How to start multimodality How to start multimodality monitoring in your ICUmonitoring in your ICU

J. Michael Schmidt, Ph.D.J. Michael Schmidt, Ph.D.Director NICU Clinical InformaticsDirector NICU Clinical Informatics

and Neuromonitoring and Neuromonitoring Columbia UniversityColumbia University

DisclosuresDisclosures

No financial disclosuresNo financial disclosures

ObjectivesObjectives

Big picture rationale for multimodality Big picture rationale for multimodality monitoringmonitoringUnderstanding that there are really 3 Understanding that there are really 3 problems plus 1, with no perfect solutionproblems plus 1, with no perfect solutionData connectivity basics and a little more.Data connectivity basics and a little more.Commercial help is likely in order. Commercial help is likely in order.

Why Multimodal Monitoring?Why Multimodal Monitoring?

CBFpbtO2, pbCO2 , pH, brain tempMicrodialysis

SjvO2

TCD

cEEG

ICP/CPP

FuelFuelPPaa OO22GlucoseGlucose

Delivery SystemDelivery SystemHRHRCardiac IndexCardiac IndexVolume StatusVolume StatusCPP = MAP CPP = MAP -- ICPICP

Traditional Cardiopulmonary Monitoring

Did fuel arrive and was it enough?Did fuel arrive and was it enough?

GoodGood--grade patient: Steer by examgrade patient: Steer by exam

PoorPoor--grade patient: Steer by gaugesgrade patient: Steer by gauges

Rationale for multimodal monitoringRationale for multimodal monitoringDid the fuel arrive?Did the fuel arrive?

–– CBF monitoringCBF monitoring–– LICOX (PLICOX (PbbOO22))–– CMA (brain glucose)CMA (brain glucose)

Was it enough fuel? Was it enough fuel? –– CMA (Lactate / Pyruvate ratio changes) CMA (Lactate / Pyruvate ratio changes)

Are there demand / metabolism changes?Are there demand / metabolism changes?–– PPbbOO22 and brain glucose changes in and brain glucose changes in

accordance to lactate and pyruvate moving accordance to lactate and pyruvate moving up or down togetherup or down together

Is the neuronal activity healthy?Is the neuronal activity healthy?–– EEG / qEEGEEG / qEEG

Go in with your wide eyes openGo in with your wide eyes open

Requires effortRequires effortNeed at least a physician Need at least a physician and nursing champion.and nursing champion.A LOT goes on A LOT goes on unnoticed unnoticed –– think EEG think EEG part II. part II. Switching mentality from Switching mentality from action / no action to action / no action to understanding physiologyunderstanding physiologyRequires more thinking, Requires more thinking, not less.not less.You might question You might question current practices.current practices.

So you really want to get wiredSo you really want to get wired

Three Problems + 1Three Problems + 1Data CollectionData CollectionData Interrogation Data Interrogation Data AnalysisData AnalysisBest use of data for Best use of data for clinical decision clinical decision makingmaking

Data CollectionData Collection

Data SourcesData SourcesPhysiologic MonitorPhysiologic Monitor–– Heart RateHeart Rate–– Blood PressureBlood Pressure–– ICPICP–– PbtO2PbtO2

VentilatorsVentilatorsInfusion PumpsInfusion PumpsStray devicesStray devices–– Cooling devicesCooling devices–– MicrodialysisMicrodialysis

LabsLabs–– Systemic GlucoseSystemic Glucose–– SodiumSodium–– HemoglobinHemoglobin

Clinical ExamClinical ExamOral MedicationsOral MedicationsPatient EventsPatient EventsPatient Plan GoalsPatient Plan Goals

Strategic ConsiderationsStrategic ConsiderationsWho Who ‘‘controlscontrols’’ the data?the data?

Clinical StaffClinical StaffHospital Hospital AdministrationAdministrationCore LabsCore LabsBiomedical Biomedical DepartmentDepartmentIT DepartmentsIT Departments

StrategicStrategicData types (parameter / Data types (parameter / waveform / lab / clinical)waveform / lab / clinical)Scope (clinical / research)Scope (clinical / research)Scale (1 bed / 40 beds)Scale (1 bed / 40 beds)Electronic versus manual Electronic versus manual data entrydata entryInstitutional investmentInstitutional investmentPolitical leveragePolitical leverage

Be open to creative solutionsBe open to creative solutions

IC2 ICP SUREKHA PATEL 1325 Mannitol 20% 3% Saline Osmolal-Serium

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Getting yourself startedGetting yourself started

The Connectivity LingoThe Connectivity Lingo

Connectivity: The BasicsConnectivity: The Basics

RJRJ--45 (Cat 5 Cable): 45 (Cat 5 Cable): Standard Ethernet Standard Ethernet CableCableIf Building a new unit If Building a new unit get as many jacks in get as many jacks in each room as possible each room as possible (>10).(>10).

Connectivity: The BasicsConnectivity: The Basics

DB9 (RS232 / RS485) DB9 (RS232 / RS485) 99--pin connectorpin connector–– RS232 allows one RS232 allows one

connection to deviceconnection to device–– RS485 allows multiple RS485 allows multiple

connections to deviceconnections to device

Why canWhy can’’t I hear you?!t I hear you?!Connecting a Device to a Computer

RSRS--232 Null Modem Adapter/Cable232 Null Modem Adapter/Cable

Allows two devices to Allows two devices to talk back and forth talk back and forth with each other.with each other.

CATCAT--5 Crossover Cable5 Crossover Cable

Allows two devices to Allows two devices to talk back and forth talk back and forth with each other.with each other.

Connection AdaptersConnection Adapters

For example: DB9 to RJFor example: DB9 to RJ--45 adapter45 adapter

Communications Port (COM)Communications Port (COM)

Creating a Device InterfaceCreating a Device Interface

Example: Arctic Sun data over Intranet to a serverExample: Arctic Sun data over Intranet to a server

Pulling It All TogetherPulling It All Together

Monitor Specific SolutionsMonitor Specific SolutionsCMA ICU Pilot allows CMA ICU Pilot allows one to interrogate the one to interrogate the relationships in the datarelationships in the data

Integra Mobius allows Integra Mobius allows archiving of waveform archiving of waveform datadata

Unit Wide Data CollectionUnit Wide Data CollectionExcel Medical Excel Medical (Bedmaster) (Bedmaster) –– Parameter data at 5 Parameter data at 5

secondsseconds–– Saves All visible Saves All visible

waveformswaveforms–– SQL database (open SQL database (open

and extensible) and extensible) –– Supports GE monitors Supports GE monitors

now, Philips in near now, Philips in near futurefuture

–– 18 bed unit requires ~ 18 bed unit requires ~ 500 GB a year in 500 GB a year in storage (not including storage (not including EEG)EEG)

Getting Other Data ElectronicallyGetting Other Data Electronically

Relevant Data: Labs, Medications, Clinical Relevant Data: Labs, Medications, Clinical Exam Scores, etc. Exam Scores, etc. Key Concepts:Key Concepts:–– Electronic Medical RecordElectronic Medical Record–– Interface enginesInterface engines–– Computable Semantic Interoperability Computable Semantic Interoperability

ADT messagesADT messagesHL7HL7

Tension between data availability and Tension between data availability and security and data integrity concerns.security and data integrity concerns.

Computable Semantic Computable Semantic InteroperabilityInteroperability

Ability for two or more systems exchange information and to use the exchanged information correctly. Syntax vs. semantics. Syntax is structure – “The dog eats red meat”– “The dog sings blue trees”

Semantics is meaning– “The patient was given pain medication”– “The patient was given medication for pain”

The Need for StandardsThe Need for Standards

Terminology Servers (Medical, Lab)Terminology Servers (Medical, Lab)Master Patient IndicesMaster Patient IndicesSystems transmit information in different formats Systems transmit information in different formats from each other from each other –– need for interface engineneed for interface engine

Interface Engines

Formats: HL7, DICOMProtocolsAsynchronous/Batch: FTP, Email, scpSynchronous: Sockets over TCP/IP, Web Services Synchronous: ServicesContent managementConversion Tables (MED)Routing and Message transformation Failure Handling

HL7 messageHL7 message

The Point!The Point!

Body Temperature

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Propofol 100 ml +R Drip 1000 mg 5Glucose: Br Right FrontalSystemic glucose

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Using data safelyUsing data safelyAlways check the deviceAlways check the deviceMultimodality monitoring is about elucidating underlying Multimodality monitoring is about elucidating underlying physiology, not making treat / no treat decisions.physiology, not making treat / no treat decisions.–– Not all physiologic processes can or should be Not all physiologic processes can or should be ‘‘treatedtreated’’–– Trust the numbers but donTrust the numbers but don’’t treat the numberst treat the numbers

PPbtbt OO22 is 15 mmHg is 15 mmHg –– is intervention required?is intervention required?PPbtbt OO22 was 30 mmHg an hour ago and now it is 20 mmHg was 30 mmHg an hour ago and now it is 20 mmHg –– something has changed, what is it!?something has changed, what is it!?

For clinical decisions For clinical decisions -- trust change more than absolute numbers.trust change more than absolute numbers.Changes frequently occur LONG BEFORE clinical exam changes Changes frequently occur LONG BEFORE clinical exam changes are observed.are observed.–– DonDon’’t say: t say: ““I didnI didn’’t believe the data changes were real because t believe the data changes were real because

there wasnthere wasn’’t a clinical exam changet a clinical exam change””You might not have ALL the data needed to make a definitive You might not have ALL the data needed to make a definitive clinical decision. Order another test (e.g., CT Perfusion scan)clinical decision. Order another test (e.g., CT Perfusion scan)Treat data change like a clinical exam change, with possibility Treat data change like a clinical exam change, with possibility of of helping figuring out what is happening. helping figuring out what is happening.

ConclusionsConclusions3 problems (collection, display, analysis)3 problems (collection, display, analysis)–– Solve data collection first.Solve data collection first.–– Open format (e.g., SQL database) best to accommodate display Open format (e.g., SQL database) best to accommodate display

and analysis possibilitiesand analysis possibilitiesWeigh effort of double (triple) charting compared to Weigh effort of double (triple) charting compared to technical / political effort to get an electronic data feed.technical / political effort to get an electronic data feed.Think about how to use data safely. Start by trying to Think about how to use data safely. Start by trying to understand physiology rather than absolute numbers understand physiology rather than absolute numbers Big data change = clinical exam changeBig data change = clinical exam changeAsk vendors of all types about data connectivity Ask vendors of all types about data connectivity –– the the more we all ask for it the easier this will become!more we all ask for it the easier this will become!