1. Advances in Non-Invasive Monitoring
Michael O’Reilly, M.D., M.S.
Chief Medical Officer
Masimo Corporation
Professor of Anesthesiology and Perioperative Care
University of California-Irvine
Adjunct Associate Professor
University of Michigan

2. Technology and Patient Safety
Michael O’Reilly, M.D., M.S.
Chief Medical Officer
Masimo Corporation
Professor of Anesthesiology and Perioperative Care
University of California-Irvine
Adjunct Associate Professor
University of Michigan

3. Technology Convergence
Information
Monitoring
Communication

4. Conflict of Interest Statement
Masimo Corporation

7. The influence of anesthesia care on surgical outcomes

8. ACS-NSQIP (ACS=American College of Surgeons)
For more than a decade, the NSQIP has been a major driving force for quality improvement in surgery in all 128 major VA Surgical Centers. More recently, it has been evaluated in 14 major academic medical centers and 4 smaller community hospitals, making it operative in a total of 142 surgical departments that are widely distributed throughout the USA.
(ACS=American College of Surgeons)

9. 3 2 1 NSQIP Annual Report – FY 2000
Mortality O/E Ratios for All Operations 3 2
Shown on this slide are the O/E ratios for mortality of all operations at each medical center as they appeared in the FY 97 Annual Report of the NSQIP. The error bars represent the 90% confidence intervals. The hospitals are identified by code, each facility being privy only of its own code. The O/E ratio ranged from 0 to The asterisks denote a statistically significant high outlier hospital, I.e. a hospital wherein the 30-day mortality rate is significantly higher than that expected on the basis of the severity of illness of the patients, and wherein quality of care is probably compromised. The pound sign denotes a statistically low O/E ratio, and hence, probably, superior quality of care.
With a pound sign or an asterix, you are passing a specific qualitative judgment 1

10. But No Intraoperative Data!
Estimated Blood Loss (EBL)
BP, HR, SPO2, Temperature
Duration of Surgery
Urine Output………Nothing.
But they have 30 Day Outcome.
Surgery meets Anesthesiology

11. European Surgical Outcomes Study (EuSOS) group for the Trials groups of the European Society of Intensive Care Medicine and the European Society of Anaesthesiology
Lancet 2012; 380: 1059–65

12. Methods: 7 day cohort study Consecutive patients aged ≥16 years
Inpatient non-cardiac surgery
498 hospitals
28 European nations
Patients followed up to 60 days
Primary endpoint in-hospital mortality
Secondary outcome LOS and ICU admission
Lancet 2012; 380: 1059–65

13. Results: 46 539 patients 1855 (4%) died before hospital discharge
3599 (8%) patients were admitted to critical care
median LOS of 1・2 days (IQR 0・9–3・6)
1358 (73%) patients who died were not admitted to critical care at any stage after surgery.
Crude mortality rates between countries (from 1.2% for Iceland to 21.5% for Latvia)
Lancet 2012; 380: 1059–65

14. Note the Log Scale!
Lancet 2012; 380: 1059–65

15. Conclusion:
The mortality rate for patients undergoing inpatient non-cardiac surgery was higher than anticipated.
Variations in mortality between countries suggest the need for national and international strategies to improve care for this group of patients.
Lancet 2012; 380: 1059–65

16. From the Michigan Surgical Collaborative
for Outcomes Research and Evaluation,
the Department of Surgery, University of
Michigan, Ann Arbor.
n engl j med 361:14; 2009

17. METHODS 84,730 patients Inpatient general and vascular surgery
Data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP)
Hospitals ranked according to risk-adjusted overall rate of death
Divided into five groups
Each overall mortality quintile assessed the incidence of overall and major complications and the rate of death among patients with major complications.
n engl j med 361:14; 2009

18. n engl j med 361:14; 2009

19. CONCLUSION
“In addition to efforts aimed at avoiding complications in the first place, reducing mortality associated with inpatient surgery will require greater attention to the timely recognition and management of complications once they occur.”
n engl j med 361:14; 2009

20. Preventing “Failure to Rescue”

21. Data Information Decisions Actions So we make the right decisions
We have a lot of data!
But what we really need is information!
Leading to the right action.
I think this is good for a high level strategy 21

22. Sensors Data Information Light Electrical Acoustic Radar Ultrasound
-SpO2
-SpHb
-Cerebral oximetry
-Tissue Oximetry
EHR
Lab
Pharmacy
Electrical
-EKG
-EEG
-Impedance
Acoustic
Radar
Ultrasound
I think this is good for a high level strategy 22

23. Different roles, different locations
Sensors
Data
Information
Decisions
Actions
Providers
I think this is good for a high level strategy
Different roles, different locations 23

24. Technology Convergence
Information
Monitoring
Communication

25. Peter Pronovost, MD

27. Preventing CLABSI !. Hand washing 2. Full barrier precautions
3. Clean the site with chlorhexidine
4. Avoid the femoral site
5. Remove unnecessary catheters

29. “To really make progress, need cooperation of vendors, clinicians and administrators.”

30. Implement known patient safety practices.
Get vendors to provide open access to data.

32. Technology Convergence
Information
Monitoring
Communication

33. Critical Care Medicine 2:317; 1974C

34. Critical Care Medicine 2:317; 1974C

35. Liver Transplant Continuous Noninvasive Hemoglobin
You can see that blood samples were obtained at regular intervals, as is typical of a liver transplant.
When you look at the continuous SpHb, you can see that it tracks the intermittent lab values very well.
When they checked the value at 2:45, it was much lower than expected (6.7) so they immediately got another sample because they thought it was a sample that was inadvertently diluted (thus giving an artifically low Hb). The repeat value confirmed that the hemoglobin was low (6.4). You can see there is a 15 minute delay before they started giving blood faster as reflected in the rapidly increasing SpHb at about 3:10.
The next animation shows lines at a Hb of 7 and 8. This means, in general, you do not want the hemoglobin to go to less than 7 and that once you start to give blood there is no good reason to go above 8; you should keep it between 7 and 8. Or between 6 and 7 depending on the pts other comorbities.
The shaded areas reflect time spent in the “out of range” area.
It is likely that SpHb will prevent the pt being in the red zone; that is, getting transfusions late or getting overtransfused.
It is likely we can make a better version of this slide that is more intuitive.

36. A blood transfusion is an organ transplant.

37. Variation of blood transfusion in patients undergoing major non-cardiac surgery
Qian F. Et al. Ann Surg Feb;257(2):266-78

38. Blood Transfusion: Who is at risk The 1-3units of RBC transfused
Goodnough L.T. Shander A. A&A 2012

39. Remote Monitoring & Clinician Notification System

40. Halo Display
Halo Index has CE Mark

41. Anesthesiology 112:284-9; 2010

42. Transfers to ICU 5.0 2.6 PSN Comparison Unit 1 Comparison Unit 2
Only the PSN unit has statistically significant change in number of transfers to ICU before and after implementation.
Anesthesiology 112:284-9; 2010

43. Reduction in Rescue Calls
PSN
Comparison Unit 1
Comparison Unit 2
3.4
1.0
Only the PSN unit had a significantly change in number of rescue calls before and after implementation.
3.4 calls per 1000 patient days before and 1.0 calls after implementation. Over a 12 month period this would mean a reduction of rescue calls from 37 to 11 for one unit.
Taenzer, et al., Anesthesiology 112:284-9; 2010

44. Significant Financial Implications
Over a 12 month period decreased transfers to the ICU from 54 to 28 for one unit.
With an average LOS of 6.3 days, translates into 163 ICU days saved