Trends in the management of acute and critically ill patients Monitoring Technology Telemetry - is the monitoring and analyzing

of data that are received at a distance from their source. It usually refers to a certain way of monitoring a hospital patient's heart activity - it allows the patient to get up and move around, at least within the device's transmitting range. - To provide skilled cardiac monitoring to patients who require cardiac monitoring, but otherwise do not warrant ICU placement. Any patient who needs continuous EKG monitoring with no other need for intensive level care, including, but not limited to: 1. Symptomatic and/or chronic or potential for life-threatening arrhythmias. 2. CCU or ICU transfers, status-post MI. 3. Post cardiothoracic surgery. 4. Drug toxicities limited to potential arrhythmogenic compounds such as digitalis and tricyclics. 5. New onset supraventricular arrhythmias (atrial fibrillation or flutter, PSVT, etc.) 6. Suspected pacemaker malfunction. 7. Observation post pacemaker or defibrillator placement or post ablation. 8. Syncope when an arrhythmia or other cardiac disorder is a suspected etiology. 9. Suspected defibrillator discharge. 10. Unstable angina of low or intermediate grade (new onset angina without EKG or enzymatic changes, crescendo angina in patient with history of coronary disease). 11. Study drug protocols requiring cardiac monitoring as a part of the protocol.

Prior to discharge from the Telemetry Unit, patients shall meet the following criteria: 1. Physician shall order the discontinuation of Telemetry monitoring. 2. Patient shall be free of chest pain for 24 hours prior to discharge. 3. Patient's vital signs shall be stable. 4. Patient does not require intravenous vasoactive medications. 5. Patient shall be able to perform minimal ADLs without shortness of breath. 6. Patient shall have normal sinus rhythm, stable rhythm, or controlled arrhythmia for the past 24 hours. Diagnostic information system Today s physicians and other caregivers have access to more than 5,000 different patient tests to help them evaluate, diagnose, and treat patients. The problem is that physicians receive these test results from a wide range of disparate sources that use vastly different reporting formats. Displaying test results in fragmented, variable and incomplete formats prevents physicians from efficiently reviewing and analyzing vital patient information. This can lead to:


Clinicians spending far too much time (an estimated 30%) gathering and organizing data

   

Critical information being missed which can cause medical errors Redundant testing (an estimated 14% to 30% of the 30 billion diagnostic tests done annually in the US are non-contributory and avoidable) The inability to share or exchange vital clinical information among providers Underutilization of EHRs and other health IT applications and an unnecessary reliance on paper, telephones, and fax machines

In order to provide cost-effective, high quality care, physicians and other caregivers need immediate access to accurate, timely, and comprehensive clinical information. The patented DISSM Solution provides rapid access to cumulative patient information in an easy to read and analyze format that increases the accuracy and efficiency of patient care and improves the productivity of physicians, nurses and others at all points of care. The patented DISSM Solution provides rapid access to cumulative patient information in an easy to read and analyze format that increases the accuracy and efficiency of patient care and improves the productivity of physicians, nurses and others at all points of care. DISSM can aggregate and collate more than 5,000 different patient test results and display them all in one place in the same user-friendly format. Its ease of access and use adds immediate value to the healthcare delivery process: 1. Converts raw patient test results data into organized, meaningful information for easy access, viewing, and analysis 2. Provides a standardized reporting format that unifies test results from all data sources for users at all points of care 3. Integrates test results data on all levels (data, application, system and network) increasing efficiency, accuracy and productivity 4. Reduces the number of pages and screens on which results are displayed by an average of 80 percent 5. Saves time and helps physicians minimize duplicate and non-contributory testing The DISSM Technology solution was specifically designed for immediate use by all test results data users in physician offices, hospital inpatient facilities and outpatient clinics and community health centers. Its implementation will depend on collaborative innovation among a number of interdependent stakeholders. These include all the test results data providers in hospital and community-based clinical laboratories and in imaging and other testing facilities and the vendors of EHRs and PHRs, as well as the vendors of HIE data integration and exchange platforms and the RHIOs/HIEs that they serve. A mechanical ventilator is a machine that generates a controlled flow of gas into a patient s airways. Oxygen and air are received from cylinders or wall outlets, the gas is pressure reduced and blended according to the prescribed inspired oxygen tension (FiO2), accumulated in a receptacle within the machine, and delivered to the patient using one of many available modes of ventilation. The mechanics of inspiratory support are more complex than previously considered. It has been established that cyclical inflation and deflation injures lung parenchyma and worsens outcome (1). Large

tidal volume ventilation, to normalize blood gases has been shown to worsen outcome in lung injury (2), presumably due to excessive pressure induced stretch injury of the parenchyma. Modern ventilation strategy involves attempting to achieve an adequate minute volume with the lowest possible airway pressure (as this relates to the degree of alveolar distension). The pressure that we are interested in minimizing is at the level of the alveolus, the plateau pressure. Ventilator cycling refers to the mechanism by which the phase of the breath switches from inspiration to expiration. Modes of ventilation are time cycled, volume cycled or flow cycled. Time cycling refers to the application of a set controlled breath rate. In controlled ventilation a number of mandatory breaths are delivered to the patient at a predetermined interval. The respiratory rate may be controlled by the operator or the patient. The patient may breathe spontaneously, and with modern ventilators these breaths are supported either by delivering facsimiles of the controlled breaths synchronously with the patient s effort or by allowing the patient more subjective control. Pressure support is a form of flow cycled ventilation in which the patient triggers the ventilator and a pressure limited flow of gas is delivered. The patient determines the duration of the breath and the tidal volume, which may vary from breath to breath. CT scans are a specialized type of x-ray. The patient lies down on a couch which slides into a large circular opening. The x-ray tube rotates around the patient and a computer collects the results. These results are translated into images that look like a "slice" of the person. Sometimes a radiologist will decide that contrast agents should be used. Contrast agents are iodine based and are absorbed by abnormal tissues. They make it easier for the doctor to see tumors within the brain tissue. There are some (rare) risks associated with contrast agents and you should make sure that you discuss this with the doctor before arriving for the examination. CT is very good for imaging bone structures. In fact, it's usually the imaging mode of choice when looking at the inner ears. It can easily detect tumors within the auditory canals and can demonstrate the entire cochlea on most patients. MRI is a completely different animal! Unlike CT it uses magnets and radio waves to create the images. No x-rays are used in an MRI scanner. The patient lies on a couch that looks very similar the ones used for CT. They are then placed in a very long cylinder and asked to remain perfectly still. The machine will produce a lot of noise and examinations typically run about 30 minutes. The cylinder that you are lying in is actually a very large magnet. The computer will send radio waves through your body and collect the signal that is emitted from the hydrogen atoms in your cells. This information is collected by an antenna and fed into a sophisticated computer that produces the images. These images look similar to a CAT scan but they have much higher detail in the soft tissues. Unfortunately, MRI does not do a very good job with bones. One of the great advantages of MRI is the ability to change the contrast of the images. Small changes in the radio waves and the magnetic fields can completely change the contrast of the image. Different contrast settings will highlight different types of tissue.

Another advantage of MRI is the ability to change the imaging plane without moving the patient. If you look at the images to the left you should notice that they look very different. The top two images are what we call axial images. This is what you would see if you cut the patient in half and looked at them from the top. The image on the bottom is a coronal image. This slices the patient from front to back. Most MRI machines can produce images in any plane. CT can not do this. Contrast agents are also used in MRI but they are not made of iodine. There are fewer documented cases of reactions to MRI contrast and it is considered to be safer than x-ray dye. Once again, you should discuss contrast agents with your physician before you arrive for the examination. ICU The ICU environment should focus on these therapeutic elements: y Windows and art that provide natural views; views of nature can reduce stress, hasten recovery, lower blood pressure and lower pain medication needs Family participation, including facilities for overnight stay and comfortable waiting rooms Providing familiarity in the ICU environment through personalization, warmer colors, natural materials, and artwork Providing a measure of privacy and personal control through adjustable lighting, adjustable curtains and blinds, accessible bed controls, and TV, VCR and CD players Noise reduction through computerized pagers and silent alarms Medical team continuity that allows one team to follow the patient through his or her entire stay A tele-ICU system involves a command center with the technological capability to remotely monitor patients in off-site intensive care units. The command center is staffed with intensivist physicians and critical care nurses who use two-way audio-visual monitoring systems to provide support and guidance to the bedside staff in those ICUs. And critical care nurses play a major role in the success of a tele-ICU. They have a great deal of potential when it comes to bridging distance barriers, influencing patient safety and even mentoring bedside nurses, noted Karen Harvey, MSN, RN, certification programs specialist for the corporation.

Laboratory testing What are the indicators of test reliability? Four indicators are most commonly used to determine the reliability of a clinical laboratory test. Two of these, accuracy and precision, reflect how well the test method performs day to day in a laboratory. The other two, sensitivity and specificity, deal with how well the test is able to distinguish disease from absence of disease. The accuracy and precision of each test method are established and are frequently monitored by the professional laboratory personnel. Sensitivity and specificity data are determined by research studies and are generally found in medical literature. Although each test has its own performance measures and appropriate uses, laboratory tests are designed to be as precise, accurate, specific, and sensitive as possible. These basic concepts are the cornerstones of reliability of your test results and provide the confidence your health care provider has in using the clinical laboratory. Accuracy and Precision Statistical measurements of accuracy and precision reveal a lab test's basic reliability. These terms, which describe sources of variability, are not interchangeable. A test method can be precise (reliable reproducibility) without being accurate (measuring what it is supposed to measure and its true value) or vice versa. Precision (Repeatability) A test method is said to be precise when repeated analyses on the same sample give similar results. When a test method is precise, the amount of random variation is small. The test method can be trusted because results are reliably reproduced time after time.

Accuracy (Trueness) A test method is said to be accurate when the test value approaches the absolute true value of the substance (analyte) being measured. Results from every test performed are compared to known "control specimens" that have undergone multiple evaluations and compared to the "gold" standard for that assay, thus analyzed to the best testing standards available.

Although a test that is 100% accurate and 100% precise is ideal, in practice, test methodology, instrumentation, and laboratory operations all contribute to small but measurable variations in results. The small amount of variability that typically occurs does not usually detract from the tests value and statistically is insignificant. The level of precision and accuracy that can be obtained is specific to each test method but is constantly monitored for reliability through comprehensive quality control and quality assurance procedures. Therefore, when your blood is tested more than once by the same laboratory, your test results should not change much unless your condition has changed. There may be some differences between laboratories in precision and accuracy due to different analytical instrumentation or methodologies, however, the test results are reported with standardized reference intervals specific for that laboratory. This helps your health care provider to correctly interpret the information and its relevance to that reference interval. Sensitivity and Specificity The tests that a provider chooses in order to diagnose or monitor a medical condition are based on their inherent ability to distinguish whether you have the condition or do not have the condition. Depending on the symptoms and medical history, a provider will order tests to confirm a condition (tests with high sensitivity) or tests to rule out the condition (tests with high specificity). Sensitivity Sensitivity is the ability of a test to correctly identify individuals who have a given disease or condition. For example, a certain test may have proven to be 90% sensitive. If 100 people are known to have a certain disease, the test that

identifies that disease will correctly do so for 90 of those 100 cases (90%). The other 10 people (10%) tested will not show the expected result for this test. For that 10%, the finding of a "normal" result can be misleading and is termed false-negative. A test's sensitivity becomes particularly important when you are seeking to exclude a dangerous disease, such as testing for the presence of the HIV antibody. Screening for HIV antibody often utilizes an ELISA test method, which has sensitivity over 99%. However, a person may get a false-negative if tested too soon after the initial infection (less than 6 weeks). Thus, the result of a false-negative gives a person the sense of being disease-free when in fact they are not. The more sensitive a test, the fewer false-negative results will be produced. Specificity Specificity is the ability of a test to correctly exclude individuals who do not have a given disease or condition. For example, a certain test may have proven to be 90% specific. If 100 healthy individuals are tested with that method, only 90 of those 100 healthy people (90%) will be found "normal" (disease-free) by the test. The other 10 people (who do not have the disease) will appear to be positive for that test. For that 10%, their "abnormal" findings are a misleading false-positive result. When it is necessary to confirm a diagnosis that requires dangerous therapy, a test's specificity is one of the crucial indicators. A patient who has been told that he is positive for a specific test yet truly does not have that disease may be subjected to potentially painful or dangerous treatment, additional expense, and unwarranted anxiety. The more specific a test, the fewer false-positive results it produces. The FDA requires that developers and manufacturers of a new test provide target values for test results and provide evidence for the expected ranges as well as information on test limitations and other factors that could generate false results. Thus it is critical for the health care provider to correlate the laboratory results with an individual's clinical condition to determine if repeat testing would be needed.