Schewanick Computer Services

Most medical devices in intensive care units (ICU) such as patient monitors, respirators, and infusion pumps are used as stand-alone devices, they are used in isolation from other devices. The patients measurements are often recorded on paper charts with diagnosis being made from interpreting that chart. Many clinical staff feel this is quite adequate to their needs, and the traditional approach is easy to adapt, easy to train, and entirely within their control. I'd like to discuss ways to bring more technology to medical devices and bring benefits to the clinicians. Traditionally, each patient in intensive care is monitored with a chart on an A3 sized piece of paper, with each chart corresponding to 24 hours. At regular intervals (every fifteen minutes or half an hour), measurements from the patient monitor, respirator, fluid monitors etc are taken and written on the chart. The expert eye will recognize trends from the chart, determining whether the patient is reacting appropriately to care, and therefore determining the correct procedure. At the end of the day the charts are sent to the records department, and usually turned into microfiche or scanned prior to storage.

So what are the areas that technology can provide benefits? Let's assume the paper charts are replaced by a computer, and the computer retrieves data from the medical devices on each patient automatically. Initially we'll assume that the computer adds nothing extra to the practices, in other words it recreates the A3 chart exactly, and displays the readings as though written in by the staff. From here we can see two basic advantages; Time saving Intensive care departments are the most expensive departments in a hospital, often requiring more financing than the rest of the hospital combined. The largest source of the costs is staff. An ICU requires many highly trained staff. Consequently ICU staff's time is a highly precious commodity, and any time spent doing menial tasks is time that should be spent utilizing the staff's expertise. Instead of looking at each medical device and writing the values onto the chart, the nurse can look at the chart and validate the results that the computer displays. At the end of the day the charts are automatically stored. There's no trip to the records department, no manual scanning or transferring to microfiche. Finally, retrieving earlier records, show even greater time savings. Although retrieving the ICU charts isn't often required, retrieving patients records often are. With paper charts this can be time consuming and frustrating to staff, while retrieving computer records is usually instant.

Transcription errors Since charts are usually analyzed for trends, rather than looking at individual figures, entering a value incorrectly is usually noticed as an anomaly. However, why take the risk automated collection of the patient measurements reduces this risk to near zero. Expanding the traditional approach

Assuming that we want to do more than just reproduce the current practices in ICU, we can utilize the other benefits that a computerized system brings. All the benefits I'm about to describe are already available on the market. Diagnosis support

Currently the clinician, assesses the patients data coming from the medical devices, the patient history and current state, and combines this with their training and experience. From this comes the diagnosis, and resulting patient care. To some extent a computer can do a similar action by cross referencing data from the patient, databases on drugs and procedures, and provide the clinician with more information to base their decisions on. This can give the clinician more options, reassure them in their decisions, or even alert them to unforeseen consequences. The clinician can not only consider the diagnosis support from the computer, but also inform the computer to actively monitor the patient for certain conditions. For instance, the clinician has administered a drug which they know will affect the patient in a certain way (e.g. lower the temperature or blood pressure). The clinician can instruct the computer to monitor for specific physiological changes in the patient, and if these don't occur the computer would issue an alert. Medical devices can only monitor the specific subset of parameters they were designed for. The computer on the other hand can use the data from all the devices, and create more intelligent alerts.

Remote monitoring

Remote monitoring of patients allows the clinician to check the patient while away from the unit. Giving clinicians the ability to remotely monitor the patients condition can alert the staff to potential problems earlier. This can also be linked to the alerting mechanisms mentioned in the previous section, and alerts can be sent by many methods such as pagers, email or even SMS texts. Technology has also allowed a completely innovative approach to added to intensive care the remote intensive monitor center (such as eICU by VISICU). This allows intensive care specialists to monitor patients from many hospitals from a single remote location. While not intending to replace the staff on the ground, the eICU uses a variety of remote monitoring methods coupled with diagnosis tools. User interfaces The ergonomics of medical devices is now a mature science, and most modern devices are extremely clear to read and use. They are still separate components though. If all the data from each device is brought together to a single point, then the entire physiological state of the patient can be displayed on a single screen. If integrated properly, then this screen can be independent of the make or model of the devices, and even if different models are used on various beds, the display will always be the same. Technology and medical devices are tools for the clinician, and should primarily adapt to their needs rather than staff to extensively change their practices. If staff can rely on a standard display then they can concentrate on using the information rather than searching for it. Add to this the remote monitoring and diagnosis support, and you have a single powerful tool for the clinician. The display can be dynamic, e.g. the patients stats no longer need to be a string of numerical characters, but transformed into graphs as the clinician requires. The diagnosis support can provide baseline graphs to compare whether the patients state is changing as expected, and an alert level can move in synchronization to provide tighter alarm controls (which reduces the number of false alerts that are all too present in current ICU's). Finally, this can be linked to the patient's stored records, and each chart is no longer limited to the last 24 hours, but for any time during the patients stay.

I hope this article shows some of the advantages of bringing more technology to the ICU. Everything I have described is currently available. However, the benefit shouldn't be blindly accepted. Technology for technology's sake will always be a poor choice. The greatest barriers to implementing these systems is cost and staff resistance to new practices. Cost is a fact of life, and only time will bring the costs down as IT infrastructure matures in hospitals and electronic medical records become widespread. Staff resistance however should be seen as a good thing. It is up to the vendors to demonstrate systems that work with the staff while clearly demonstrating benefits. Generally this seems to be the case, and the future of a more technological ICU is looking bright.

About the author:

Nicholas Cain is the CEO of Cain Medical Ltd, a company that specializes in interfacing medical devices for research and EMR systems.