Patient Care and Monitoring Systems

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Patient Care and Monitoring Systems
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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 disciplines 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.

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Care Process

• Care begins with collecting data and assessing
  the patients 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

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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.

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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?

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History

• The genesis of patient care systems occurred in
  the mid-1960s.
• 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.

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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.

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Patient Care Components
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HELP System at LDS Hospital
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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.

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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.

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History

• 1852 Ludwig Taube Course of patients 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.

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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).

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Harvey Cushing

• 1900s Harvey Cushing introduced an apparatus to
  measure blood pressure during operations.
• Raised the questions
• Are we collecting too much data?
• Are the instruments used in clinical medicine too
  accurate?
• 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.

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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.

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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.

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History

• 1950 The ICUs were established to meet
  increasing demand for acute and intensive care
  required by patients with complex disorders.
• 1963 Day - treatment of postmyocardial-infarctio
  n 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
  nursepatient contact.
• 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.

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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.

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Patient Monitoring in ICUs

• Categories of patients who need physiologic
  monitoring
• Patients with unstable physiologic regulatory
  systems
• Example a patient whose respiratory system is
  suppressed by a drug overdose or anesthesia.
• Patients with a suspected life-threatening
  condition
• Example a patient who has findings indicating an
  acute myocardial infarction (heart attack).
• 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.
• Patients in a critical physiological state
• Example patients with multiple trauma or septic
  shock.

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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

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Intensive care Unit Bed
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Use of computers for patient monitoring
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ICU
Bed
Bed
Bed
Bed
Nurse station
Telemetry
WEB connection
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Some instruments in mind
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Types of Data Used in Patient monitoring in
different ICUs
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Patient monitoring
Features Matrix ECG 3 leads ECG 5 leads ECG 10
leads Respiration Invasive BP Dual
Temp/C.O. NIBP SpO2
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Understanding ECG - Normal ECG summary
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Respiration

• 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