Telecare

Monitoring systems

October 2005

What is remote care monitoring?

It means you keep a continuous electronic watch on patients’ vital signs, their activity patterns, or the state of their homes. This helps to track their state of health and to give early warning of problems. The equipment needed is basically a set of sensors and devices linked by telephone to a call centre. Remote care monitoring will help elderly and chronically ill people live at home, which they generally prefer to moving into residential care. By giving early warning of (for example) heart attacks or high blood-sugar levels in diabetics, it can help them avoid emergency hospital admissions. In these days of widespread MRSA and emerging Clostridium difficile, of course, the fewer people we hospitalise the better.

What are the principal types of remote monitoring?

There are two broad categories: activity monitoring and physiological monitoring.

Activity monitors include devices like wearable personal alarms, motion and smoke sensors, and fall detectors. These are generally linked by the telephone line to community alarm systems that trigger a warning at a 24-hourstaffed control centre.

Fall detectors are particularly useful: in one year, there were 648,000 recorded A&E attendances for fall-related injuries in people aged 60 and over, costing the NHS about £600 million.

Other devices measure vital signs like blood pressure, cardiac rhythm, blood-sugar level in diabetics, or breathing patterns and airflow in patients with respiratory illnesses like asthma or chronic bronchitis.

Some examples of activity sensors?

Some activity monitors keep track of household equipment and how much it is being used. This could indicate that a person has, through forgetfulness, stopped using their cooker, or has not turned it off. Sensors can also detect gas escapes and automatically shut off the gas. Or they can turn lights on at night. They can even spot risky behaviour like wandering by patients with dementia (of whom there are hundreds of thousands living alone in the UK).

Movement detectors can differentiate, for instance, between an old lady opening the door to pick up her milk bottles and opening the door to leave the flat, so that carers are not alerted every time the door opens. Bed pressure sensors can detect when a patient leaves her bed during the night, and will perhaps trigger an alarm if she doesn’t come back within a few minutes. They can even be programmed to record how many times she visits the toilet during the night — a good way to spot a urinary tract infection.

This sort of system can be taken even further using intelligent control systems like Tunstall’s Lifestyle Reassurance Solution. Sensors on kitchen cupboards, fridges and other electric appliances identify when the patient is eating and drinking and pass this information to the control system, which gradually builds up a pattern of the patient’s typical behaviour. The control system will notice if this pattern changes, and will then automatically warn a carer to check on the patient.

And physiological sensors?

Home diabetes monitoring — already well established in countries like the US and Germany — is likely to be the first popular application in the UK. One such device, e-San’s t+ diabetes system (see LastBytes, bjhc&im October 2005 p40), sends blood-sugar data from the patient’s mobile phone to a central server. The patient himself inputs information on carbohydrate intake and exercise. The graphical results are sent back to the patient for self monitoring, and to his GP.

Cardiac monitoring devices are much more accurate guides to the dangers of a heart attack than are the patient’s symptoms, so they can help prevent false ambulance callouts. There are 250,000 recorded instances of heart attacks every year in the UK, so it’s important to make best use of resources by directing them to real events rather than false alarms.

Cardiac monitors come in different levels of sophistication. Healthwatch’s TeleMedical cardiac service uses either single-lead or 12-lead portable ECGs to collect pulse, breathing rate, heart rate and heart rhythm data.

Some cardiac monitors are about the size of a phone and are strapped to the chest. Others are small enough to be strapped on the wrist like a watch. Results are transmitted to a 24-hour monitoring centre, either by modem, by fax, or even as email attachments. Continuous cardiac monitoring can also capture transient events like palpitations, which can fail to be picked up during an ECG.

Some instruments monitor many different life signs at once. Tunstall’s S21 telemedicine monitor, for example, can measure temperature, pulse rate, blood oxygenation levels, blood pressure and breathing rate and amplitude. These are all important indicators in chronic obstructive pulmonary disease.

What communications links do they use?

At the moment, simple landline telephones are the norm. But the rapid spread of cheap broadband will also make it easier to send large amounts of data over the Internet in future — perhaps by telephone calls using VOIP technology (see Jargon buster, below).

Some monitoring devices can already communicate via mobile phone technology — especially popular with young adult patients. But in future it will also allow more fancy types of home monitoring such as video images of a room in the house, or the use of GPS satellite technology (see Jargon buster) to report a person’s location.

Wireless technology will soon allow connectivity of monitoring devices around the home and in the community without cabling, while the Bluetooth standard (already familiar with hands-free mobile phones) will allow domestic equipment in patients’ homes to be remotely controlled. So it’s easy to set up? Pilot installations already exist.

The HomeBridge project in Ashford, Kent, is a purpose-built unit of seven bungalows fitted with various alarm-call and fall-detection systems. It will also pilot vital signs monitoring technology for people with long-term conditions.

But the problem in implementing routine home monitoring will be the usual squabbling between different NHS organisations and social services over who gets the benefits and who pays the costs.

For instance, the National Institute for Clinical Effectiveness (NICE) guidelines say pumps and monitors should be the first-choice treatment for diabetes, because they reduce the number of A&E admissions due to hypoglycaemic (low blood sugar) episodes. But few have been purchased by the NHS, because the organisation that buys them doesn’t necessarily get the benefit of their cost effectiveness. As a result less than 2,000 diabetics in the UK use insulin pumps compared with over 40,000 in Germany.

Similarly, home cardiac monitors are cheaper than hospital referrals, which cost about £100 a time (most GP practices don’t have their own ECG and have to refer patients to local hospital cardiology units). But this does not mean home ECGs will become widely used; it all depends who pays.

Why the sudden interest, after it’s been talked about for years?

Because England’s Department of Health (DoH) and the Scottish Executive, among others, are now making substantial efforts toward getting monitoring implemented in people’s homes. The DoH wants monitoring to be available in all homes that need it by December 2010, and is providing local authorities with £80m from next April to spend on innovative home monitoring services.

The recent Scottish Executive initiative, Building a health service fit for the future — a national framework for service change in the NHS in Scotland, has as one of its key aims that technology should be introduced to “facilitate, support and monitor the care of older people”, at home and elsewhere.