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.
