Patient monitoring and care

systems

Dr. Adrian Mondry

Concepts of patient care
Patient care begins with data
collection and assessment of
current patient status.

Decision making as to therapeutic

goals and diagnostic means follows.

At specified intervals, the patient is

re- assessed, and objectives are re-
defined.

Multidisciplinary tasks make

process more complex. 2
 Information needs for patient care
Who is involved in patient care?

What information needs has the individual professional?

From where, when, and how does this information come?

What information does each professional generate?

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 Patient care systems: history
1965 Technicon Medical Informatics System (TMIS) in California
with purpose to simplify and standardize documentation.
Change in demands:
1970s- 1990s: shift from single institution to integrated delivery
systems.
1980s- 1990s: shift from fee for service to prospective payment
to capitation => new need for information on costs
1970s- 1990: shift in methods of quality assessment from
retrospective audit to concurrent influencing, and need for data
capture for benchmarking purposes
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 Patient care systems: history
Patient care systems were separately introduced in hospital care
ann ambulatory setting, due to different needs.
In 1980s, most common systems were supporting nursing care
planning and documentation.
Ambulatory systems used paper- based documentation that was
later transferred to computer.
Modern systems have direct input with little free text capacity.
Voice recognition technology is advancing.
Need to switch from a patchwork of systems to integrated system
is there, but task very demanding.
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 Patient care systems: current research
Formulating models for acquisition, representation, processing,
display and transmission of biomedical information.
Developing innovative computer based systems, using these
models, that deliver information or knowledge to healthcare
providers.
Installation and reliable functionality in real life.
Study of the effects of such systems on reasoning and behaviour
of health care providers.

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 Patient monitoring systems
what is it?
repeated or continuous observations or measurements
of the patient, his physiological functions, and the
function of the life support equipment, for the purpose of
guiding management decisions, including when to make
therapeutic interventions, and assessment of those
interventions. Hudson L. Respir. Care 1985; 30: 638 ff

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 History (1/3)
In 1625, first methods for temperature measurement and
pulse rate measurement, were published in Italy by
Santorio.

In 1707, Sir John Floyer published Pulse- Watch.

In 1852, the first fever curve was plotted by Taube.

In 1896, the blood pressure cuff was invented by Riva-

Rocci.

In 1903, Einthoven invented ECG measurement 8

 History (2/3)
Since 1920, the four vital signs: blood pressure, pulse rate,
temperature and respiratory rate, have been recorded in all
medical charts.

Concomitantly, development of transducers and electronic

instrumentation increased the number of physiological
variables that could be monitored.

In the 1950s, the concept of ICU was created, initially as

post- operative recovery rooms, then more variations came
about, including from the 1960s coronary care units
monitoring cardiac rhythmicity.
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 History (3/3)
1966: Shubin & Weil in Los Angeles took computers to the ICU.
Objectives:
-increase availability and accuracy of data
-Compute derived variables that cannot be measured directly
-Increase patient- care efficacy
-Allow display of time trend of patient data
-Assist computer aided decision making

Today, systems with database functions, reprot generation

systems, and some decision making capabilities are called
computer- based patient monitors, while the basic signal
conversion and storage is built into monitors and considered
patient monitoring 10
Data acquisition & signal processing (1/4)

Advantages of built- in microcomputers:

-Pattern recognition and feature extraction
-Monitoring of signal quality
-Early conversion to digital form, then processing
-Easier transmission of digitized signals
-Easier storage for later review
-Stored variables can be graphed over longer periods
-Smarter alarms
-Easier upgrade (software instead of hardware)

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 Data acquisition & signal processing (2/4)
Arrhythmia monitoring- Signal acquisition and processing:
-ECG arrhythmia analysis is a most sophisticated task
-Conventional, i.e. human monitoring, is expensive, unreliable, tedious and
stressful.
-Arrhythmia monitoring systems with central computer, monitoring 8- 16
patients, introduced in late 70s
-Arrhythmia monitoring now integrated into bedside monitors
-These retain ECG tracing record
Wave form classification:
Incoming waveshapes are compared to stored templates, which in turn are
updated
Full- disclosure and multi- lead ECG monitoring
Modern central monitors can store several days of signals, combined with 12
digital waveform analysis
Data acquisition & signal processing (3/4)
Bedside point of care laboratory testing:
Over the past decade, standard laboratory tests have
been made available as point of care test, in which
analyses are performed by bringing a blood sample in
contact with a reagent pack.

Results can be displayed on the bedside monitor and

stored for comparison with previous results.

Link with other (central) laboratory data storage devices

allows integration into patients record etc.
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Data acquisition & signal processing (4/4)
Commercial development:
Development based on standard microcomputer based
server hardware and software platforms has led to wide
scale distribution.

Over 2000 ICUs worldwide use such systems.

Bedside monitor is focus of development

.
To cater for the needs of specialized demands, specific
ICU systems have been developed.
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 Information management in the ICU (1/4)
More analyses => more data => higher chance to miss data =>
Need for well organized data: medical record must guarantee the
continuity of data.
Computer based charting:
1984 Bradshaw et al. showed that bedside monitors accounted for
only 13% of physicians decision making => need to integrate data
from various sources into unified medical record.
Display must fulfill practical needs (day- to- day, weekly summary)

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 Information management in the ICU (2/4)
Calculation of derived variables :
Relieves end user and frees him to do more practical work,
speeds up decision making.

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 Information management in the ICU (3/4)
Decision making assistance :
System collects and integrates patient data from a wide variety of
sources.

New information is immediately processed by fixed algorithms to

determine whether it alone or in combination with existing data
leads to new decision making process.

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 Information management in the ICU (4/4)
Response by health care professionals :
Computerized systems that are tailored to the practical needs are
well received by staff.

So far, however, no benefit regarding time saving has been

demonstrated.

An unpublished study (Dorenfest and Associates, Chicago 1989)

found that there is time saving of about 25% regarding
administrative work done by health care professionals.

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 Current issues in patient monitoring
Data quality and data validation.

Continuous vs. intermittent monitoring

Data recording: frequency and quantity

Integration of patient- monitoring devices

Treatment protocols.

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 Questions you should know to
answer after this lecture:
What is patient monitoring, and why is it done?

How do computer- based patient- monitors aid health

professionals in collecting, analyzing and displaying data?

What are the important issues for collecting high- quality data
either automatically or manually in the intensive- care unit?

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