of whom half will be given the Cloud DX monitoring technology, while the other half will be discharged home and cared for in the traditional manner. The project will evaluate the outcomes of one randomized group versus the other.

Dr. McGillion and Dr. Devereaux are already planning the next study, called Vision 2. In it, they intend to enrol 20,000 patients worldwide to test the technology, which will progress to the use of automatic, continuous monitoring of vital signs using a next-generation version of Cloud DX technology called the Vitaliti continuous vital sign monitor.

As well, the system will incorporate artificial intelligence. “By applying this to 20,000 patients, it will allow us to collect Big Data. And using that data, we’ll be able to develop algorithms that can predict bleeds, sepsis, surgical site infections, injuries to the heart muscle, and other problems,” said Dr. Devereaux.

He explained that often, readings of vital signs, taken individually, do not appear significant to human observers. But machine learning can take a more nuanced approach, and detects how seemingly insignificant, multiple factors may together indicate the onset of a serious problem.