1. BY: BRIGITTE MARIE GALAURA NURSING INFORMATICS Critical Care Applications

2. Objectives 1. Identify information technology application in critical care 2. Understand the basic components of arrhythmia monitors and physiologic monitors 3. Describe how hemodynamic monitoring systems are used in critical care settings 4. Understand the capabilities purposes, types, benefits, ad issues of critical care information systems (CCIS) 5. Describe the relationship between hemodynamic monitoring systems and CCISs 6. Identify trends in monitoring and computerized information management 7. Identify special-purpose applications available.

3. Key words information systems hospital information systems critical care information systems integrated care information systems

4. What is Critical Care? CRITICAL CARE multidisciplinary health care specialty that cares for patients with acute, life threatening illness or injury Data must be accessible at the point of care.

5. Developments Advantages of monitoring systems resemble the advantages of electronic nursing documentation these systems focus heavily on collecting storing and displaying physiological data

6. INFORMATION TECHNOLOGY AND CAPABILITIES AND APPPLICATIONS IN CRITICAL CARE SETTINGS Process store and integrate physiological and diagnostic information from various sources Present deviations from preset ranges by an alarm or an alert Accept and store patient care documentation in a lifetime’s clinical repository Trend data in a graphical presentation Provide clinical decision support through alerts alarms and protocols Provide access to vital patient information from any location both inside and outside of the critical care setting Comparatively evaluate patients for outcomes analysis Present clinical data based on concept-oriented views

7. What technology is used? Information technology applications described in this chapter are: Physiologic monitors, including: arrhythmia and hemodynamic monitors mechanical ventilators CCIS

8. DEVICE CONNECTIVITY INFRASTRUCTURE Aside from monitoring, devices are capable of sending information to software applications. Medical information Bus (MIB) is used to classify the backbone of information exchange allowing data to be moved from one point to another. Most Medical Devices have small communication ports

9. PHYSIOLOGICAL MONITORING SYSTEMS Physiological monitors were developed to oversee the vital signs of the astronauts. By the 1970's these monitors found their way into the hospital setting. Physiologic systems consist of 5 basic parts SENSORS SIGNAL CONDITIONERS FILE TO RANK AND ORDER INFORMATION COMPUTER PROCESSOR to analyze data and direct reports EVALUATION OR CONTROLLING COMPONENT to regulate the equipment or alert the nurse

10. Microprocessors Physiologic signals are typically of very small amplitude and must be amplified, conditioned and digitized by the device in in preparation for processing by its embedded microprocessors. Analyzes information store pertinent information in specific places, and controls the direction in reporting Alerts nursing personnel through a report, an alarm or a visual notice.

11. Physiologic Monitoring Cont’d Monitoring systems also store various data elements with a time stamp derived from the monitoring system's internal clock Physiologic monitoring systems typically have modern platform allowing the selection of various monitoring capabilities to match the needs of a variety of clinical settings More specialized monitoring capabilities such as intracranial pressure or bispectral index monitoring are also in modular format. Physiologic monitors are usually built to incorporate both arrhythmia and hemodynamic monitoring capabilities

12. HEMODYNAMIC MONITORS Can be used to: measure hemodynamic parameters closely examine cardiovascular function Evaluate cardiac pump output and volume status Recognize patterns (arrhythmia analysis) and extract features Assess vascular system integrity Evaluate the patient's physiologic response to stimuli Continuously assess respiratory gases (capnography) Continuously evaluate glucose levels Store waveforms Automatically transmit selected data to a computerized patient database

13. Thermodilution Technique The bolus must be injected within 4 seconds Amount of solution must be accurate Temperature of the injectate must be measured and accurately maintained Catheter must be properly placed Computer must have the appropriate computation constant Bolus must be injected at the appropriate time in the respiratory cycle.

14. What does it look like?

15. How Does It Work? The influence of these user-related issues is negated by using heat of a thermal filament embedded in the catheter to replace the injectate. An alternative means of measuring cardiac output noninvasively if provided by thoracic electrical bioimpedance. Four sensor are positioned on the sides of the neck and thorax Monitoring these changes permits measurement of stroke volume: indices of contractility such as velocity and acceleration of blood flow, supraventricular rhythm and index. Using bioimpedance as a factor integrated with analysis of the finger blood pressure waveform has also been demonstrated as a method of cardiac output measurement

16. Pulse Oximetry A critical piece of hemodynamic information involves the availability of oxygen to bodily tissues. the standard for measurement of blood's oxygen saturation is coximetry Pulse oximetry is a noninvasive method of measuring oxygen saturation that also uses spectrophotometry. Light is emitted through a pulsatile arteriolar bed and then detected by photosensor.

17. Problems? largest contributor to alarms in the ICU caused by: blood pressure cuff tourniquet air splint that may cause venous pulsations limits the sensors ability to distinguish between arterial or venous blood pressure while pulse oximetry provides a measure of oxygen delivered to the tissue, mixed venous oxygen saturation provides a measure of the amount of oxygen used by the patient.

18. What is telemetry? Hemodynamic monitoring can take place at the bedside of can be conducted from a remote location via telemetry. Telemetry allows for the continuous monitoring of patients usually outside of the ICU. telemetry monitoring is susceptible to signal loss. Computer-based hemodynamic monitoring offers the critical care nurse a wealth of information does not replace clinical judgement

19. ARRHYTHMIA MONITORS Computerized monitoring and analysis of cardiac rhythm have proved reliable and effective and in detecting potentially lethal heart rhythms. A key functional element is the system's ability to detect ventricualr fibrillation and respond with an alarm. SYSTEM TYPES Detection Surveillance Diagnostic or Interpretive.

20. Picture?

21. Where do you put them?

22. What’s the difference? In a detection system, the criteria for a normal ECG are programmed into the computer. Interpretive systems search the ECG complex for five parameters Location of QRS complex Time from the beginning to the end of the QRS Comparison of amplitude, duration, and rate of QRS complex with all limb leads P and T waves Comparison of P and T waves with all limb leads

23. Basic Components of arrhythmia Monitors sensor signal conditioner cardiograph Pattern recognition Rhythm analysis Diagnosis Written report

24. CRITICAL CARE INFORMATION SYSTEMS A CCIS is a system designed to collect store, organize, retrieve, and manipulate all data related to care of the critically ill patient. CCIS is the organization of a patient's current and historical data. CCIS allows the free flow of data between the critical care unit and other departments. Provides a rich repository of patient information that can be integrated for use i our outcomes management. Each patient's data can be accessed from any terminal or workstation. This capability can extend across units and departments or be restricted to a single unit.

25. CCIS include: Patient management service length of stay mortality readmit rates. Prognostic scoring systems can be integrated to facilitate assessing the severity of an illness. The CCIS can use the healthcare organization’s system to schedule patient care activities, treatment, and diagnostic testing )

26. Vital Sign Monitoring Vital signs and other physiologic data can be automatically acquired from bedside instruments and incorporated into the clinical database Data can be incorporated into flow sheets with other data elements such as laboratory results body system assessment findings problem lists.

27. CIS also includes: Diagnostic Testing Result Results can be displayed in flow sheets such as Laboratory Radiology Cardiology results Clinicians can also access picture archival information

28. Clinical Documentation to support the process of Physical assessment findings As the critical care environment requires frequent assessments, these flowsheets may be configured to ease this extensive data collection. Flowsheets may also be organized by body system. All disciples can document patient assessment findings into the CCIS. Automatic calculation of physiologic indices can be performed

29. Decision support The CCIS can provide alerts and reminders to guide care in accordance with evidence-based guidelines. Point of care access to knowledge bases that contain information on evidence-based guide-lines of care, drug information, procedures and policies. Data can be integrated with patient information.

30. Medication Management Can facilitate the medication administration process Medication administration of flowsheets incorporate the use of bar code technology

31. Interdisciplinary plans of care Special flowsheets incorporating required treatments and interventions may be provided Work flow management solutions that help orchestrate all of the numerous, simultaneous processes

32. Provider Order Entry Electronic entry and communication of patient orders can help clinicians improve communication, streamline processes, facilitate care, and can help clinicians all providers in managing quality.

33. COORDINATION AND SCHEDULING OF PATIENT CARE ACTIVITIES Critical care flowsheet is a predominant display format for CCIS the goal of CCIS is to have as much information integrated into the system as possible to obtain a comprehensive picture of the patients.

34. What are the Future Developments?

35. THE END