Innovative designs for the smart ICU: Part 3: Advanced ICU informatics

A Novel Continuous Real-Time Vital Signs Viewer for Intensive Care Units: Design and Evaluation Study

BACKGROUND

Clinicians working in intensive care units (ICUs) are immersed in a cacophony of alarms and a relentless onslaught of data. Within this frenetic environment, clinicians make high-stakes decisions using many data sources and are often oversaturated with information of varying quality. Traditional bedside monitors only depict static vital signs data, and these data are not easily viewable remotely. Clinicians must rely on separate nursing charts-handwritten or electric-to review physiological patterns, including signs of potential clinical deterioration. An automated physiological data viewer has been developed to provide at-a-glance summaries and to assist with prioritizing care for multiple patients who are critically ill.

OBJECTIVE

This study aims to evaluate a novel vital signs viewer system in a level 1 trauma center by subjectively assessing the viewer's utility in a high-volume ICU setting.

METHODS

ICU attendings were surveyed during morning rounds. Physicians were asked to conduct rounds normally, using data reported from nurse charts and briefs from fellows to inform their clinical decisions. After the physician finished their assessment and plan for the patient, they were asked to complete a questionnaire. Following completion of the questionnaire, the viewer was presented to ICU physicians on a tablet personal computer that displayed the patient's physiologic data (ie, shock index, blood pressure, heart rate, temperature, respiratory rate, and pulse oximetry), summarized for up to 72 hours. After examining the viewer, ICU physicians completed a postview questionnaire. In both questionnaires, the physicians were asked questions regarding the patient's stability, status, and need for a higher or lower level of care. A hierarchical clustering analysis was used to group participating ICU physicians and assess their general reception of the viewer.

RESULTS

A total of 908 anonymous surveys were collected from 28 ICU physicians from February 2015 to June 2017. Regarding physicians' perception of whether the viewer enhanced the ability to assess multiple patients in the ICU, 5% (45/908) strongly agreed, 56.6% (514/908) agreed, 35.3% (321/908) were neutral, 2.9% (26/908) disagreed, and 0.2% (2/908) strongly disagreed.

CONCLUSIONS

Morning rounds in a trauma center ICU are conducted in a busy environment with many data sources. This study demonstrates that organized physiologic data and visual assessment can improve situation awareness, assist clinicians with recognizing changes in patient status, and prioritize care.

Timing errors and temporal uncertainty in clinical databases-A narrative review

A firm concept of time is essential for establishing causality in a clinical setting. Review of critical incidents and generation of study hypotheses require a robust understanding of the sequence of events but conducting such work can be problematic when timestamps are recorded by independent and unsynchronized clocks. Most clinical models implicitly assume that timestamps have been measured accurately and precisely, but this custom will need to be re-evaluated if our algorithms and models are to make meaningful use of higher frequency physiological data sources. In this narrative review we explore factors that can result in timestamps being erroneously recorded in a clinical setting, with particular focus on systems that may be present in a critical care unit. We discuss how clocks, medical devices, data storage systems, algorithmic effects, human factors, and other external systems may affect the accuracy and precision of recorded timestamps. The concept of temporal uncertainty is introduced, and a holistic approach to timing accuracy, precision, and uncertainty is proposed. This quantitative approach to modeling temporal uncertainty provides a basis to achieve enhanced model generalizability and improved analytical outcomes.

Technology integration in complex healthcare environments: A systematic literature review

To support safety and efficient care, effective integration of technology into the timepressured, high-risk healthcare environments is critical. This systematic literature review aimed to highlight the impact of technology on the physical environment as well as the facilitators for and barriers to technology integration into complex healthcare settings, including operating rooms and trauma rooms. PsycINFO, Web of Science, and PubMed databases were utilized, along with a hand search. PRISMA and MMAT guidelines were used for reporting and quality appraisal. Out of 1,001 articles, 20 were eligible. Identified categories included hybrid and integrated environments, technological ambiance, and information technologies. Technology integration has implications for direct patient care, efficiency, throughput, patient safety, teamwork, communication, and the perception of care. The facilitators for and barriers to technology integration included layout design, equipment positioning, and decluttering. The physical environment can improve the impact of technology on factors such as patient safety and efficiency.

Keeping a 2009 Design Award-Winning Intensive Care Unit Current: A 13-Year Case Study

In a complex medical center environment, the occupants of newly built or renovated spaces expect everything to "function almost perfectly" immediately upon occupancy and for years to come. However, the reality is usually quite different. The need to remediate initial design deficiencies or problems not noted with simulated workflows may occur. In our intensive care unit (ICU), we were very committed to both short-term and long-term enhancements to improve the built and technological environments in order to correct design flaws and modernize the space to extend its operational life way beyond a decade. In this case study, we present all the improvements and their background in our 20-bed, adult medical-surgical ICU. This ICU was the recipient of the Society of Critical Care Medicine's 2009 ICU Design Award Citation. Our discussion addresses redesign and repurposing of ICU and support spaces to accommodate expanding clinical or entirely new programs, new regulations and mandates; upgrading of new technologies and informatics platforms; introducing new design initiatives; and addressing wear and tear and gaps in security and disaster management. These initiatives were all implemented while our ICU remained fully operational. Proposals that could not be implemented are also discussed. We believe this case study describing our experiences and real-life approaches to analyzing and solving challenges in a dynamic environment may offer great value to architects, designers, critical care providers, and hospital administrators whether they are involved in initial ICU design or participate in long-term ICU redesign or modernization.

Conceptualization of an ICU Infrastructure for Simulation Based Education in Medical Engineering & eHealth

The use of simulation-based training is gaining importance in medical as well as engineering related education. The complex environment of an intensive care unit is characterized by a high need of interaction between clinical as well as technical components and views. These diverse interactions and the connected requirements are the focus for the presented simulation infrastructure, enabling research, education and training. The presented concept of a modular and flexible intensive care environment provides a high degree of interoperability and flexibility for individual research questions and full support of connectivity for typical clinical workflows. The presented simulation and testing bed will allow both, education for engineering and medical students using patient simulation and simultaneous data transfer as well as research on medical workflows, infrastructural demands and connectivity conformance questions.

Structure of the Anesthesia Intensive Care Units: Recommendations of the Intensive Care Section of the Spanish Society of Anaesthesiology

BACKGROUND AND OBJECTIVE

In this article, the Intensive Care Section of the Spanish Society of Anesthesiology (SCI-SEDAR) establishes new recommendations based on the standards published by the Ministry of Health, Consumer Affairs and Social Welfare and aligned with the principle international guidelines, and develops a tool to improve quality and efficiency.

MATERIALS AND METHOD

Over a 12-month period (2018), 3 members of the SCI-SEDAR defined the methodology, developed the recommendations and selected the panel of experts. Due to the limited evidence available for many of the recommendations and the significant structural differences between existing anesthesia intensive care units, we chose a modified Delphi approach to determine the degree of consensus.

RESULTS

The panel consisted of 24 experts from 21 institutions. The group put forward 175 recommendations on 8 sections, including 129 with strong consensus and 46 with weak consensus.

CONCLUSIONS

The SCI-SEDAR has established a series of structural recommendations that should be used when renovating or creating new anesthesia intensive care units.

The Location and Timing of Failure-to-Rescue Events Across a Statewide Trauma System

BACKGROUND

Failure to rescue (FTR) refers to death after a major complication. Defining the optimal context in which to reduce FTR after injury requires knowledge of where and when FTR events occur.

MATERIALS AND METHODS

Retrospective observational study of patients >16 y with a minimum Abbreviated Injury Score ≥2 at all 30 level I and II Pennsylvania trauma centers (2007-2015). Location and timing of the first major complication were collected. Complication, mortality, and FTR rates were calculated by location (prehospital, emergency department, operating room, stepdown unit, interventional radiology, intensive care unit (ICU), radiology, and the surgical ward) and by postadmission day. Kruskal-Wallis and chi-squared tests were used to compare variables.

RESULTS

Major complications occurred in 15,388 of 178,602 (8.6%) patients. The median age was 58 y (interquartile range [IQR] 37-77 y), 78% were Caucasian, 68% were male, 89% were bluntly injured, and the median Injury Severity Score was 19 (IQR 10-29). Death occurred in 2512 of 15,388 patients with a major complication, for an FTR rate of 16.3%. Compared with non-FTR, FTR had earlier major complications (median day 2 [IQR 0-5 d] versus day 4 [IQR 2-8 d], P < 0.001). FTR rates were highest in the prehospital setting (42%), the operating room (33%), and the emergency department (32%), but the greatest number (1608 of 2512 total FTR events, 64%) occurred in the ICU. Pulmonary (32%) and cardiac (26%) complications most frequently contributed to FTR deaths.

CONCLUSIONS

Interventions designed to reduce FTR after injury should focus on pulmonary and cardiac complications in the ICU.

Does the architectural layout of a NICU affect alarm pressure? A comparative clinical audit of a single-family room and an open bay area NICU using a retrospective study design

OBJECTIVES

To determine differences in alarm pressure between two otherwise comparable neonatal intensive care units (NICUs) differing in architectural layout-one of a single-family room (SFR) design and the other of an open bay area (OBA) design.

DESIGN

Retrospective audit of more than 2000 patient days from each NICU cataloguing the differences in the number and duration of alarms for critical and alerting alarms, as well as the interaction of clinicians with the patient monitor.

SETTING

Two level 3 NICUs.

RESULTS

A total of more than 150 000 critical and 1.2 million alerting alarms were acquired from the two NICUs. The number of audible alarms and the associated noise pollution varied considerably with the OBA NICU generating 44% more alarms per infant per day even though the SFR NICU generated 2.5 as many critical desaturation alarms per infant per day.

CONCLUSION

Differences in the architectural layout of NICUs and the consequent differences in delays, thresholds and distribution systems for alarms are associated with differences in alarm pressure.

Informatics for the Modern Intensive Care Unit

Advanced informatics systems can help improve health care delivery and the environment of care for critically ill patients. However, identifying, testing, and deploying advanced informatics systems can be quite challenging. These processes often require involvement from a collaborative group of health care professionals of varied disciplines with knowledge of the complexities related to designing the modern and "smart" intensive care unit (ICU). In this article, we explore the connectivity environment within the ICU, middleware technologies to address a host of patient care initiatives, and the core informatics concepts necessary for both the design and implementation of advanced informatics systems.

Development and Validation of a Multi-Algorithm Analytic Platform to Detect Off-Target Mechanical Ventilation

Healthcare-specific analytic software is needed to process the large volumes of streaming physiologic waveform data increasingly available from life support devices such as mechanical ventilators. Detection of clinically relevant events from these data streams will advance understanding of critical illness, enable real-time clinical decision support, and improve both clinical outcomes and patient experience. We used mechanical ventilation waveform data (VWD) as a use case to address broader issues of data access and analysis including discrimination between true events and waveform artifacts. We developed an open source data acquisition platform to acquire VWD, and a modular, multi-algorithm analytic platform (ventMAP) to enable automated detection of off-target ventilation (OTV) delivery in critically-ill patients. We tested the hypothesis that use of artifact correction logic would improve the specificity of clinical event detection without compromising sensitivity. We showed that ventMAP could accurately detect harmful forms of OTV including excessive tidal volumes and common forms of patient-ventilator asynchrony, and that artifact correction significantly improved the specificity of event detection without decreasing sensitivity. Our multi-disciplinary approach has enabled automated analysis of high-volume streaming patient waveform data for clinical and translational research, and will advance the study and management of critically ill patients requiring mechanical ventilation.

Innovative Designs for the Smart ICU

Successfully designing a new ICU requires clarity of vision and purpose and the recognition that the patient room is the core of the ICU experience for patients, staff, and visitors. The ICU can be conceptualized into three components: the patient room, central areas, and universal support services. Each patient room should be designed for single patient use and be similarly configured and equipped. The design of the room should focus upon functionality, ease of use, healing, safety, infection control, communications, and connectivity. All aspects of the room, including its infrastructure; zones for work, care, and visiting; environment, medical devices, and approaches to privacy; logistics; and waste management, are important elements in the design process. Since most medical devices used at the ICU bedside are really sophisticated computers, the ICU needs to be capable of supporting the full scope of medical informatics. The patient rooms, the central ICU areas (central stations, corridors, supply rooms, pharmacy, laboratory, staff lounge, visitor waiting room, on-call suite, conference rooms, and offices), and the universal support services (infection prevention, finishings and flooring, staff communications, signage and wayfinding, security, and fire and safety) work best when fully interwoven. This coordination helps establish efficient and safe patient throughput and care and fosters physical and social cohesiveness within the ICU. A balanced approach to centralized and decentralized monitoring and logistics also offers great flexibility. Synchronization of the universal support services in the ICU with the hospital's existing systems maintains unity of purpose and continuity across the enterprise and avoids unnecessary duplication of efforts.

Automatic detection of ventilatory modes during invasive mechanical ventilation

BACKGROUND

Expert systems can help alleviate problems related to the shortage of human resources in critical care, offering expert advice in complex situations. Expert systems use contextual information to provide advice to staff. In mechanical ventilation, it is crucial for an expert system to be able to determine the ventilatory mode in use. Different manufacturers have assigned different names to similar or even identical ventilatory modes so an expert system should be able to detect the ventilatory mode. The aim of this study is to evaluate the accuracy of an algorithm to detect the ventilatory mode in use.

METHODS

We compared the results of a two-step algorithm designed to identify seven ventilatory modes. The algorithm was built into a software platform (BetterCare® system, Better Care SL; Barcelona, Spain) that acquires ventilatory signals through the data port of mechanical ventilators. The sample analyzed compared data from consecutive adult patients who underwent >24 h of mechanical ventilation in intensive care units (ICUs) at two hospitals. We used Cohen's kappa statistics to analyze the agreement between the results obtained with the algorithm and those recorded by ICU staff.

RESULTS

We analyzed 486 records from 73 patients. The algorithm correctly labeled the ventilatory mode in 433 (89 %). We found an unweighted Cohen's kappa index of 84.5 % [CI (95 %) = (80.5 %: 88.4 %)].

CONCLUSIONS

The computerized algorithm can reliably identify ventilatory mode.

Trending autoregulatory indices during treatment for traumatic brain injury

Our goal is to use automatic data monitoring for reliable prediction of episodes of intracranial hypertension in patients with traumatic brain injury. Here we test the validity of our method on retrospective patient data. We developed the Continuous Hemodynamic Autoregulatory Monitor (CHARM), that siphons and stores signals from existing monitors in the surgical intensive care unit (SICU), efficiently compresses them, and standardizes the search for statistical relationships between any proposed index and adverse events. CHARM uses an automated event detector to reliably locate episodes of elevated intracranial pressure (ICP), while eliminating artifacts within retrospective patient data. A graphical user interface allowed data scanning, selection of criteria for events, and calculating indices. The pressure reactivity index (PRx), defined as the least square linear regression slope of intracranial pressure versus arterial BP, was calculated for a single case that spanned 259 h. CHARM collected continuous records of ABP, ICP, ECG, SpO2, and ventilation from 29 patients with TBI over an 18-month period. Analysis of a single patient showed that PRx data distribution in the single hours immediately prior to all 16 intracranial hypertensive events, significantly differed from that in the 243 h that did not precede such events (p < 0.0001). The PRx index, however, lacked sufficient resolution as a real-time predictor of IH in this patient. CHARM streamlines the search for reliable predictors of intracranial hypertension. We report statistical evidence supporting the predictive potential of the pressure reactivity index.

Multimodal monitoring in the pediatric intensive care unit: new modalities and informatics challenges

We review several newer modalities to monitor the brain in children with acute neurologic disease in the pediatric intensive care unit, such as partial brain tissue oxygen tension (PbtO2), jugular venous oxygen saturation (SjvO2), near infrared spectroscopy (NIRS), thermal diffusion measurement of cerebral blood flow, cerebral microdialysis, and EEG. We then discuss the informatics challenges to acquire, consolidate, analyze, and display the data. Acquisition includes multiple data types: discrete, waveform, and continuous. Consolidation requires device interoperability and time synchronization. Analysis could include pressure reactivity index and quantitative EEG. Displays should communicate the patient's current status, longitudinal and trend information, and critical alarms.

Innovative designs for the smart ICU: part 1: from initial thoughts to occupancy

Designing a smart ICU is a time-consuming, complex, multiphased, political, and costly exercise. This process begins with two notions: First, all hospital parties agree that a new or renovated ICU is required, and second, the hospital has agreed to allocate space, personnel, and fiscal resources for the project. In this first of a three-part series on innovative designs for the smart ICU, we will explore the roles of the ICU design team in managing the design process. The team must be administratively empowered, knowledgeable, and forward thinking. The first charge of the design team is to develop a clear vision for the goals, look and feel, and functionality of the new ICU. This vision must be guided by the imperative to positively impact patients, staff, and visitors. The team must concentrate on innovative but practical ideas that are in compliance with building codes and design guidelines and address issues related to renovation vs new construction. Mock-ups, both physical and computer generated, and a simulation laboratory for advanced technologies should be used to test design assumptions and reveal problems well in advance of actual ICU construction and technology implementation. Technology platforms need to be standardized within the ICU and equipment purchases protected against early obsolescence. The ramifications and expectations of the new ICU must be thoughtfully considered and dealt with during the design process. Last, it is essential that the design group continue its involvement in the new ICU during construction, occupancy, and post occupancy.