Patient Care and Monitoring Syst

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					Patient Care and Monitoring
                   Patient care

• Patient care is the focus of many clinical
   – 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
• 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
• 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?
• 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
• 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
  – Managing and storing data
  – Support nursing care decisions
  – Aggregate data for research leading to improved
    patient care.
                Patient Care Components
Patient-Care        Examples: Hospital                Examples: Ambulatory Care
Problem lists       Problem-Oriented Medical          Computer-Stored Ambulatory
                    Information System                Record (COSTAR),
                    (PROMIS), Medical Center          Massachusetts General
                    Hospital of Vermont,              Hospital, Boston, MA
                    Burlington, VT [Weed, 1975];      [Barnett, 1976];
                    Tri-Service Medical               Summary Time-Oriented
                    Information System                Record (STOR), University of
                    (TRIMIS), Department of           California, San Francisco, CA
                    Defense [Bickel, 1979]            [Whiting-O'Keefe et al., 1980]
Summary reports     Technicon Medical Information     Regenstrief, Regenstrief
                    System (TMIS),                    Institute,
                    Clinical Center at National       Indianapolis, IN [McDonald,
                    Institutes of Health, Bethesda,   1976]; Computer-Stored
                    MD [Hodge, 1990];                 Ambulatory Record
                    Decentralized Hospital            (COSTAR), Massachusetts
                    Computer Program (DHCP),          General Hospital, Boston, MA
                    Department of Veteran’s           [Barnett, 1976]
                    Affairs [Ivers & Timson, 1985]
Order entry         Health Evaluation Logical         The Medical Record (TMR),
                    Processing (HELP), Latter         Duke University Medical
                    Day Saints Hospital, Salt Lake    Center, Durham, NC
                    City, UT [Kuperman et al.,        [Hammond et al., 1980];
                    1991]; Technicon Medical
                    Information System (TMIS),
                    Clinical Center at National
                    Institutes of Health, Bethesda,
                    MD [Hodge, 1990];
Patient-Care Component       Examples: Hospital             Examples: Ambulatory

Results review               University of Missouri--       Computer-Stored
                             Columbia System, Columbia,     Ambulatory
                             MO [Lindberg, 1965];           Record (COSTAR),
                             Decentralized Hospital         Massachusetts General
                             Computer Program (DHCP),       Hospital, Boston, MA
                             Department of Veteran’s        [Barnett, 1976]; Summary
                             Affairs[Ivers & Timson,        Time-Oriented Record
                             1985]                          (STOR), University of
                                                            California, San Francisco,
                                                            CA [Whiting-O'Keefe et al.,
Nursing protocols and care   Health Evaluation Logical
plans                        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      Regenstrief, Regenstrief
                             Processing (HELP), Latter      Institute,
                             Day Saints Hospital, Salt      Indianapolis, IN [McDonald,
                             Lake                           1976];
                             City, UT [Kuperman et al.,     The Medical Record (TMR),
                             1991];                         Duke University Medical
                             Beth Israel Hospital System,   Center,
                             Boston, MA [Safran et al.,     Durham, NC [Hammond et
                             1989]                          al.,
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 life-
  support devices.
       History of Physiological data
• 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
   – He published his findings in his works called " Physician's Pulse
     Watch" , but doctors largely ignored Floyer's advice for over a
     hundred years.
• 1852 Ludwig Taube Course of patient‟s fever
• 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 vital-
   sign 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.
•   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.
• 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.
• 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
• 1968 Maloney - having the nurse record vital signs every
  few hours was “only to assure regular nurse–patient
• Late „60s and early „70 bedside monitors built around
  bouncing balls or conventional oscilloscope.
• „90 Computer-based patient monitors     - Systems with:
   – database functions,
   – report-generation systems, and
   – some decision-making capabilities.
             Myocardial Infarction

• “Heart attack“, non-medical term, is "Myocardial
• 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
          Patient Monitoring in ICUs
• Categories of patients who need physiologic
  1. Patients with unstable physiologic regulatory
     • 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
     • Example: patients immediately post open-heart surgery, or a
       premature infant whose heart and lungs are not fully
  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
  – 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


Patient     Transducers   equipment      Computer   DBMS

Clinician    Display

             Mouse and

      Bed                Bed   Bed               Bed

             Nurse station
Some instruments in mind
            Types of Data Used in Patient
            monitoring in different ICU’s
                     Sampled           Coded Data        Free Text
variables            variables
Cardiac              Temperature       Patient           All other
ECG                    Central         observation       observations
  Heart rate           Peripheral      Color             or
  (HR)                                 Pain              interventions
  HR variability                       Position          that cannot
  PVCs                                 Etc.,             be measured
                                                         or coded
Blood pressure       Blood Chemistry   Interventions
Arterial/venous      Hb                 Infusions
Pulmonary            PH                 Drugs
Left/right           PO2                Defibrillation
atrial/ventricular   PCO2               Artificial
Systolic/Dyastol     Etc.,             ventilations
Per beat/average                        Anesthesia
Systolic time
Respiratory          Fluid balance
Frequency              Infusions
Depth/vol/flow         Blood plasma
Pressure/Resist        Urine loss
Patient monitoring

Features Matrix
ECG 3 leads
ECG 5 leads
ECG 10 leads
Invasive BP
Dual Temp/C.O.
Understanding ECG - Normal ECG
 Normal rate     Between 50bpm and 99bpm
 Sinus rhythm    Normal P wave before each QRS
                complex Regular QRS complexes May be
                a variation with respiration
 Normal Axis     Axis between 30 degrees and +90
 P wave          May be negative in Lead V1 Normal
                morphology PR interval between 0.12
                and 0.2 seconds
 QRS complex     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
 T waves         Normal morphology May be inverted in
                Lead III,aVR and V1 May also be
                inverted in V2 and V3 in blacks
 QT interval     QTc between 0.35 and 0.43 seconds
 U waves         Small U waves often seen in leads V2
• 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
• intracranial, right atrial, femoral arterial, umbilical venous, umbilical
  arterial, and special.
• Trends: 24 hours with 1-minute resolution