Transcript Patient Care and Monitoring Systems

Patient Care and Monitoring
Systems
Patient care
• Patient care is the focus of many clinical
disciplines
– Various disciplines sometimes overlaps
– Each has its own primary focus, emphasis, and
methods of care delivery
– Each discipline’s work is complex
• Collaboration among disciplines adds
complexity.
• In all disciplines, the quality of clinical decisions
depends in part on the quality of information
available to the decision-maker.
Care Process
• Care begins with collecting data and assessing the
patient’s current status
• Through cognitive processes specific to the discipline:
– diagnostic labels are applied,
– therapeutic goals are identified with timelines for evaluation, and
– therapeutic interventions are selected and implemented
• At specified intervals:
– patient is reassessed,
– effectiveness of care is evaluated, and
– therapeutic goals and interventions are continued or adjusted as
needed
• If the reassessment shows that the patient no longer
needs care, services are terminated
Discipline in patient care
• Patient care is a multidisciplinary process
centered on
–
–
–
–
the care recipient in the context of the
family,
significant others, and
community.
Information to Support Patient Care
• The information for direct patient care is defined
in the answers to the following questions:
– Who is involved in the care of the patient?
– What information does each professional require to
make decisions?
– From where, when, and in what form does the
information come?
– What information does each professional generate?
Where, when, and in what form is it needed?
History
• The genesis of patient care systems occurred in
the mid-1960’s.
• One of the first and most successful systems
was the Technicon Medical Information System
(TMIS), begun in 1965 as a collaborative project
between Lockheed and El Camino Hospital in
Mountain View, California.
• TMIS designed to simplify documentation
through the use of standard order sets and care
plans.
• More than three decades later, the technology
has moved on.
Recent History
• Part of what changed users’ expectations for
patient care systems was:
• Development and evolution of the HELP system
at LDS Hospital in Salt Lake City, Utah.
– Decision support to physicians during the process of
care
– Managing and storing data
– Support nursing care decisions
– Aggregate data for research leading to improved
patient care.
Patient Care Components
Patient-Care
Component
Problem lists
Examples: Hospital
Examples: Ambulatory Care
Problem-Oriented Medical
Information System
(PROMIS), Medical Center
Hospital of Vermont,
Burlington, VT [Weed, 1975];
Tri-Service Medical
Information System
(TRIMIS), Department of
Defense [Bickel, 1979]
Computer-Stored Ambulatory
Record (COSTAR),
Massachusetts General
Hospital, Boston, MA
[Barnett, 1976];
Summary Time-Oriented
Record (STOR), University of
California, San Francisco, CA
[Whiting-O'Keefe et al., 1980]
Summary reports
Technicon Medical Information
System (TMIS),
Clinical Center at National
Institutes of Health, Bethesda,
MD [Hodge, 1990];
Decentralized Hospital
Computer Program (DHCP),
Department of Veteran’s
Affairs [Ivers & Timson, 1985]
Health Evaluation Logical
Processing (HELP), Latter
Day Saints Hospital, Salt Lake
City, UT [Kuperman et al.,
1991]; Technicon Medical
Information System (TMIS),
Clinical Center at National
Institutes of Health, Bethesda,
MD [Hodge, 1990];
Regenstrief, Regenstrief
Institute,
Indianapolis, IN [McDonald,
1976]; Computer-Stored
Ambulatory Record
(COSTAR), Massachusetts
General Hospital, Boston, MA
[Barnett, 1976]
Order entry
The Medical Record (TMR),
Duke University Medical
Center, Durham, NC
[Hammond et al., 1980];
Patient-Care Component
Examples: Hospital
Examples: Ambulatory
Care
Results review
University of Missouri-Columbia System, Columbia,
MO [Lindberg, 1965];
Decentralized Hospital
Computer Program (DHCP),
Department of Veteran’s
Affairs[Ivers & Timson,
1985]
Computer-Stored
Ambulatory
Record (COSTAR),
Massachusetts General
Hospital, Boston, MA
[Barnett, 1976]; Summary
Time-Oriented Record
(STOR), University of
California, San Francisco,
CA [Whiting-O'Keefe et al.,
1980]
Nursing protocols and care
plans
Health Evaluation Logical
Processing (HELP), Latter
Day Saints Hospital, Salt
Lake City, UT [Kuperman et
al., 1991];
Technicon Medical
Information System (TMIS),
El Camino Hospital,
Mountain View, CA
[Watson, 1977]
Alerts and reminders
Health Evaluation Logical
Processing (HELP), Latter
Day Saints Hospital, Salt
Lake
City, UT [Kuperman et al.,
1991];
Beth Israel Hospital System,
Boston, MA [Safran et al.,
1989]
Regenstrief, Regenstrief
Institute,
Indianapolis, IN [McDonald,
1976];
The Medical Record (TMR),
Duke University Medical
Center,
Durham, NC [Hammond et
al.,
1980]
HELP System at LDS Hospital
Patient Monitoring
• “Repeated or continuous observations or
measurements of the patient, his or her
physiological function, and the function of
life support equipment, for the purpose of
guiding management decisions, including
when to make therapeutic interventions, and
assessment of those interventions”
[Hudson, 1985, p. 630].
• A patient monitor may not only alert
caregivers to potentially life-threatening
events; many provide physiologic input data
used to control directly connected lifesupport devices.
History of Physiological data
measurements
• 1625 Santorio-measure body temperature with spirit thermomoeter.
– Santorio was first to apply a numerical scale to his thermo
scope, which later evolved into the thermometer.
• Timing pulse with pendulum. Principles were established by Galileo.
These results were ignored.
– Claudius Galen, was physician to five Roman emperors.
– He also understood the value of the pulse in diagnosis.
– John Floyer, 1707, acknowledged Galen's skill in identifying
various pulse beats, but was appalled that even 1500 years later
the doctors were still not using any standard procedure for
measuring them.
– He said that the pulse should be counted using a watch or a
clock and he had a special pulse watch made for timing 60
seconds.
– He published his findings in his works called " Physician's Pulse
Watch" , but doctors largely ignored Floyer's advice for over a
hundred years.
History
• 1852 Ludwig Taube Course of patient’s fever
measurement
• At this time Temperature, pulse rate respiratory rate had
become standard vital signs.
• Scipione Riva-Rocci introduced the sphygmomanometer
(blood pressure cuff). (4th vital sign).
– Scipione Riva-Rocci his fundamental contribution (1896) was the
mercury sphygmomanometer, which is easy to use and gives
sufficiently reliable results.
– This device, the standard instrument for measuring blood
pressure, led to many new developments in the therapy of
hypertension disease.
• Nikolai koroktoff applied the cuff with the stethoscope
(developed by Renne Lannec-French Physician) to
measure systolic and diastolic blood pressures.
What is blood pressure?
• Blood is carried from the heart to all parts of your body in vessels
called arteries.
• Blood pressure is the force of the blood pushing against the walls of
the arteries.
• Each time the heart beats (about 60-70 times a minute at rest), it
pumps out blood into the arteries.
• Your blood pressure is at its highest when the heart beats, pumping
the blood.
• This is called systolic pressure.
• When the heart is at rest, between beats, your blood pressure falls.
• This is the diastolic pressure.
• Blood pressure is always given as these two numbers, the systolic
and diastolic pressures.
– Both are important.
• When the two measurements are written down, the systolic
pressure is the first or top number, and the diastolic pressure is the
second or bottom number (for example, 120/80).
Harvey Cushing
•
•
1900s Harvey Cushing introduced an apparatus to
measure blood pressure during operations.
Raised the questions:
1. Are we collecting too much data?
2. Are the instruments used in clinical medicine too accurate?
3. Would not approximated values be just as good?
Cushing answered his own questions by stating that vitalsign measurement should be made routinely and that
accuracy was important [Cushing, 1903].
History (Cont.)
•
1903 Willem Einthoven devised the string galvanometer
– An instrument used to detect, measure, and determine the direction of small
electric currents by means of mechanical effects produced by a current-carrying
coil in a magnetic field.
•
to measure ECG (Nobel Prize 1924)
– 1901, Einthoven invented a new galvanometer for producing electrocardiograms
using a fine quartz string coated in silver based on ideas by Deprez and
d'Arsonval, who used a wire coil. His "string galvanometer" weighs 600 pounds.
Einthoven acknowledged the similar system by Clément Ader (1841-1926), but
later, in 1909, calculated that his galvanometer was in fact many thousands of
times more sensitive.
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•
•
Improvement over the capillary galvanometer, and the original galvanometer
invented by Johann Salomo Christoph Schweigger (1779-1857) in Halle in
1820. Einthoven published the first electrocardiogram recorded on a string
galvanometer in 1902.
1905, Einthoven began transmitting electrocardiograms from the hospital to
his laboratory 1.5 km away via telephone cable.
On March 22nd that year the first telecardiogram was recorded from a
healthy and vigorous man and the tall R waves were attributed to his cycling
from laboratory to hospital for the recording.
electrocardiograph
• An instrument used in the detection and
diagnosis of heart abnormalities that
measures electrical potentials on the body
surface and generates a record of the
electrical currents associated with heart
muscle activity. Also called cardiograph.
History
• 1950 The ICU’s were established to meet increasing
demand for acute and intensive care required by patients
with complex disorders.
• 1963 Day - treatment of post–myocardial-infarction
patients in a coronary-care unit reduced mortality by 60
percent.
• 1968 Maloney - having the nurse record vital signs every
few hours was “only to assure regular nurse–patient
contact”.
• Late ‘60s and early ‘70 bedside monitors built around
bouncing balls or conventional oscilloscope.
• ‘90 Computer-based patient monitors
– database functions,
– report-generation systems, and
– some decision-making capabilities.
- Systems with:
Myocardial Infarction
• “Heart attack“, non-medical term, is "Myocardial
Infarction".
• Either term is scary.
• "Myocardial Infarction" (abbreviated as "MI") means
there is death of some of the muscle cells of the heart as
a result of a lack of supply of oxygen and other nutrients.
• This lack of supply is caused by closure of the artery
("coronary artery") that supplies that particular part of the
heart muscle with blood.
• This occurs 98% of the time from the process of
arteriosclerosis ("hardening of the arteries") in coronary
vessels.
Patient Monitoring in ICUs
• Categories of patients who need physiologic
monitoring:
1. Patients with unstable physiologic regulatory
systems;
• Example: a patient whose respiratory system is suppressed
by a drug overdose or anesthesia.
2. Patients with a suspected life-threatening condition;
• Example: a patient who has findings indicating an acute
myocardial infarction (heart attack).
3. Patients at high risk of developing a life-threatening
condition;
• Example: patients immediately post open-heart surgery, or a
premature infant whose heart and lungs are not fully
developed.
4. Patients in a critical physiological state;
• Example: patients with multiple trauma or septic shock.
Care of the Critically Ill
• Requires prompt and accurate decisions.
• ICUs use computers almost universally :
– acquire physiological data frequently or continuously, (e.g. blood
pressure)
– communicate information from data-producing systems to
remote locations (e.g., laboratory and radiology departments)
– store, organize, and report data
– integrate and correlate data from multiple sources
– provide clinical alerts and advisories based on multiple sources
of data
– function as a decision-making tool that health professionals may
use in planning then care of critically ill patients
– measure the severity of illness for patient classification purposes
– analyze the outcomes of ICU care in terms of clinical
effectiveness and cost-effectiveness
Intensive care Unit Bed
Use of computers for patient monitoring
Automatic
control
Patient
Clinician
Transducers
equipment
Computer
Display
Reports
Mouse and
keyboard
DBMS
ICU
Bed
Bed
Nurse station
WEB
connection
Bed
Bed
Telemetry
Some instruments in mind
Types of Data Used in Patient
monitoring in different ICU’s
Continuous
variables
Sampled
variables
Coded Data
Free Text
Cardiac
ECG
Heart rate
(HR)
HR variability
PVCs
Temperature
Central
Peripheral
Patient
observation
Color
Pain
Position
Etc.,
All other
observations
or
interventions
that cannot
be measured
or coded
Blood pressure
Arterial/venous
Pulmonary
Left/right
atrial/ventricular
Systolic/Dyastol
Per beat/average
Systolic time
intervals
Respiratory
Frequency
Depth/vol/flow
Pressure/Resist
Respiratory
gases
Neurological
EEG
Frequency
components
Amplitudes
Coherence
Blood Chemistry
Hb
PH
PO2
PCO2
Etc.,
Interventions
Infusions
Drugs
Defibrillation
Artificial
ventilations
Anesthesia
Fluid balance
Infusions
Blood plasma
Urine loss
Patient monitoring
Features Matrix
ECG 3 leads
ECG 5 leads
ECG 10 leads
Respiration
Invasive BP
Dual Temp/C.O.
NIBP
SpO2
Understanding ECG - Normal ECG
summary
Normal rate
Sinus rhythm
Normal Axis
P wave
QRS complex
T waves
QT interval
U waves
Between 50bpm and 99bpm
Normal P wave before each QRS
complex Regular QRS complexes May be
a variation with respiration
Axis between 30 degrees and +90
degrees
May be negative in Lead V1 Normal
morphology PR interval between 0.12
and 0.2 seconds
Normal morphology No longer than 0.12
seconds Q waves are normal in Leads I,
aVL and V6 R waves increase across the
chest leads
Normal morphology May be inverted in
Lead III,aVR and V1 May also be
inverted in V2 and V3 in blacks
QTc between 0.35 and 0.43 seconds
Small U waves often seen in leads V2
V4
Respiration
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Rate range: 1 to 200 breaths/min
Impedance range: 100 to 1000 ohms at 52.6 kHz
Detection sensitivity range: 0.4 to 10 ohms impedance variation
Low rate alarm range: 1 to 199 breaths/min
High rate alarm range: 2 to 200 breaths/min
Apnea alarm rate: 0 to 30 seconds in one-second increments
Cardiac artifact alarm
Waveform display bandwidth: 0.05 to 2.5 Hz (-3 dB)
Analog output: Selectable
Trends: 24 hours with 1-minute resolution
Invasive Blood pressure
Catheter sites: Arterial, pulmonary arterial, central venous, left
atrial,
• intracranial, right atrial, femoral arterial, umbilical venous, umbilical
arterial, and special.
• Trends: 24 hours with 1-minute resolution