By Mark Tosczak
Fred Presnell, a 68-year-old retired battery plant worker, had been in a Ramseur nursing home for four weeks recovering from an emergency amputation of his left leg.
On a recent Thursday morning, as two home health nurses visited him, he looked pale. He had been having trouble breathing and was on oxygen. He had been in and out of the hospital since before the amputation and didn’t want to go back.
But he, his wife Bernice and staff at the nursing home were worried that he had dangerous levels of fluid in his lungs, a complication that could require him to return to the hospital.
The two nurses fitted him with a vest-like device — Sensible Medical’s ReDS system — that measures fluid in the lungs.
“Just lay back and try to relax,” Kathy Carter, one of the nurses, told Presnell.
“Hopefully this is going to give us the answers we need,” Bernice Presnell said, watching from the other side of the room. “He’s looking forward to this being done.”
Ninety seconds later it was. The results, however, were distressing. The device had given them a reading of 49 percent, the highest they had ever seen. That meant nearly half the volume of Presnell’s lungs had fluid in them. A normal rating is 20 to 35 for a healthy person.
Carter and Vivian Byrd, the other nurse, left the room to confer.
“We’re going to get on him aggressively,” said Cone Health cardiologist Dan Bensimhon over the phone a few hours later.
‘Heart failure army’
Bensimhon is the physician leading the effort to use ReDS devices in patients’ homes and some clinical settings as a way to better understand and treat the severity of fluid in the lungs of heart failure patients.
Heart failure by the numbers
- Affects 5.7 million people in the U.S.
- $32 billion per year in direct and indirect costs
Source: Triad HealthCare Network
Left unchecked, the condition can lead to death.
As part of the Affordable Care Act, federal regulators ordered that hospitals should reduce readmissions of heart failure patients and others who frequently boomerang back into the hospital after discharge. Hospitals have to strike a balance between keeping patients in an expensive hospital bed or discharging them earlier and longer closely monitoring them at home in order to avoid re-hospitalization.
Hospitals that miss their target of keeping readmission rates below roughly one in five (the exact rate is adjusted for risk and depends on other factors) can lose as much as 1 percent of their total annual Medicare revenue.
Fluid in the lungs is the leading cause of heart failure readmissions.
In the last year, Bensimhon, through Cone’s Triad HealthCare Network, provided home health nurses in Randolph County with one of his $25,000 ReDS systems. The nurses visit heart failure patients at home or other places, such as nursing homes, and measure how much fluid the patients have in their lungs.
He is also a paid consultant to Sensible Medical and has received research funding from the company. ReDS is still pretty novel, it’s only been reviewed in two studies available through the National Library of Medicine’s extensive database of research, so it remains to be seen whether Cone decides the device is cost-effective.
Bensimhon has developed a protocol they can follow, without a doctor examining a patient in person. If fluid levels are dangerously high, the nurses double a patient’s diuretic medicine and come back the next day for a follow-up visit and blood work. Daily visits can go on for a while, as the nurses check lung fluid levels and consult with physicians.
“The hardest part of assessing the heart failure patient is assessing the fluid,” Bensimhon said.
In the past, if a home health nurse reported a patient had symptoms that might indicate increased fluid in the lungs — trouble breathing or sudden weight gain, for example — the best a cardiologist like Bensimhon could do was to have the patient come in for a visit.
The nurses, armed with the vest and a protocol, have changed all that.
“This is our heart failure army we’re creating,” Bensimhon said. “We’re giving them tools to be better soldiers.”
With the ReDS vest quantifying fluid in the lungs — or ruling it out — Bensimhon argues patients can be treated more quickly and more appropriately, and often kept out of the hospital.
Prior to the day they visited Presnell, Carter, Byrd and a third nurse trained on the vest had seen 51 heart failure patients over the last year. Just two were readmitted within 30 days of leaving the hospital. A more typical rate, Bensimhon said, would be around 20 percent, or about 10 patients.
For Randolph Health’s 145-bed Asheboro hospital, 30-day heart failure readmission rates were 23 percent before nurses started using the ReDS system, according to a Triad HealthCare Network study. That readmission rate was cut to 8 percent, saving an estimated $150,000 in health care costs. It also resulted in the hospital avoiding the Medicare penalty for 2016.
“All it took was three nurses, a vest and a protocol and [a heart failure specialist] to text every once in awhile,” said Bensimhon.
Patients who have moderately elevated fluid levels — a reading of about 36 to 42 — often just need adjustments to their medications to get back to a healthy level. Higher levels indicate a bigger problem, and can prompt a more aggressive response. Because fluid levels can be checked daily, doctors and nurses can tell if a given treatment regimen is helping or not.
Of the three dozen or so cardiologists in Greensboro, Bensimhon said, there’s just him and one other who specialize in congestive heart failure. In many communities, there are no heart failure specialists.
That’s why he calls the nurses and others using the ReDS system an “army.”
Israeli military tech
The military terminology is appropriate here. Sensible Medical, a 10-year-old company based in Israel, developed the ReDS vests based on technology designed for the Israeli military that allows soldiers to “see through walls” to find people buried in the rubble of collapsed buildings.
The ReDS vests send an electromagnetic beam through the middle lobe of the right lung. It measures how much fluid is detected. With each reading, the data is sent back to Sensible Medical’s servers. In Presnell’s case, the nurses checked with Sensible Medical to see if their readings showed any sign of inaccuracy. They didn’t.
The device can’t be used with every patient. It only gives accurate readings with patients who have a body-mass index between 21, which is normal weight, and 38, which would be a 6-foot tall man weighing about 280 pounds.
A pacemaker and certain prior surgeries can also rule out the device.
A company spokesperson said the ReDS system was approved by the Food and Drug Administration two years ago and is now being used in about 60 health systems around the country.
Cone, Bensimhon said, was the first to use the vests with nurses in nonclinical settings, such as patients’ homes. He is also using them in other places. In his own Greensboro clinic, for example, his pharmacist uses the system with patients and can make adjustments to their medicines based on the readings.
At Alamance Regional Medical Center in Burlington, another Cone hospital, the vests are used in the emergency department to assess heart failure patients and help doctors decide whether to admit them.
“You have a history of heart failure on your chart and you say ‘Doctor, I have shortness of breath,’ 85 to 90 percent of patients may get admitted,” Bensimhon said. The vests change the math, though.
“If the number’s low, it’s not heart failure, look for something else. If the number’s medium, give them a dose of IV heart failure medicine,” he explained. “Even if we could reduce that [admissions] number from 90 percent to 50 percent, that would still be a gigantic win.”
It’s also a win for patients.
When nurses returned the next day to Presnell’s nursing home room and measured his lung fluid levels with the ReDS system, his score had declined to 46. While still high, it was moving in the right direction.