Erfahrungen mit einem neuen Computer-gestützten System zur automatischen Erfassung und Überwachung von nosokomialen Infektionen an Intensivstationen –
MONI 4
A. Blacky, W. Koller, H. Mandl, und K.P. Adlassnig
Fully Automated Surveillance of Healthcare-Associated Infections with MONI-ICU
A Breakthrough in Clinical Infection Surveillance
ICU Wards at the Vienna General Hospital
• 13B1• 13B3• 13C1• 13C2• 13C3• 13H1• 13H3• 13I1• 13I2• 13I3• transplant ICU• neurosurgery ICU• NICU 9C• NICU E10• NICU E12
Erfolge bei der Infektions- prävention
Aufwand für die Surveillance
Hoher Dokumentationsaufwand bei hoher Datenredundanz:
Viele Daten liegen redundant in verschiedenen IT-Systemen vor . . .So often are the same data in various IT-Systems stored ….. Verwaltungssystem, Laborinformationssystem,Billingsystems, Laboratorysystems, ……Pflegedokumentation, Anästhesieinformationssystem,Caredocumentation, ……Medizinische Patientendokumentation, etc.
„Der Mensch ist für den Computer da“
Der Computer ist für die Menschen da!!!
Computers in Clinical Medicine
• step 1: patient administration– admission, transfer, discharge, and cost billing
• step 2: documentation of patients’ medical data– electronic health record: life-long, multimedia
• step 3: patient data retrieval– medical research databases (data mining)– quality assurance in the medical institution
• step 4: software-based clinical decision support– quality assurance for the particular patient
patient-specific alerts
infection control
natural-language definitions of nosocomial infections
Fuzzy theories
Artificial intelligence
Monitoring of
nosocomial infections
knowledge-based systems
fuzzy sets and logic
ICUICU
microbiology
cockpit surveillance remote
clinical data
Medicine
data on microorganisms
cockpit surveillance at ward ICU
Bloodstream Infections (BSI)
• bloodstream infection with
– recognized pathogen– clinical signs and growth
of same skin contaminant from two separate blood samples
– clinical signs and growth skin contaminant from blood and intravascular line in place and AB Therapy
– clinical signs and positive antigen test from blood
Bloodstream infection with clinical signs and growth of same skin contaminant from two separate blood samples
BSI-A2
1
clinical_signs_of_BSI (t-1d, t, t+1d)
same_skin_contaminant_from_two_separate_blood_samples
Decomposition—clinical signs
clinical_signs_of_BSI (t-1d, t, t+1d)[yesterday, today, tomorrow]
=fever (t-1d)
hypotension (t-1d)
clinical_signs_of_BSI (t-1d) = leucopenia (t-1d)
leucocytosis (t-1d)
CRP increased (t-1d)
fever (t)
hypotension (t)
clinical_signs_of_BSI (t) = leucopenia (t)
leucocytosis (t)
CRP increased (t)
fever (t+1d)
hypotension (t+1d)
clinical_signs_of_BSI (t+1d) = leucopenia (t+1d)
leucocytosis (t+1d)
CRP increased (t+1d)
fever (t-1d)
...
body temperature
fever (t)
thermoregulation applied
fever (t+1d)
...
Clinical signs—fever
data import
intensive care unit
maximum value of the day e.g., 38.5 C
C
1
037 37.5 38 38.5
Clinical Signs—CRP Increased
CRP increased (t-1d)
…
CRP increased (t)
CRP increased (t+1d)
…
data import
intensive care unit
maximum value of the day e.g., 5 mg/dl
mg/dl0
1 6
CRP
0.8
1
5
Decomposition—skin contaminant
first blood culture
- coagulase-negative staphylococci
- Micrococcus sp.
- Propionibacterium acnes
- Bacillus sp.
- Corynebacterium sp.
same_skin_contaminant_from_two_separate_blood_samples
second blood culture
- coagulase-negative staphylococci
- Micrococcus sp.
- Propionibacterium acnes
- Bacillus sp.
- Corynebacterium sp.
data import
microbiology
(within 48 hours)
Aller Anfang ist schwer . . .
Data sources and integration
HIS: hospital information system (here: HIS of the City of Vienna)PDMS: patient data management systems (here: CareVue by Philips)CDA: clinical data archiveISM: information support martLIS: laboratory information system of the microbiology (here: HIS of the City of Vienna)HIS DB: relational data base of medical data
LIS
PDMS s
CDA
ISMHIS
DBHIS
…
Moni 4
clinical data
microbiological data
CareVueCareVue
CareVueCareVue
administrative data +
HIS
patient-specific alerts
infection control
natural-language definitions of nosocomial infections
Fuzzy theories
Artificial intelligence
Monitoring of
nosocomial infections
knowledge-based systems
fuzzy sets and logic
ICUICU
microbiology
cockpit surveillance remote
clinical data
Medicine
data on microorganisms
cockpit surveillance at ward ICU
Cockpit Surveillance at the infection control unit
Catheter-Associated Symptomatic Urinary Tract Infection
completely fulfilled (100%)
Backtracking of the Logical Chain of Reasoning
patient has urinary catheter
Elevated CRP as a Clinical Sign present (100%)
Elevated CRP is Present 6 mg/dl is measured
Other Signs of Urinary Tract Infection Pyurie
Neues MONI 4: MONI ICU und MONI N- ICU
„The Next Generation“
n without HCAI with HCAI
patients 52ICU stays 55 44 11*
LOS (days)median:7 shortest:1 longest:25
patient days 422 367 55
* comprising 18 HCAI episodes: 7 with one, 1 with two and 3 with three distinct infection episodes during one stay
MONI 4: Evaluierung
1 ICU:
MONI reported: 11 stays with HCAI 44 stays without HCAI
HCAI present 8 (72.7%) 0 (0%)
HCAI absent 3* (27.3%) 44 (100%)
human expert reported:
HCAI present 8 (72.7%) 1** (2.3%)
HCAI absent 3*** (27.3%) 43 (97.7%)
# one or more HCAIs during one stay* 2 PN episodes and 1 CRI episode not reported due to missing import of electronic microbiology report ** human expert wrongly reported a UTI due to clinical notes in dismission report which could not be verified by any data in the patient charts (UT-colonisation only)*** human expert missed 2 CRI and 1 BSI episodes
HCAI condition# per ICU stay correctly or falsely identified by MONI and by the human expert
Sensitivity and specificity of automated MONI vs. human expert HCAI surveillance
MONI human expert
syndrome n sensitivity specificity sensitivity specificity
BSI 3 100% 100% 0% 100%
CRI 9 88.8% 100% 33.3% 100%
PN 5 40% 100% 100% 100%
overall HCAI** 11 72.7% 100% 72.7% 97.7%
** comprising 18 HCAI episodes: 7 with one, 1 with two and 3 with three distinct infection episodes during one stay
Conventional surveillance
MONI-ICU surveillance
Time spent82.5 h (100%)
12.5 h (15.2%)
Surveillance - Zeitbedarf
2 ICUs alle ICUs
Erfolge bei der Infektions- prävention
Aufwand für die Surveillance
Herzlichen Dank!
Der Computer ist für die Menschen da!!!
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