U.S. patent application number 11/072359 was filed with the patent office on 2006-04-20 for remote command center for patient monitoring relationship to other applications.
This patent application is currently assigned to VISICU, Inc.. Invention is credited to Michael Breslow, Brian A. Rosenfeld.
Application Number | 20060085229 11/072359 |
Document ID | / |
Family ID | 46304074 |
Filed Date | 2006-04-20 |
United States Patent
Application |
20060085229 |
Kind Code |
A9 |
Rosenfeld; Brian A. ; et
al. |
April 20, 2006 |
Remote command center for patient monitoring relationship to other
applications
Abstract
A remote command center for providing services to geographically
dispersed hospitalized patients. A datastore accessible to the
remote command center receives patient data from geographically
dispersed hospitalized patients. Monitored data elements of
geographically dispersed hospitalized patients are also received at
the remote command center and stored in the datastore. A smart
alert module generates and applies patient specific rules to
selected data elements. If a patient-specific rule for a
hospitalized patient has been contravened, an alert is issued from
the remote command center. A patient care module displays selected
data elements of the hospitalized patients at the remote command
center. A decision support module applies decision support
algorithms to selected data elements of a hospitalized patient and
to user input to provide patient care advice. Patient care advice
comprises a diagnosis, a method of treatment, and a laboratory
protocol. The decision support module may also write orders for
medication, laboratory protocols and surgical procedures.
Inventors: |
Rosenfeld; Brian A.;
(Baltimore, MD) ; Breslow; Michael; (Lutherville,
MD) |
Correspondence
Address: |
ROBERTS ABOKHAIR & MARDULA
SUITE 1000
11800 SUNRISE VALLEY DRIVE
RESTON
VA
20191
US
|
Assignee: |
VISICU, Inc.
|
Prior
Publication: |
|
Document Identifier |
Publication Date |
|
US 20050177400 A1 |
August 11, 2005 |
|
|
Family ID: |
46304074 |
Appl. No.: |
11/072359 |
Filed: |
March 4, 2005 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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10654668 |
Sep 4, 2003 |
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11072359 |
Mar 4, 2005 |
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10946548 |
Sep 21, 2004 |
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11072359 |
Mar 4, 2005 |
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09443072 |
Nov 18, 1999 |
6804656 |
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10654668 |
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09443072 |
Nov 18, 1999 |
6804656 |
|
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10946548 |
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60141520 |
Jun 23, 1999 |
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Current U.S.
Class: |
705/3 |
Current CPC
Class: |
A61B 5/411 20130101;
G06Q 10/10 20130101; A61B 5/0205 20130101; G06Q 40/08 20130101;
G16H 10/60 20180101; A61B 5/0022 20130101; G16H 80/00 20180101;
A61B 5/412 20130101; G16H 70/60 20180101; G16H 20/40 20180101; A61B
5/002 20130101; G16H 50/20 20180101; G16H 40/20 20180101; G16H
40/67 20180101; G08B 21/0476 20130101; A61B 5/4094 20130101 |
Class at
Publication: |
705/003 |
International
Class: |
G06F 17/60 20060101
G06F017/60 |
Claims
1. A remote command center for providing services to geographically
dispersed hospitalized patients comprising: a datastore, wherein
the datastore comprises patient data elements of the geographically
dispersed hospitalized patients; a network interface, wherein the
network interface is adapted to receive monitored data elements
from the geographically dispersed hospitalized patients via a
network; and a smart alert module, wherein the smart alert module
is adapted to: receive the monitored data elements from the
geographically dispersed hospitalized patients; access patient data
elements indicative of a medical condition associated with each of
the geographically dispersed hospitalized patients; establish
patient-specific rules based at least in part on the indicated
medical condition associated with each of the geographically
dispersed hospitalized patients; and apply the patient-specific
rules continuously using a rules engine adapted to: select data
elements from the monitored data elements and the patient data
elements associated with a hospitalized patient; apply a
patient-specific rule associated with the hospitalized patient to
the selected data elements; determine whether the patient-specific
rule for the hospitalized patient has been contravened; and if the
patient-specific rule for the hospitalized patient has been
contravened, then issue an alert from the remote command
center.
2. The remote command center of claim 1, wherein the patient
specific rule for the hospitalized patient comprises an
algorithm.
3. The remote command center of claim 1, wherein the selected data
elements comprise a physiological data element of the hospitalized
patient and a clinical data element of the hospitalized
patient.
4. The remote command center of claim 1, wherein the selected data
elements comprise a physiological data element of the hospitalized
patient and a medication data element of the hospitalized
patient.
5. The remote command center of claim 1, wherein the selected data
elements comprise a physiological data element of the hospitalized
patient and a laboratory data element of the hospitalized
patient.
6. The remote command center of claim 1, wherein the selected data
elements comprise a clinical data element of the hospitalized
patient and a laboratory data element of the hospitalized
patient.
7. The remote command center of claim 1, wherein the selected data
elements comprise a physiological data element of the hospitalized
patient and another physiological data element of the hospitalized
patient.
8. The remote command center of claim 1, wherein the selected data
elements comprise at least two data elements of the hospitalized
patient selected from the group consisting of a physiological data
element, a clinical data element of the hospitalized patient, a
medication data element of the hospitalized patient, and a
laboratory data element of the hospitalized patient.
9. The remote command center of claim 1, wherein the alert
comprises a patient intervention protocol and order.
10. The remote command center of claim 1, wherein the rules engine
is further adapted to: determine whether the hospitalized patient
requires monitoring by the remote command center; and in the event
the hospitalized patient does not require monitoring by the remote
command center, issue a stop monitoring order.
11. The remote command center of claim 1 further comprising a
patient care management system, wherein the patient care management
system is adapted to: aggregate and display monitored data elements
of a hospitalized patient; maintain monitored data elements of the
hospitalized patient in the datastore; display patient data
elements of the hospitalized patient; display an assessment plan
for the hospitalized patient comprising short term and long term
therapeutic objectives for the hospitalized patient; maintain a
task list comprising treatments identified for the hospitalized
patient; chart selected monitored data elements and patient data
elements; create orders for medications, wherein the orders are
screened for drug interactions and patient allergies; and create
physician notes, wherein a physician note comprises freeform text
and information selected from menus.
12. The remote command center of claim 11, wherein patient data
elements are selected from the group consisting of laboratory data,
clinical data, microbiology/antibiotic data, medication data,
catheter data, drug infusion data, event data, a radiographic
report, a diagnosis, and trend data.
13. The remote command center of claim 11, wherein the patient data
elements are displayed according to an organ system associated with
the patient data element.
14. The remote command center of claim 11, wherein the current
assessment plan for the hospitalized patient comprises sedation,
analgesia, ventilation, nutrition and volume status requirements
for the hospitalized patient.
15. The remote command center of claim 11, wherein the monitored
data elements comprise vital sign data and wherein the patient care
management system is further adapted to display current and
historical vital sign data.
16. The remote command center of claim 1, wherein the remote
command center further comprises a decision support module, wherein
the decision support module is adapted to: access a decision
support algorithm; apply the decision support algorithm to selected
data elements of a hospitalized patient; apply the decision support
algorithm to user input; and provide patient care advice to the
user.
17. The remote command center of claim 16, wherein the decision
support algorithm comprises a guideline selected from the list
consisting of: Acalculous Cholecystitis, Acute Pancreatitis
Algorithms, Acute Renal Failure-Diagnosis, Acute Renal
Failure-Management & Treatment, Adrenal Insufficiency.
Agitation and Anxiety, Depression & Withdrawal, Aminoglycoside
Dosing and Therapeutic Monitoring, an Amphotericin-B Treatment
Guidelines, Analgesia, Antibiotic Classification & Costs,
Antibiograms Algorithm, Antibiotic associated Colitis Algorithm,
ARDS: Hemodynamic Management, ARDS: Steroid Use, ARDS: Ventilator
Strategies, Asthma, Bleeding Patient, Bloodstream Infections, Blunt
Cardiac Injury, Bradyarrhythmias, Brain Death, Bronchodilator Use
in Ventilator Patients, Bronchoscopy & Thoracentesis
Guidelines, Candiduria, Cardiogenic Shock, CardioPulmonary
Resuscitation Guideline, Catheter Related Septicemia, a Catheter
Replacement Strategies, Cervical Cord Injury, Congestive Heart
Failure, COPD Exacerbation & Treatment, CXR (Indications),
Dealing with Difficult patients and families, Diabetic
Ketoacidosis, Dialysis, Diuretic Use, Drug Changes with Renal
Dysfunction, Emergency Cardiac Pacing, Endocarditis Diagnosis and
Treatment, Endocarditis Prophylaxis, End of Life Decisions,
Endotracheal Tubes & Tracheotomy, Ethical Guidelines, Febrile
Neutropenia, FUO, Fluid Resuscitation, Guillain-Barre Syndrome,
Heparin, Heparin-Induced Thrombocytopenia, Hepatic Encephalopathy,
Hepatic Failure, HIV+Patient Infections, Hypercalcemia Diagnosis
and Treatment, Hyperglycemia Insulin Treatment, Hyperkalemia:
Etiology & Treatment, Hypernatremia: Etiology & Treatment,
Hypertensive Crisis, Hypokalemia: Etiology & Treatment,
Hyponatremia: Etiology & Treatment, Hypothermia, Identification
of Cervical Cord Injury, Implantable Cardio-defibrillator,
Intra-Aortic Balloon Device, Intracerebral Hemorrhage, Latex
Allergy, Magnesium Administration, Management of Hypotension,
Inotropes, Management of Patients with Ascites, Empiric Meningitis,
Meningitis, a Myasthenia Gravis, Myocardial Infarction, Myocardial
Infarction with left bundle branch block, Necrotizing Soft Tissue
Infections, Neuromuscular Blockers, Neuromuscular Complications of
Critical Illness, Non-Infectious Causes of Fever, Non-Traumatic
Coma, Noninvasive Modes of Ventilation, Nutritional Management,
Obstetrical Complication, Oliguria, Open Fractures, Ophthalmic
Infections, Organ Procurement Guidelines, PA Catheter Guideline and
Troubleshooting, Pancreatitis, Penetrating Abdominal Injury,
Penetrating Chest Injury, Penicillin Allergy, Permanent Pacemaker
and Indications, Pneumonia Community Acquired, Pneumonia Hospital
Acquired, Post-Op Bleeding, Post-Op Hypertension, Post-Op
Management of Abdominal Post-Op Management of Carotid, Post-Op
Management of Open Heart, Post-Op Management of Thoracotomy,
Post-Op Myocardial Ischemia (Non-Cardiac Arrhythmias after Cardiac
Surgery), Post-Op Power Weaning, Pressure Ulcers, Pulmonary
Embolism Diagnosis, Pulmonary Embolism Treatment, Respiratory
Isolation, Sedation, Seizure, Status Epilepticus, Stroke,
Sub-Arachnoid Hemorrhage, Supra-Ventricular Tachyarrhythmia,
Supra-Ventricular Tachycardia, Wide Complex QRS Tachycardia,
Therapeutic Drug Monitoring, Thrombocytopenia, Thrombolytic
Therapy, Transfusion Guidelines, Traumatic Brain Injury, Assessment
of Sedation, Sedation, Septic Shock, Bolus Sliding, Scale
Midazolam, Short Term Sedation Process, Sinusitis, SIRS, Spinal
Cord Injury, Steroid Replacement Strategy, Thyroid Disease,
Transplant Infection Prophylaxis, Transplant Related Infections,
Treatment of Airway Obstruction, Unknown Poisoning, Unstable
Angina, Upper GI Bleeding Stress Prophylaxis, Vancomycin, Upper GI
Bleeding Non-Variceal, Upper GI Bleeding Variceal, Use of
Hematopoietic Growth Factors, Ventilator Weaning, Ventilator
Weaning Protocol, Venous Thrombosis Diagnosis and Treatment, Venous
Thromboembolism Prophylaxis, Ventricular Arrhythmia, Warfarin,
Warfarin Dosing, and Wound Healing Strategies.
18. The remote command center of claim 16, wherein the patient care
advice is a diagnosis.
19. The remote command center of claim 16, wherein the patient care
advice is a method of treatment.
20. The remote command center of claim 16, wherein the patient care
advice is a laboratory protocol.
21. The remote command center of claim 16, wherein the decision
support module is further adapted to: access an order writing
module; and issue an order from the order writing module.
22. The remote command center of claim 21, wherein the order
comprises authorization to administer medication to the
hospitalized patient.
23. The system of claim 21, wherein the order comprises
authorization to subject the hospitalized patient to a diagnostic
procedure selected from the group consisting of a laboratory
protocol, a ventilator protocol, a hemodynamic protocol, and a
radiology test.
24. The system of claim 21, wherein the order comprises
authorization to subject the hospitalized patient to a treatment
procedure selected from the group consisting of a radiological
procedure and a surgical procedure.
25. The remote command center of claim 1, wherein the network
interface is further adapted to received video images of the
geographically dispersed hospitalized patients via the network, and
wherein the remote command center further comprises a video display
for displaying the video images.
26. The remote command center of claim 1, wherein the network
interface is further adapted to received audio data generated by
the geographically dispersed hospitalized patients via the network,
and wherein the remote command center further comprises an audio
transducer for reproducing the audio data.
27. The remote command center of claim 1, wherein the alert
comprises an audio signal.
28. The remote command center of claim 1, wherein the alert
comprises a message displayed on a computer screen.
29. The remote command center of claim 1, wherein the alert
comprises displaying the hospitalized patient's name in a color
indicative of the severity of the alert.
30. A method for providing services to geographically dispersed
hospitalized patients from a remote command center comprising:
receiving at the remote command center monitored data elements from
geographically dispersed hospitalized patients; accessing patient
data elements indicative of a medical condition associated with
each of the geographically dispersed hospitalized patients;
establishing patient-specific rules based at least in part on the
indicated medical condition associated with each of the
geographically dispersed hospitalized patients; selecting data
elements from the monitored data elements associated with the
hospitalized patient and the patient data elements associated with
the hospitalized patient; applying a patient-specific rule
associated with the hospitalized patient to the selected data
elements; making a determination whether the patient-specific rule
for the hospitalized patient has been contravened; and in the event
the patient-specific rule for the hospitalized patient has been
contravened, issuing an alert from the remote command center.
31. The method for providing services to geographically dispersed
hospitalized patients from a remote command center of claim 30,
wherein the patient specific rule for the hospitalized patient
comprises an algorithm.
32. The method for providing services to geographically dispersed
hospitalized patients from a remote command center of claim 30,
wherein the selected data elements comprise a physiological data
element of the hospitalized patient and a clinical data element of
the hospitalized patient.
33. The method for providing services to geographically dispersed
hospitalized patients from a remote command center of claim 30,
wherein the selected data elements comprise a physiological data
element of the hospitalized patient and a medication data element
of the hospitalized patient.
34. The method for providing services to geographically dispersed
hospitalized patients from a remote command center of claim 30,
wherein the selected data elements comprise a physiological data
element of the hospitalized patient and a laboratory data element
of the hospitalized patient.
35. The method for providing services to geographically dispersed
hospitalized patients from a remote command center of claim 30,
wherein the selected data elements comprise a clinical data element
of the hospitalized patient and a laboratory data element of the
hospitalized patient.
36. The method for providing services to geographically dispersed
hospitalized patients from a remote command center of claim 30,
wherein the selected data elements comprise a physiological data
element of the hospitalized patient and another physiological data
element of the hospitalized patient.
37. The method for providing services to geographically dispersed
hospitalized patients from a remote command center of claim 30,
wherein the selected data elements comprise at least two data
elements of the hospitalized patient selected from the group
consisting of a physiological data element, a clinical data element
of the hospitalized patient, a medication data element of the
hospitalized patient, and a laboratory data element of the
hospitalized patient.
38. The method for providing services to geographically dispersed
hospitalized patients from a remote command center of claim 30,
wherein the alert comprises a patient intervention protocol and
order.
39. The method for providing services to geographically dispersed
hospitalized patients from a remote command center of claim 30,
wherein the method further comprises: determining whether the
hospitalized patient requires monitoring by the monitoring station;
and in the event the hospitalized patient does not require
monitoring by the monitoring station, issuing a stop-monitoring
order.
40. The method for providing services to geographically dispersed
hospitalized patients from a remote command center of claim 30, the
method further comprising: making a determination whether the
hospitalized patient requires monitoring by the remote command
center; and in the event the hospitalized patient does not require
monitoring by the remote command center, issuing a release protocol
and order.
41. The method for providing services to geographically dispersed
hospitalized patients from a remote command center of claim 30,
wherein monitored data elements comprises physiological data
elements.
42. The method for providing services to geographically dispersed
hospitalized patients from a remote command center of claim 30,
wherein monitored data elements comprise video image data elements
and audio data elements.
43. The method for providing services to geographically dispersed
hospitalized patients from a remote command center of claim 30, the
method further comprising: aggregating and displaying monitored
data elements of a hospitalized patient; maintaining monitored data
elements of the hospitalized patient in the datastore; displaying
patient data elements of the hospitalized patient; displaying an
assessment plan for the hospitalized patient comprising short term
and long term therapeutic objectives for the hospitalized patient;
maintaining a task list comprising treatments identified for the
hospitalized patient; charting selected monitored data elements and
patient data elements; creating orders for medications, wherein the
orders are screened for drug interactions and patient allergies;
and creating physician notes, wherein a physician note comprises
freeform text and information selected from menus.
44. The method for providing services to geographically dispersed
hospitalized patients from a remote command center of claim 43,
wherein patient data elements are selected from the group
consisting of laboratory data, clinical data,
microbiology/antibiotic data, medication data, catheter data, drug
infusion data, event data, a radiographic report, a diagnosis, and
trend data.
45. The method for providing services to geographically dispersed
hospitalized patients from a remote command center of claim 43,
wherein the patient data elements are displayed according to an
organ system associated with the patient data element.
46. The method for providing services to geographically dispersed
hospitalized patients from a remote command center of claim 43,
wherein the current assessment plan for the hospitalized patient
comprises sedation, analgesia, ventilation, nutrition and volume
status requirements for the hospitalized patient.
47. The method for providing services to geographically dispersed
hospitalized patients from a remote command center of claim 43,
wherein the monitored data elements comprise vital sign data and
wherein the method further comprises displaying current and
historical vital sign data.
48. The method for providing services to geographically dispersed
hospitalized patients from a remote command center of claim 30, the
method further comprising: accessing a decision support algorithm;
applying the decision support algorithm to selected data elements
of a hospitalized patient; applying the decision support algorithm
to user input; and providing patient care advice to the user.
49. The method for providing services to geographically dispersed
hospitalized patients from a remote command center of claim 48,
wherein the decision support algorithm comprises a guideline
selected from the list consisting of: Acalculous Cholecystitis,
Acute Pancreatitis Algorithms, Acute Renal Failure-Diagnosis, Acute
Renal Failure-Management & Treatment, Adrenal Insufficiency.
Agitation and Anxiety, Depression & Withdrawal, Aminoglycoside
Dosing and Therapeutic Monitoring, an Amphotericin-B Treatment
Guidelines, Analgesia, Antibiotic Classification & Costs,
Antibiograms Algorithm, Antibiotic associated Colitis Algorithm,
ARDS: Hemodynamic Management, ARDS: Steroid Use, ARDS: Ventilator
Strategies, Asthma, Bleeding Patient, Bloodstream Infections, Blunt
Cardiac Injury, Bradyarrhythmias, Brain Death, Bronchodilator Use
in Ventilator Patients, Bronchoscopy & Thoracentesis
Guidelines, Candiduria, Cardiogenic Shock, CardioPulmonary
Resuscitation Guideline, Catheter Related Septicemia, a Catheter
Replacement Strategies, Cervical Cord Injury, Congestive Heart
Failure, COPD Exacerbation & Treatment, CXR (Indications),
Dealing with Difficult patients and families, Diabetic
Ketoacidosis, Dialysis, Diuretic Use, Drug Changes with Renal
Dysfunction, Emergency Cardiac Pacing, Endocarditis Diagnosis and
Treatment, Endocarditis Prophylaxis, End of Life Decisions,
Endotracheal Tubes & Tracheotomy, Ethical Guidelines, Febrile
Neutropenia, FUO, Fluid Resuscitation, Guillain-Barre Syndrome,
Heparin, Heparin-Induced Thrombocytopenia, Hepatic Encephalopathy,
Hepatic Failure, HIV+Patient Infections, Hypercalcemia Diagnosis
and Treatment, Hyperglycemia Insulin Treatment, Hyperkalemia:
Etiology & Treatment, Hypernatremia: Etiology & Treatment,
Hypertensive Crisis, Hypokalemia: Etiology & Treatment,
Hyponatremia: Etiology & Treatment, Hypothermia, Identification
of Cervical Cord Injury, Implantable Cardio-defibrillator,
Intra-Aortic Balloon Device, Intracerebral Hemorrhage, Latex
Allergy, Magnesium Administration, Management of Hypotension,
Inotropes, Management of Patients with Ascites, Empiric Meningitis,
Meningitis, a Myasthenia Gravis, Myocardial Infarction, Myocardial
Infarction with left bundle branch block, Necrotizing Soft Tissue
Infections, Neuromuscular Blockers, Neuromuscular Complications of
Critical Illness, Non-Infectious Causes of Fever, Non-Traumatic
Coma, Noninvasive Modes of Ventilation, Nutritional Management,
Obstetrical Complication, Oliguria, Open Fractures, Ophthalmic
Infections, Organ Procurement Guidelines, PA Catheter Guideline and
Troubleshooting, Pancreatitis, Penetrating Abdominal Injury,
Penetrating Chest Injury, Penicillin Allergy, Permanent Pacemaker
and Indications, Pneumonia Community Acquired, Pneumonia Hospital
Acquired, Post-Op Bleeding, Post-Op Hypertension, Post-Op
Management of Abdominal Post-Op Management of Carotid, Post-Op
Management of Open Heart, Post-Op Management of Thoracotomy,
Post-Op Myocardial Ischemia (Non-Cardiac Arrhythmias after Cardiac
Surgery), Post-Op Power Weaning, Pressure Ulcers, Pulmonary
Embolism Diagnosis, Pulmonary Embolism Treatment, Respiratory
Isolation, Sedation, Seizure, Status Epilepticus, Stroke,
Sub-Arachnoid Hemorrhage, Supra-Ventricular Tachyarrhythmia,
Supra-Ventricular Tachycardia, Wide Complex QRS Tachycardia,
Therapeutic Drug Monitoring, Thrombocytopenia, Thrombolytic
Therapy, Transfusion Guidelines, Traumatic Brain Injury, Assessment
of Sedation, Sedation, Septic Shock, Bolus Sliding, Scale
Midazolam, Short Term Sedation Process, Sinusitis, SIRS, Spinal
Cord Injury, Steroid Replacement Strategy, Thyroid Disease,
Transplant Infection Prophylaxis, Transplant Related Infections,
Treatment of Airway Obstruction, Unknown Poisoning, Unstable
Angina, Upper GI Bleeding Stress Prophylaxis, Vancomycin, Upper GI
Bleeding Non-Variceal, Upper GI Bleeding Variceal, Use of
Hematopoietic Growth Factors, Ventilator Weaning, Ventilator
Weaning Protocol, Venous Thrombosis Diagnosis and Treatment, Venous
Thromboembolism Prophylaxis, Ventricular Arrhythmia, Warfarin,
Warfarin Dosing, and Wound Healing Strategies.
50. The method for providing services to geographically dispersed
hospitalized patients from a remote command center of claim 48,
wherein the patient care advice is a diagnosis.
51. The method for providing services to geographically dispersed
hospitalized patients from a remote command center of claim 48,
wherein the patient care advice is a method of treatment.
52. The method for providing services to geographically dispersed
hospitalized patients from a remote command center of claim 48,
wherein the patient care advice is a laboratory protocol.
53. The method for providing services to geographically dispersed
hospitalized patients from a remote command center of claim 48,
wherein the method further comprises: accessing an order writing
module; and issuing an order from the order writing module.
54. The method for providing services to geographically dispersed
hospitalized patients from a remote command center of claim 53,
wherein the order comprises authorization to administer medication
to the hospitalized patient.
55. The method for providing services to geographically dispersed
hospitalized patients from a remote command center of claim 53,
wherein the order comprises authorization to subject the
hospitalized patient to a diagnostic procedure selected from the
group consisting of a laboratory protocol, a ventilator protocol, a
hemodynamic protocol, and a radiology test.
56. The method for providing services to geographically dispersed
hospitalized patients from a remote command center of claim 53,
wherein the order comprises authorization to subject the
hospitalized patient to a treatment procedure selected from the
group consisting of a radiological procedure and a surgical
procedure.
Description
RELATIONSHIP TO OTHER APPLICATIONS
[0001] This application is a continuation of application Ser. No.
09/443,072, now U.S. Pat. No. 6,804,656, filed Nov. 18, 1999. The
09/443,072 application is hereby incorporated by reference in its
entirety for all purposes.
FIELD OF THE INVENTION
[0002] This invention relates generally to the care of patients in
Intensive Care Units (ICUs). More particularly this invention is a
system and method for care of the critically ill that combines a
real-time, multi-node telemedicine network and an integrated,
patient care management system to enable specially-trained
Intensivists to provide 24-hour/7-day-per-week patient monitoring
and management to multiple, geographically dispersed ICUs from both
on-site and remote locations.
BACKGROUND OF THE INVENTION
[0003] While the severity of illness of ICU patients over the past
15 years has increased dramatically, the level of and type of
physician coverage in most ICUs has remained constant. Most ICU
patients receive brief minutes of attention during morning rounds
from physicians with limited critical care experience. During the
remainder of the day and night, nurses are the primary caregivers,
with specialists called only after patient conditions have started
to deteriorate. The result of this mismatch between severity of
illness and physician coverage is an unacceptably high ICU
mortality rate (10% nationwide), and a high prevalence of avoidable
errors that result in clinical complications. In 1998, an Institute
of Medicine Roundtable determined that avoidable patient
complications were the single largest problem in medical care
delivery. In another prominent 1998 study of 1000 patients, 46%
experienced an avoidable adverse event in care, with 40% of these
errors resulting in serious disability or death.
[0004] The physicians who can remedy this situation are in
critically short supply. Numerous studies have shown that
Intensivists (physicians who have trained and board certified in
Critical Care Medicine) can markedly improve patient outcomes.
However, only one-third of all ICU patients ever has an Intensivist
involved in their care, and the number of Intensivists would need
to increase tenfold (nationally) to provide 24-hour coverage to all
ICU patients. With the rapid aging of the population, this
shortfall of expertise is going to increase dramatically.
[0005] Even where Intensivists are present (and especially where
they are not), patients suffer from unnecessary variation in
practice. There is little incentive for physicians to develop and
conform to evidence-based best practices (it takes significant work
and a change in behavior to develop and implement them). This
variation contributes to sub-optimal outcomes, in both the quality
and cost of care delivered to ICU patients.
[0006] What is needed is a redesigning of the critical care regimen
offered to patients in an ICU. Rather than the consultative model
where a periodic visit takes place and the doctor then goes away, a
more active 24-hour intensivist managed care is required. Further,
technology that leverages the intensivists' expertise and
standardizes the care afforded to patients in an ICU is required.
Further, continuous feedback to improve the practice of
intensivists in an ICU is necessary to provide the intervention
required to minimize adverse events. This invention seeks to
provide new methods for managing and delivering care to the
critically ill.
[0007] Attempts to automate various aspects of patient care have
been the subject of various inventions. For example, U.S. Pat. No.
5,868,669 to Iliff was issued for "Medical Diagnostic and Treatment
Advice System." The disclosed invention is for a system and method
for providing knowledge based medical diagnostic and treatment
advice to the general public over a telephone network.
[0008] U.S. Pat. No. 5,823,948 to Ross, Jr. et al was issued for
"Medical Records Documentation, Tracking and Order Entry System".
The disclosed invention is for a system and method that
computerizes medical records, documentation, tracking and order
entries. A teleconferencing system is employed to allow patient and
medical personnel to communicate with each other. A video system
can be employed to videotape a patient's consent.
[0009] U.S. Pat. No. 4,878,175 to Norden-Paul et al. was issued for
"Method for Generating Patient-Specific Flowsheets By
Adding/Deleting Parameters." The disclosed invention is for an
automated clinical records system for automated entry of bedside
equipment results, such as an EKG monitor, respirator, etc. The
system allows for information to be entered at the bedside using a
terminal having input means and a video display.
[0010] U.S. Pat. No. 5,544,649 to David et al. was issued for
"Ambulatory Patient Health Monitoring Techniques Utilizing
Interactive Visual Communications." The disclosed invention is for
an interactive visual system, which allows monitoring of patients
at remote sites, such as the patient's home. Electronic equipment
and sensors are used at the remote site to obtain data from the
patient, which is sent to the monitoring site. The monitoring site
can display and save the video, audio and patient's data.
[0011] U.S. Pat. No. 5,867,821 to Ballantyne et al. was issued for
"Method and Apparatus for Electronically Accessing and Distributing
Personal Health Care Information and Services in Hospitals and
Homes." The disclosed invention is for an automated system and
method for distribution and administration of medical services,
entertainment services, and electronic health records for health
care facilities.
[0012] U.S. Pat. No. 5,832,450 to Myers et al. issued for
"Electronic Medical Record Using Text Database." The disclosed
invention is for an electronic medical record system, which stores
data about patient encounters arising from a content generator in
freeform text.
[0013] U.S. Pat. No. 5,812,983 to Kumagai was issued for "Computer
Medical File and Chart System." The disclosed invention is for a
system and method which integrates and displays medical data in
which a computer program links a flow sheet of a medical record to
medical charts.
[0014] U.S. Pat. No. 4,489,387 to Lamb et al. was issued for
"Method and Apparatus for Coordinating Medical Procedures." The
disclosed invention is for a method and apparatus that coordinates
two or more medical teams to evaluate and treat a patient at the
same time without repeating the same steps.
[0015] U.S. Pat. No. 4,731,725 to Suto et al. issued for "Data
Processing System which Suggests a Pattern of Medical Tests to
Reduce the Number of Tests Necessary to Confirm or Deny a
Diagnosis." The disclosed invention is for a data processing system
that uses decision trees for diagnosing a patient's symptoms to
confirm or deny the patient's ailment.
[0016] U.S. Pat. No.5,255,187 to Sorensen issued for "Computer
Aided Medical Diagnostic Method and Apparatus." The disclosed
invention is for an interactive diagnostic system which relies on
color codes which signify the presence or absence of the
possibility of a disease based on the symptoms a physician provides
the system.
[0017] U.S. Pat. No. 5,553,609 to Chen et al. issued for
"Intelligent Remote Visual Monitoring System for Home Health Care
Service." The disclosed invention is for a computer-based remote
visual monitoring system, which provides in-home patient health
care from a remote location via ordinary telephone lines.
[0018] U.S. Pat. No. 5,842,978 to Levy was issued for "Supplemental
Audio Visual Emergency Reviewing Apparatus and Method." The
disclosed invention is for a system which videotapes a patient and
superimposes the patient's vital statistics onto the videotape.
[0019] While these inventions provide useful records management and
diagnostic tools, none of them provides a comprehensive method for
monitoring and providing real time critical care at disparate ICUs.
In short, they are NOT designed for critical care. Further, none of
these inventions provide for the care of a full time intensivist
backed by appropriate database and decision support assistance in
the intensive care environment. What would be useful is a system
and method for providing care for the critically ill that maximizes
the presence of an intensivist trained in the care of the
critically ill. Further such a system would standardize the care in
ICUs at a high level and reduce the mortality rate of patients
being cared for in ICUs.
SUMMARY OF THE INVENTION
[0020] The present invention provides a core business of Continuous
Expert Care Network (CXCN) solution for hospital intensive care
units (ICUs). This e-solution uses network, database, and decision
support technologies to provide 24-hour connectivity between
Intensivists and ICUs. The improved access to clinical information
and continuous expert oversight leads to reduced clinical
complications, fewer medical errors, reduced mortality, reduced
length of stay, and reduced overall cost per case.
[0021] The technology of the present invention as explained below
can be implemented all at once or in stages. Thus the technology,
as more fully explained below is available in separate components
to allow for the fact that hospitals may not be able to implement
all of the technology at once. Thus modular pieces (e.g.
videoconferencing, vital sign monitoring with smart alarms,
hand-held physician productivity tools, etc.) can be implemented,
all of which can add value in a stand-alone capacity. First amongst
these offerings will be an Intensivist Decision Support System, a
stand-alone software application that codifies evidence-based, best
practice medicine for 150 common ICU clinical scenarios. These
support algorithms are explained more fully below.
[0022] The "Command Center" model, again as more fully set forth
below, will ultimately give way to a more distributed remote
management model where Intensivists and other physicians can access
ICU patients and clinicians (voice, video, data) from their office
or home. In this scenario, the present invention will be available
in hospital applications that centralize ICU information, and offer
physicians web-based applications that provide them with real-time
connectivity to this information and to the ICUs. This access and
connectivity will enable physicians to monitor and care for their
patients remotely. These products will be natural extensions and
adaptations of the present invention and the existing applications
disclosed herein that those skilled in the art will appreciate and
which do not depart from the scope of the invention as disclosed
herein.
[0023] The present invention addresses these issues and
shortcomings of the existing situation in intensive care, and its
shortfalls via two major thrusts. First, an integrated
video/voice/data network application enables continuous real-time
management of ICU patients from a remote setting. Second, a
client-server database application--integrated to the remote care
network--provides the data analysis, data presentation,
productivity tools and expert knowledge base that enables a single
Intensivist to manage the care of up to 40 patients simultaneously.
The combination of these two thrusts--care management from a remote
location and new, technology-enhanced efficiency of Intensivist
efforts--allows health care systems to economically raise the
standard of care in their ICUs to one of 24.times.7 continuous
Intensivist oversight.
[0024] It is therefore an object of the present invention to reduce
avoidable complications in an ICU.
[0025] It is a further object of the present invention to reduce
unexplained variations in resource utilization in an ICU.
[0026] It is a further objective of the present invention to
mitigate the serious shortage of intensivists.
[0027] It is yet another objective of the present invention to
reduce the occurrence of adverse events in an ICU.
[0028] It is a further objective of the present invention to
standardize the care at a high level among ICUs.
[0029] It is yet another objective of the present invention to
reduce the cost of ICU care.
[0030] It is yet another objective of the present invention to
dramatically decrease the mortality in an ICU.
[0031] It is yet another objective of the present invention to
bring information from the ICU to the intensivist, rather than
bring the intensivist to the ICU.
[0032] It is a further objective of the present invention to
combine tele-medical systems comprising two-way audio/video
communication with a continuous real time feed of clinical
information to enable the intensivist to oversee care within the
ICU.
[0033] It is a further objective of the present invention to allow
intensivists to monitor ICUs from a site remote from each
individual ICU.
[0034] It is a further objective of the present invention to bring
organized detailed clinical information to the intensivist, thereby
providing standardized care in the ICU.
[0035] It is yet another objective of the present invention to
utilize knowledge-based software to use rules, logic, and expertise
to provide preliminary analysis and warnings for the
intensivists.
[0036] The present invention comprises a command center/remote
location, which is electronically linked to ICUs remote from the
command center/remote location. The command center/remote location
is manned by intensivists 24 hours a day, seven days per week. Each
ICU comprises a nurse's station, to which data flows from
individual beds in the ICU. Each patient in the ICU is monitored by
a video camera, as well as by clinical monitors typical for the
intensive care unit. These monitors provide constant real time
patient information to the nurse's station, which in turn provides
that information over a dedicated T-1 (high bandwidth) line to the
ICU command center/remote location. As noted earlier, the command
center/remote location is remote from the ICU, thereby allowing the
command center/remote location to simultaneously monitor a number
of patients in different ICUs remote from the command center/remote
location.
[0037] At each command center/remote location, video monitors exist
so that the intensivist can visually monitor patients within the
ICU. Further, the intensivist can steer and zoom the video camera
near each patient so that specific views of the patient may be
obtained, both up close and generally. Audio links allow
intensivists to talk to patients and staff at an ICU bed location
and allow those individuals to converse with the intensivist.
[0038] Clinical data is constantly monitored and presented to the
command center/remote location in real time so that the intensivist
can not only monitor the video of the patient but also see the
vital signs as transmitted from the bedside. The signals from the
clinical data and video data are submitted to a relational
database, which comprises 1) standardized guidelines for the care
of the critically ill, 2) various algorithms to support the
intensive care regimen, 3) order writing software so that
knowledge-based recommendations and prescriptions for medication
can be made based upon the clinical data, and 4) knowledge-based
vital-sign/hemodynamic algorithms that key the intensivist to
engage in early intervention to minimize adverse events.
[0039] The advantage of the present invention is that intensivists
see all patients at a plurality of ICU's at all times. Further,
there is a continuous proactive intensivist care of all patients
within the ICU, thereby minimizing adverse events. Intervention is
triggered by evidence-based data-driven feedback to the intensivist
so that standardized care can be provided across a plurality of
ICUs.
[0040] The economic benefits of the present invention are manifold.
For the first time, 24-hour a day, seven day a week intensivist
care for patients in an ICU can be obtained. Further, more timely
interventions in the care of the patients can be created by the
knowledge-based guidelines of the present invention, thereby
minimizing complications and adverse events. This in turn will lead
to a reduced mortality within the ICU, and hence, a reduced
liability cost due to the dramatic reduction in avoidable errors in
health care.
[0041] By providing timely interventions, the length of stay within
the ICU can be greatly reduced, thereby allowing more critically
ill patients to be cared for in the ICU.
[0042] In addition, by reviewing and standardizing the care
afforded to patients in an ICU, a more standardized practice across
a variety of ICUs can be achieved. This will lead to more
cost-effective care within the ICU, and reduced ancillary cost for
the care of the critically ill.
[0043] The overall architecture of the present invention comprises
a "pod." The pod comprises a tele-medicine command center/remote
location connected to a plurality multiple ICUs at various
locations. The connection between the command center/remote
location and the ICUs is via a dedicated wide-area network linking
the ICUs to the command center/remote location and a team of
intensivists who integrate their services to provide 24-hour, seven
day a week care to all of the pod ICUs.
[0044] The pod is connected via a wide-area network using dedicated
T-1 lines, for example, with redundant backup. This network
provides reliable, high speed secure transmission of clinical data
and video/audio signals between each patient room and the command
center/remote location. The use of a T-1 line is not meant as a
limitation. It is expected that more and higher bandwidth networks
will become available. Such high bandwidth networks would come
within the scope of the invention as well.
[0045] Each patient room is equipped with a pan/tilt/zoom video
camera with audio and speaker to enable full videoconferencing
capability. In addition, computer workstations are dedicated for
exclusive physician use in each ICU, preferably at the nurse's
station. Intensivists use the workstations to view patient
information, consult decision support information, record their
notes, and generate patient orders.
[0046] The patient management software used by intensivists is
provided across the pod. Updates and changes made to the record are
available at both the ICU and the command center/remote location
for any given patient.
[0047] Each command center/remote location contains at least three
workstations: one for the intensivist, one for the critical care
registered nurse, and one for a clerk/administrative person.
[0048] The intensivist workstation comprises separate monitors for
displaying ICU video images of patients and/or ICU personnel,
output from bedside monitoring equipment, patient clinical data
comprising history, notes, lab reports, etc., and decision support
information. The staff at the command center/remote location are
able to activate and control the cameras in each patient's room so
that appropriate visual views of the patient can be generated.
[0049] Intensivists are able to switch between rooms and patients
and can monitor at least two rooms simultaneously via the video
screens. Patient data such as X-ray and ECG images are scanned and
transmitted to the command center/remote location upon request of
the intensivist.
[0050] Remote patient management is utilized in the present
invention's critical care program to supplement traditional onsite
care. The rationale underlying the remote patient management of the
present invention is that critically ill patients are inherently
unstable and require continuous expert care that is not now offered
in existing ICU monitoring regimens. Further, remote monitoring
allows a single intensivist to care for patients in multiple ICU
locations, thereby creating an efficiency that makes continuous
care feasible.
[0051] Remote intensivist care of the present invention is
proactive. Intensivists will order needed therapies and check
results of tests and monitor modalities in a more timely fashion
than is currently offered. Patients can be observed visually when
needed using the ceiling-mounted cameras in each room.
[0052] Command center/remote location personnel communicate with
ICU staff through videoconferencing and through "hot phones," which
are dedicated telephones directly linked between the command
center/remote location and the ICU. These communications links are
used to discuss patient care issues and to communicate when a new
order has been generated.
[0053] Intensivists document important events occurring during
their shift in progress notes generated on the command
center/remote location computer terminal.
[0054] Intensivists detect impending problems by intermittently
screening patient data, including both real time and continuously
stored vital sign data. Patient severity of illness determines the
frequency with which each patient's data is reviewed by the
intensivists.
[0055] Embodiments of the present invention provide a system for
providing continuous, expert network health care services from a
remote location. The system comprises a plurality of health care
locations, at least one remote command center for managing
healthcare at said plurality of health care locations, and at least
one network. The plurality of health care locations are
electronically connected to said at least one remote command center
by the network. The at least one remote command center provides
intensivist monitoring of the plurality of health care locations 24
hours per days seven days per week.
[0056] The remote command center further comprises a patient care
management system for monitoring and treating individual patients
at any of said plurality of healthcare locations. The patient care
management system further comprises a data server/data warehouse
for storing and analyzing data from the at least one remote command
center.
[0057] Each of the plurality of health care locations further
comprises patient monitoring equipment electronically connected to
the at least one remote command center over the network. In another
embodiment of the present invention each health care location
further comprises a nurses' station electronically connected to
said monitoring equipment and to the at least one remote command
center over the network. In still another embodiment of the present
invention, the healthcare locations comprise intensive care units
(ICU's).
[0058] Optionally, the patient care management system further
comprises a relational database for storing a plurality of decision
support algorithms and for prompting intensivists to provide care
to patients based upon any of the decision support algorithms. The
algorithms are selected from the group consisting of algorithms for
treating Acalculous Cholecystitis, Acute Pancreatitis Algorithms,
Acute Renal Failure-Diagnosis, Acute Renal Failure-Management &
Treatment, Adrenal Insufficiency. Agitation and Anxiety, Depression
& Withdrawal, Aminoglycoside Dosing and Therapeutic Monitoring,
an Amphotericin-B Treatment Guidelines, Analgesia, Antibiotic
Classification & Costs, Antibiograms Algorithm, Antibiotic
associated Colitis Algorithm, ARDS: Hemodynamic Management, ARDS:
Steroid Use, ARDS: Ventilator Strategies, Asthma, Bleeding Patient,
Bloodstream Infections, Blunt Cardiac Injury, Bradyarrhythmias,
Brain Death, Bronchodilator Use in Ventilator Patients,
Bronchoscopy & Thoracentesis Guidelines, Candiduria,
Cardiogenic Shock, CardioPulmonary Resuscitation Guideline,
Catheter Related Septicemia, a Catheter Replacement Strategies,
Cervical Cord Injury, Congestive Heart Failure, COPD Exacerbation
& Treatment, CXR (Indications), Dealing with Difficult patients
and families, Diabetic Ketoacidosis, Dialysis, Diuretic Use, Drug
Changes with Renal Dysfunction, Emergency Cardiac Pacing,
Endocarditis Diagnosis and Treatment, Endocarditis Prophylaxis, End
of Life Decisions, Endotracheal Tubes & Tracheotomy, Ethical
Guidelines, Febrile Neutropenia, FUO, Fluid Resuscitation,
Guillain-Barre Syndrome, Heparin, Heparin-Induced Thrombocytopenia,
Hepatic Encephalopathy, Hepatic Failure, HIV+Patient Infections,
Hypercalcemia Diagnosis and Treatment, Hyperglycemia Insulin
Treatment, Hyperkalemia: Etiology & Treatment, Hypernatremia:
Etiology & Treatment, Hypertensive Crisis, Hypokalemia:
Etiology & Treatment, Hyponatremia: Etiology & Treatment,
Hypothermia, Identification of Cervical Cord Injury, Implantable
Cardio-defibrillator, Intra-Aortic Balloon Device, Intracerebral
Hemorrhage, Latex Allergy, Magnesium Administration, Management of
Hypotension, Inotropes, Management of Patients with Ascites,
Empiric Meningitis, Meningitis, a Myasthenia Gravis, Myocardial
Infarction, Myocardial Infarction with left bundle branch block,
Necrotizing Soft Tissue Infections, Neuromuscular Blockers,
Neuromuscular Complications of Critical Illness, Non-Infectious
Causes of Fever, Non-Traumatic Coma, Noninvasive Modes of
Ventilation, Nutritional Management, Obstetrical Complication,
Oliguria, Open Fractures, Ophthalmic Infections, Organ Procurement
Guidelines, PA Catheter Guideline and Troubleshooting,
Pancreatitis, Penetrating Abdominal Injury, Penetrating Chest
Injury, Penicillin Allergy, Permanent Pacemaker and Indications,
Pneumonia Community Acquired, Pneumonia Hospital Acquired, Post-Op
Bleeding, Post-Op Hypertension, Post-Op Management of Abdominal
Post-Op Management of Carotid, Post-Op Management of Open Heart,
Post-Op Management of Thoracotomy, Post-Op Myocardial Ischemia
(Non-Cardiac Arrhythmias after Cardiac Surgery), Post-Op Power
Weaning, Pressure Ulcers, Pulmonary Embolism Diagnosis, Pulmonary
Embolism Treatment, Respiratory Isolation, Sedation, Seizure,
Status Epilepticus, Stroke, Sub-Arachnoid Hemorrhage,
Supra-Ventricular Tachyarrhythmia, Supra-Ventricular Tachycardia,
Wide Complex QRS Tachycardia, Therapeutic Drug Monitoring,
Thrombocytopenia, Thrombolytic Therapy, Transfusion Guidelines,
Traumatic Brain Injury, Assessment of Sedation, Sedation, Septic
Shock, Bolus Sliding, Scale Midazolam, Short Term Sedation Process,
Sinusitis, SIRS, Spinal Cord Injury, Steroid Replacement Strategy,
Thyroid Disease, Transplant Infection Prophylaxis, Transplant
Related Infections, Treatment of Airway Obstruction, Unknown
Poisoning, Unstable Angina, Upper GI Bleeding Stress Prophylaxis,
Vancomycin, Upper GI Bleeding Non-Variceal, Upper GI Bleeding
Variceal, Use of Hematopoietic Growth Factors, Ventilator Weaning,
Ventilator Weaning Protocol, Venous Thrombosis Diagnosis and
Treatment, Venous Thromboembolism Prophylaxis, Ventricular
Arrhythmia, Warfarin, Warfarin Dosing, and Wound Healing
Strategies.
[0059] In yet another embodiment of the present invention, the
patient care management system further comprises order writing
software for providing knowledge-based recommendations and
prescriptions for medication based upon the clinical data. In
another embodiment of the present invention, the patient care
management system further comprises knowledge-based vital
sign/hemodynamic algorithms that prompt said intensivist to engage
in early intervention.
[0060] Embodiments of the present invention provide methods for
continuous expert critical care. Patients are monitored in a
plurality of ICU's. Information from the patient monitoring is
communicated to at least one command center over a first network.
The information from the patient monitoring is received and
analyzed at the command center over the first network; and guidance
is provided from the command center to the plurality of ICU's to
take actions regarding patient care. In another embodiment of the
present invention, providing guidance from the command center
further comprises an intensivist reviewing decision support
algorithms that provide guidance for treating a plurality of
critical care conditions. The algorithms are taken from the group
consisting of algorithms for treating Acalculous Cholecystitis,
Acute Pancreatitis Algorithm, Acute Renal Failure-Diagnosis, Acute
Renal Failure-Management & Treatment, Adrenal Insufficiency,
Agitation and Anxiety, Depression & Withdrawal, Aminoglycoside
Dosing and Therapeutic Monitoring, an Amphotericin-B Treatment
Guidelines, Analgesia, Antibiotic Classification & Costs,
Antibiograms Algorithm, Antibiotic associated Colitis Algorithm,
ARDS: Hemodynamic Management, ARDS: Steroid Use, ARDS: Ventilator
Strategies, Asthma, Bleeding Patient, Bloodstream Infections, Blunt
Cardiac Injury, Bradyarrhythmias, Brain Death, Bronchodilator Use
in Ventilator Patients, Bronchoscopy & Thoracentesis
Guidelines, Candiduria, Cardiogenic Shock, CardioPulmonary
Resuscitation Guideline, Catheter Related Septicemia, a Catheter
Replacement Strategies, Cervical Cord Injury, Congestive Heart
Failure, COPD Exacerbation & Treatment, CXR (Indications),
Dealing with Difficult patients and families, Diabetic
Ketoacidosis, Dialysis, Diuretic Use, Drug Changes with Renal
Dysfunction, Emergency Cardiac Pacing, Endocarditis Diagnosis and
Treatment, Endocarditis Prophylaxis, End of Life Decisions,
Endotracheal Tubes & Tracheotomy, Ethical Guidelines, Febrile
Neutropenia, FUO, Fluid Resuscitation, Guillain-Barre Syndrome,
Heparin, Heparin-Induced Thrombocytopenia, Hepatic Encephalopathy,
Hepatic Failure, HIV+Patient Infections, Hypercalcemia Diagnosis
and Treatment, Hyperglycemia Insulin Treatment, Hyperkalemia:
Etiology & Treatment, Hypernatremia: Etiology & Treatment,
Hypertensive Crisis, Hypokalemia: Etiology & Treatment,
Hyponatremia: Etiology & Treatment, Hypothermia, Identification
of Cervical Cord Injury, Implantable Cardio-defibrillator,
Intra-Aortic Balloon Device, Intracerebral Hemorrhage, Latex
Allergy, Magnesium Administration, Management of Hypotension,
Inotropes, Management of Patients with Ascites, Empiric Meningitis,
Meningitis, a Myasthenia Gravis, Myocardial Infarction, Myocardial
Infarction with left bundle branch block, Necrotizing Soft Tissue
Infections, Neuromuscular Blockers, Neuromuscular Complications of
Critical Illness, Non-Infectious Causes of Fever, Non-Traumatic
Coma, Noninvasive Modes of Ventilation, Nutritional Management,
Obstetrical Complications, Oliguria, Open Fractures, Ophthalmic
Infections, Organ Procurement Guidelines, PA Catheter Guideline and
Troubleshooting, Pancreatitis, Penetrating Abdominal Injury,
Penetrating Chest Injury, Penicillin Allergy, Permanent Pacemaker
and Indications, Pneumonia Community Acquired, Pneumonia Hospital
Acquired, Post-Op Bleeding, Post-Op Hypertension, Post-Op
Management of Abdominal, Post-Op Management of Carotid, Post-Op
Management of Open Heart, Post-Op Management of Thoracotomy,
Post-Op Myocardial Ischemia, (Non-Cardiac Arrhythmias after Cardiac
Surgery), Post-Op Power Weaning, Pressure Ulcers, Pulmonary
Embolism Diagnosis, Pulmonary Embolism Treatment, Respiratory
Isolation, Sedation, Seizure, Status Epilepticus, Stroke,
Sub-Arachnoid Hemorrhage, Supra-Ventricular Tachyarrhythmia,
Supra-Ventricular Tachycardia, Wide Complex QRS Tachycardia,
Therapeutic Drug Monitoring, Thrombocytopenia, Thrombolytic
Therapy, Transfusion Guidelines, Traumatic Brain Injury, Assessment
of Sedation, Sedation, Septic Shock, Bolus Sliding Scale Midazolam,
Short Term Sedation Process, Sinusitis, SIRS, Spinal Cord Injury,
Steroid Replacement Strategy, Thyroid Disease, Transplant Infection
Prophylaxis, Transplant Related Infections, Treatment of Airway
Obstruction, Unknown Poisoning, Unstable Angina, Upper GI Bleeding
Stress Prophylaxis, Vancomycin, Upper GI Bleeding Non-Variceal,
Upper GI Bleeding Variceal, Use of Hematopoietic Growth Factors,
Ventilator Weaning, Ventilator Weaning Protocol, Venous Thrombosis
Diagnosis and Treatment, Venous Thromboembolism Prophylaxis,
Ventricular Arrhythmia, Warfarin, Warfarin Dosing, and Wound
Healing Strategies.
[0061] In another embodiment, a method further comprises a data
server/ data warehouse storing and analyzing patient data from the
at least one command center and providing analysis in results over
a second network to the at least one command center.
BRIEF DESCRIPTION OF THE FIGURES
[0062] FIG. 1A illustrates the logical data structure for billing,
insurance and demographic information.
[0063] FIG. 1B illustrates the logical data structure for billing,
insurance and demographic information (cont).
[0064] FIG. 2A illustrates the command center logical data
structure.
[0065] FIG. 2B illustrates the command center logical data
structure (cont).
[0066] FIG. 3 illustrates the logical data structure for creating a
medical history.
[0067] FIG. 4A illustrates the logical data structure for creating
notes relating to patient treatment and diagnosis.
[0068] FIG. 4B illustrates the logical data structure for creating
notes relating to patient treatment and diagnosis (cont).
[0069] FIG. 4C illustrates the logical data structure for creating
notes relating to patient treatment and diagnosis (cont).
[0070] FIG. 5 illustrates the logical data structure for entry of
medical orders.
[0071] FIG. 6A illustrates the logical data structure for patient
care, laboratory testing and diagnostic imaging.
[0072] FIG. 6B illustrates the logical data structure for patient
care, laboratory testing and diagnostic imaging (cont).
[0073] FIG. 7A illustrates the logical data structure for
categories of information that are permitted to be presented to
intensivists and other care givers by the system.
[0074] FIG. 8A illustrates the logical data structure for
documenting patient vital signs.
[0075] FIG. 8B illustrates the logical data structure for
documenting patient vital signs (cont).
[0076] FIG. 9 illustrates the distributed architecture of the
present invention.
[0077] FIG. 10 illustrates the system architecture of the present
invention.
[0078] FIG. 11 illustrates the decision support algorithm for
diagnosis and treatment of pancreatitis.
[0079] FIG. 12 illustrates the vital signs data flow.
[0080] FIG. 13A illustrates capture and display of diagnostic
imaging.
[0081] FIG. 13B illustrates establishing videoconferencing in the
present invention.
[0082] FIG. 14 illustrates the physician resources order writing
data interface of the present invention.
[0083] FIG. 15 illustrates the physician resources database data
interface of the present invention.
[0084] FIG. 16 illustrates the automated coding and billing system
integrated with the workflow and dataflow of the present
invention.
[0085] FIG. 17 illustrates the order writing data flow of the
present invention.
[0086] FIG. 18 illustrates the event log flow of the present
invention.
[0087] FIG. 19 illustrates the smart alarms implementation of the
present invention.
[0088] FIG. 20 illustrates the procedure note creation and line log
for the present invention.
[0089] FIGS. 21A-B illustrate the acalculous cholecystitis decision
support algorithm.
[0090] FIG. 22 illustrates the adrenal insufficiency decision
support algorithm.
[0091] FIG. 23 illustrates the blunt cardiac injury decision
support algorithm.
[0092] FIGS. 24A-B illustrate the candiduria decision support
algorithm.
[0093] FIGS. 25A-B illustrate the cervical spine injury decision
support algorithm.
[0094] FIGS. 26A-B illustrate the oliguria decision support
algorithm.
[0095] FIGS. 26C-D illustrate the oliguria decision support
algorithm (cont).
[0096] FIG. 26E illustrates the oliguria decision support algorithm
(cont).
[0097] FIGS. 27A-B illustrate the open fractures decision support
algorithm.
[0098] FIGS. 28A-B illustrate the pancreatitis decision support
algorithm.
[0099] FIGS. 29A-B illustrate the penicillin allergy decision
support algorithm.
[0100] FIGS. 30A-B illustrate the post-op hypertension decision
support algorithm.
[0101] FIG. 31A illustrates the pulmonary embolism decision support
algorithm.
[0102] FIG. 31B illustrates the pulmonary embolism decision support
algorithm (cont).
[0103] FIG. 32 illustrates the seizure decision support
algorithm.
[0104] FIGS. 33A-B illustrate the SVT determination decision
support algorithm.
[0105] FIG. 33C illustrates the SVT unstable decision support
algorithm.
[0106] FIGS. 34A-B illustrate the wide complex QRS Tachycardia
decision support algorithm.
[0107] FIG. 34C illustrates the wide complex QRS Tachycardia
decision support algorithm (cont).
[0108] FIG. 35A illustrates the assessment of sedation decision
support algorithm.
[0109] FIG. 35B illustrates the assessment of sedation decision
support algorithm (cont).
[0110] FIG. 36 illustrates the bolus sliding scale midazolam
decision support algorithm.
[0111] FIG. 37 illustrates the sedation assessment algorithm
decision support algorithm.
[0112] FIG. 38 illustrates the short term sedation process,
decision support algorithm.
[0113] FIG. 39 illustrates the respiratory isolation decision
support algorithm.
[0114] FIG. 40 illustrates the empiric meningitis treatment
decision support algorithm.
[0115] FIG. 41A illustrates the ventilator weaning decision support
algorithm.
[0116] FIG. 41B illustrates the ventilator weaning decision support
algorithm (cont).
[0117] FIG. 42 illustrates the warfarin dosing decision support
algorithm.
[0118] FIG. 43 illustrates the HIT-2 diagnostic decision support
algorithm.
DEFINITIONS OF TERMS AND DATA
[0119] In the following Detailed Description of the Invention, a
number of modules and procedures are described. For purposes of
definitions, the following module definitions apply and are more
fully amplified in the descriptions of the figures that follow.
[0120] Term Definitions
Following are a series of definitions for certain terms used in
this specification:
[0121] Insurance carrier: This is a table of all the valid
insurance carriers listed in the system of the present invention.
[0122] Patient guarantor: Provides the insurance guarantor
information for a given patient. [0123] Patient information:
Provides demographic information for each patient. [0124] Medical
event date history: This contains the various disorders of the
patient and the dates associated with major medical events relating
to those disorders. [0125] Medical history: Contains non-major
system medical history of a patient. [0126] Drug: Contains what
medication and allergies have been identified for a patient at
admission. [0127] Address: Contains the address or addresses for a
given patient. [0128] Patient visit: There may be multiple records
for any given patient, since the patient may visit the ICU on more
than one occasion. This file contains a record of each visit to an
ICU by a patient. [0129] Physician-patient task: Contains the task
that had been defined for each patient. [0130] Present illness:
This contains a textural description of the patient illness for the
specific ICU visit. [0131] Physical exam: This contains the
information gathered as a result of a physical examination of the
patient during the admission to the ICU. [0132] Surgical fluids:
This provides all the information related to the fluids provided
during surgery. [0133] Surgery: This contains all information
pertaining to any surgical procedure performed on a patient while
the patient is at the ICU. [0134] Patient admit: This provides
general information that needs to be gathered when a patient is
admitted into the ICU. [0135] Medical orders: This provides the
general information for all types of medical orders associated with
a given patient. [0136] Daily treatment: This contains the
treatment provided for a given patient on a given day. [0137] Daily
diagnosis: This contains the daily diagnosis for a given patient,
which includes neurological, cardiological, pulmonary, renal,
endocrinological, and any other diagnosis that may be associated
with a patient.
[0138] Vital sign information is also critical to the
administration of care in the ICU. A number of different modules
collect information relating to patient vital signs. For example:
[0139] Patient admit: This provides the general information that
needs to be gathered when a patient is admitted to the ICU [0140]
Patient visit: This contains a record of each visit to an ICU by a
patient. [0141] Patient: Provides demographic information for each
patient. [0142] Vital sign header: This contains general
information related to the vital sign data for the particular
patient. [0143] Vital sign: Contains the vital sign data taken at
specific intervals for a given patient. [0144] Hospital: This
contains identifying information for a particular hospital where
the care is given. [0145] ICU bed: Contains the association for
identifying which beds are in a given ICU
[0146] Command center/remote location definitions and modules have
also been created for the present invention to allow for the
orderly storage and retrieval and entering of data. For example:
[0147] Physician-physician (such as nurses and LPN and the like):
Contains the names of all of the physicians and physician extenders
for the command center/remote location as well as for ICUs
associated with the command center/remote location. [0148]
Communication: Contains all of the various types of communication
vehicles used to contact an individual physician or physician
extender. [0149] Physician role: Contains the role a physician is
playing for a given patient, (i.e., primary care, consultant, etc.)
[0150] Patient: Provides demographic information for each patient.
[0151] Command center/remote location: Provides identifying
information for a particular command center/remote location. [0152]
Hospital: Contains identifying information for a particular
hospital wherein an ICU is located. [0153] ICU: Contains
identifying information for an ICU at a hospital. [0154] ICU bed:
Contains the association for identifying which beds are in a given
hospital. [0155] ICU patient location: Provides the association
between an ICU and a patient and identifies where a patient is
located within an ICU in a particular hospital.
[0156] The order entry functionality of the present invention
provides a critical service for obtaining information on the
patient during admission, medical orders, and procedures provided
to the patient during the ICU stay. For example: [0157] Radiology:
Contains all radiology performed on a particular patient. [0158]
Radiology results: Contains the results of each radiology test
performed on the particular patient. [0159] Drugs: Contains all
relevant information for all the drugs that a patient has been
administered. [0160] Laboratory: Contains all laboratory tests
ordered for a patient. [0161] Microbiology result: Contains the
results of microbiology organisms taken on a patient. [0162]
Laboratory result: Contains the results for a laboratory test
ordered for a particular patient.
DETAILED DESCRIPTION OF THE INVENTION
[0163] The present invention is a system and method for remote
monitoring of ICU's from a distant command center/remote location.
By monitoring a plurality of ICU's remotely, intensivists can
better spread their expertise over more ICU beds that heretofore
achievable. The presence of 24-hour a day/7 day-per-week
intensivist care dramatically decreases the mortality rates
associated with ICU care.
[0164] Referring to FIGS. 1A and 1B, the Billing and Demographic
data structure of the present invention is illustrated. Patient
demographic information 9010 is collected on the particular
patient. This information comprises all the typical kinds of
information one would normally gather on a patient such as first
name, last name, telephone number, marital status, and other types
of information. Patient insurance information 9012 is collected and
associated with the patient demographic information 9010. Patient
insurance information 9012 relates to information on the type of
accident and related information such as employment, employer name,
place of service, and other information that would relate to the
accident that actually occurred (if at all) and which would have to
be reported to an insurance agency. This information is associated
with the patient demographic information which assigns the unique
patient ID to the particular patient.
[0165] Insurance plan information 9008 is also created and stored
and comprises insurance carrier ID's, the plan name, policy number,
and group number. This information on the insurance plan 9008 is
also associated with the patient ID and demographic information
9010.
[0166] Physician information 9002 is also created and stored for
each physician associated with the system of the present invention.
Information such as first and last name, credentials, and other
information concerning the physician is saved. In addition, the
physician's role is identified 9004 and information concerning the
physician and the physician's role is associated with the
particular patient via the patient ID stored in the demographic
information 9010.
[0167] Patients are entered into the hospital by a hospital
representative 9006 who has a representative ID which also is
ultimately associated with the patient ID. In addition,
communications data 9000 is stored concerning how a representative
can be reached (cell phone, home phone etc.).
[0168] Referring now to FIG. 1B, the Overall Billing and Insurance
data structure is illustrated. An insurance provider number 9014 is
also stored in the system. Each physician is given a provider
number and provider ID by each insurance company. Thus data must be
stored regarding the ID that is given to a particular physician by
each insurance provider. This information is also stored and can be
associated ultimately with treatment of the patient.
[0169] Each patient admitted to the hospital and to the ICU has a
patient visit ID associated with the patient 9017. This visit ID
has patient ID information, ICU information, admission date, and
other information relevant to the specific visit. This information
is illustrated in FIG. 1B. The visit ID 9017 is associated with the
patient ID 9010 so that each visit can be tracked by patient.
[0170] Insurance carrier information 9018 is stored by the system
and is associated with the insurance plan information 9008 as
appropriate. Thus the particular insurance carrier with its name,
address, and other identifying information 9018 is associated with
the type of plan 9008 carried by the patient. The insurance carrier
information 9018 together with the insurance plan information 9008
is associated with the patient via the patient ID information
9010.
[0171] Patient address information 9020 and 9022 are collected for
each individual patient and associated with the patient demographic
information 9010. If there is a patient guarantor, this information
is obtained and stored with information on the guarantor 9026. Such
information as the guarantor's first and last name, date of birth,
and other information is stored and is illustrated in FIG. 1B.
Further, the guarantor's address 9024 is also collected and
ultimately associated with the patient demographic information
9010.
[0172] Referring to FIGS. 2A and 2B, the Command Center logical
data structure is illustrated. The various information associated
with demographic and insurance information is again used to manage
the care and operations of the command center. Therefore,
communications information 9000 is combined with physician and
physician extender (i.e. nurse, LPN and the like) information 9002
and physician role 9004 to be associated with the demographic
information 9010. The patient visit information 9017 together with
this information is associated with the patient's location which
has a unique identifier 9030. Each location ID has patient ID
information and visit ID information associated with it.
[0173] Referring now to FIG. 2B, the Command Center logical data
structure illustration continues. Each ICU bed has an associated
location ID which comprises hospital ICU information, room number,
and bed number 9038. In addition, and as described earlier,
instrumentation such as cameras are also associated with the
particular patient. Therefore the camera setting 9040 will have a
location ID relating to the ICU bed as well as have camera value
settings and associated camera identifier information.
[0174] Each ICU bed 9038 is associated with an ICU 9032. Each ICU
has information associated with it that uniquely identifies the ICU
as being associated with the particular hospital, and having
particular phone numbers, fax numbers, work space addresses, and
other information, that help to identify the ICU.
[0175] As noted above, each ICU is associated with a hospital 9034.
Each hospital has a unique identifier, as well as its own name,
address, and other identifying information. Further, since each
hospital ICU is to be coordinated through a remote command center,
information on the remote command center 9036 is associated with
the hospital information. Each command center has a unique ID and
has associated address information stored as well.
[0176] Thus in the Command Center logical data structure, patient
ID information 9010 is linked to a patient location 9030 which in
turn is associated with an ICU bed 9038 each of which beds are
uniquely associated an ICU 9032 which is associated with a hospital
9034 which in turn has the ICU managed by a command center
9036.
[0177] An integral part of the system of the present invention is
the recording of medical history. Referring to FIG. 3, the logical
relationship among data elements for medial history is illustrated.
Patient visit information 9017 combined with the
physician-physician extender information 9002 is combined with
specific note-taking information 9042. The note information
comprises the date and time the notes are taken as well as the note
type. The note ID is fed information from the medical history item
9044, which has its own unique medical ID associated with it. This
information comprises medical text, category of information, and
other information relevant to the medical history. As noted, this
information for medical history 9044 is associated with a note ID
9042, which in turn is associated with the patient visit and
physician information 9017 and 9002.
[0178] Referring to FIG. 4A, 4B, and 4C, the note-keeping logical
data structure of the present invention is illustrated. As noted
earlier, the note ID 9042 combines information from visit ID,
treating physician, and other information relating to the time the
note was entered. Other information is associated with the note ID.
Referring first to FIG. 4A, the patient visit information 9017, is
associated with the note ID 9042. Various procedural information
9046 is kept by the system of the present invention and is
associated with the visit ID 9017. Physicians are able to create
free text patient illness notations 9048 and associate them with
the note 9042. Similarly, free text information regarding
functioning of the system 9050 is permitted and also associated
with notes regarding the particular patient and procedure 9042.
[0179] Specific notes regarding, for example, surgical procedures
are also kept. Surgery notes 9054 are associated with a particular
note ID and have such information as anesthesia, surgical
diagnosis, elective information, and other related surgical
information. Surgical fluids 9052 administered during the course of
surgery are associated with the surgery information 9054.
Additionally, any surgical complications 9056 are noted and also
associated with the surgery which in turn has an associated note
ID.
[0180] Referring now to FIG. 4B, the logical data structure for
notes and its description is continued. An assessment plan 9058 is
created and associated with the same note ID for the particular
patient. The plan has a free text field that allows a physician to
create the appropriate assessment plan and associate it with a note
ID 9042.
[0181] Various daily notes are also kept and associated with the
individual note ID 9042. For example, the daily mental state 9060
is recorded to document the mental state of the patient. The daily
treatment 9062 administered to the patient is associated with the
unique note ID. The daily diagnosis 9068 is also created and
associated with unique note ID 9042.
[0182] Any unstable conditions are also noted 9070 and records kept
of those conditions. Similarly mortality performance measures (MPM)
information 9072 is kept and associated with the unique note ID. To
the extent that any physical exam 9074 is administered, that
physical exam and any free text created by the physician is
associated with the unique ID and records kept. Allergy information
9076 for the particular patient is also created and stored along
with the allergy type, and allergy name. This information is
uniquely associated with the note ID. Referring now to FIG. 4C, the
Logical Data Structure for the Notes Creation and Storage
description is continued. A specific note item record 9078 is also
kept and associated with unique note ID. This note item comprises
the principal diagnosis, the chief complaint, the past history of
the patient, the reason for the note, and various other
identifications and flags of information which help in documenting
the patient's condition.
[0183] Any drugs that are administered to the patient, including
dosage, type, and number 9086 is kept and associated with the
unique note ID 9042.
[0184] Procedural note items are also documented 9082. Procedural
notes involve the procedural type, the principal diagnosis, the
procedural location, procedural indications, and other information
of a procedural nature. Procedural description information 9088 is
kept as input to the procedural note item. This information is also
associated with a procedural evaluation 9084 which comprises text
describing the procedural evaluation that occurred, These three
items, the procedural description 9088, procedural evaluation 9084,
and procedural note items 9082, are all uniquely associated with
the note ID 9042.
[0185] Referring now to FIG. 5, the Logical Data Structure of the
Medical Order Functionality of the Present Invention is
illustrated. Each medical order 9092 has a unique order ID
associated with it. This information derives its uniqueness from
the visit ID, the representative ID, and various information about
the date in which the order was created and other such relevant
information. Any non-drug orders 9090 are associated with a unique
non-drug order ID. The order is classified, identified, and free
text can be created by the physician to describe the order. This
information in the non-drug order 9090 is associated with the
unique medical order for that particular patient 9092.
[0186] Again physician and physician extender identification
information 9002 is also uniquely associated with the medical order
to identify the physician involved in creating the particular order
in question.
[0187] Drug orders 9094 are created each with its own unique drug
order ID. Various information is collected as part of the drug
order including the type of drug, the dosage, start date,
frequency, stop date, to name but a few elements typical of a drug
order. The drug order information 9094 is associated with the
unique medical order ID 9092 assigned to that particular patient.
All of the medical order information is associated with patient
visit information 9017 which allows that information to be uniquely
identified with a particular patient for a particular visit.
[0188] Referring again to FIG. 4C, the system is also capable of
annotating and storing various log items 9080. For example, an
event log item is given a number, a patient profile item has its
own number, as do neurological, cardiographic, pulmonary, renal,
and other events can have log items associated with them and may be
used as input to any of the note taking of the present
invention.
[0189] Referring to FIGS. 6A and 6B, the logical data structure of
the patient care functionality of the present invention is
illustrated. Each patient visit with its unique ID 9017 has a
number of other pieced of information associated with it. For
example, physician-patient tasks are tracked 9098 and have a unique
task ID associated with them. The patient code status 9096 is
documented and associated with the physician-patient task 9098 task
ID. This information is uniquely associated with the patient visit
via the the patient visit ID 9017.
[0190] Laboratory information 9100 has a unique lab ID associated
with it. That information is keyed to the visit ID and records the
specimen taken, the date it was taken, and various other
information germaine to the laboratory procedure involved. Other
lab procedures 9102 are also documented with another unique ID.
"Other" lab ID is associated with the laboratory ID 9100 which
again is uniquely associated with the particular patient.
[0191] Microbiological studies 9104 are documented together with
the date and the date taken and the type of study involved. Any
study of microorganisms 9106 is documented with a unique
microorganism ID. Micro sensitivities 9108 which record the
sensitivity to microorganisms and certain antibiotics is recorded
and associated with the microorganism ID 9106. This information in
turn is associated with a microbiological study 9104, all of which
is associated with the unique patient visit ID 9107.
[0192] Respiratory studies 9101 are also recorded with unique
identification numbers and a description. This information is again
associated with the patient visit ID 9017.
[0193] Referring now to FIG. 6B, the logical data structure of the
patient care functionality of the Present Invention is further
illustrated. Other organism studies 9118 are also conducted to
determine any other conditions associated with microorganisms that
might exist with the particular patient. This other organism
information 9118 is associated with the microorganism studies 9106
which in turn is associated with the microbiology category of
information of the present invention 9104.
[0194] Various diagnostic imaging also takes place and is recorded.
This image information 9114 has unique image ID associated with
each image and comprises associated information such as the image
type, the date performed, and other information relevant to the
diagnostic imagery. The result of the image taken 9116 is also
uniquely identified with the image ID and a unique image result ID.
This information is associated with the image information 9114
which again is uniquely associated with the patient visit ID.
[0195] Various intake and output for the patient's biological
functioning is recorded 9110. Intake and output total 9112 is
recorded and uniquely associated with the intake/output
identification note 9110. Intake/output totals 9112 also comprised
the weight the total taken in, the total out, and five-day
cumulative totals for biological functioning of the particular
patient.
[0196] Referring to FIG. 7, The Logical Data Structure Concern with
Reference Information for the present invention is illustrated.
This data structure allows only certain ranges of data to be input
by care givers into the system. This is accomplished by having
categories of information 9120 each category capable of having only
certain values. Similarly, each type of data 9126 associated with
each category is only permitted to have certain values. This
combination of Category and Type results in a Combined ID 9122
which can be used in combination with certain values 9128 to create
a value and combination 9124 that can be presented to a care giver
viewing and entering data. This effectively limits errors in data
entry by only allowing certain values to be entered for given types
of data. For example, if only milligrams of a medication are
supposed to be administered, this data structure prevents a care
giver from administering kilograms of material since it is not a
permitted range of data entry. The "nextkey" function 9027 is the
function that keeps track of the ID's that are given during the
administration of the present invention. This function insures that
only unique ID's are given and that no identical ID's are given to
two different patients for example.
[0197] Referring to FIG. 8A, the Logical Data Structure of the
Vital Signs Functionality of the Present Invention is illustrated.
Vital sign header information 9120 is created and uniquely
associated with the visit ID for the particular patient. This
header information comprises a date-time stamp combined with
hospital information, medical reference numbers, and identification
of the patient. Vital sign details 9122 are also created and
uniquely date-time stamped and associated with the particular visit
ID for the patient. This information comprises all manner of vital
sign information relating to blood pressure, respiration, and other
factors. Vital sign information is associated with the patient
visit 9017 and the demographic information concerning the patient
9016. Such associations of information can be the basis for later
studies.
[0198] Referring to FIG. 8B, Additional Vital Sign Logical Data
Structures are illustrated. For example, a vital sign log header
9120 is created using the unique hospital ID and medical record
numbers. Other information such a patient name, and date-time stamp
are also stored. Vital sign log details 9124 are created and
associated with the vital sign log header 9120. For example, blood
pressure measurements, respiration, and other factors are all
detailed for a particular hospital ID. It should be noted that all
vital sign data is logged in and kept by the systems of the present
invention. Where vital sign information is received but cannot be
associated with a particular patient, such communications are noted
as errors.
[0199] Vital sign error details 9126 are also recorded and
associated with a particular hospital. Information and the vital
sign error detail also comprises heart rate, blood pressure, and
other information. This information is associated with a vital sign
error header 9130 which is associated with the hospital identifier
and the patient first and last name and other information. Various
vital sign error codes 9128 exist with the present invention and
are used in association with the vital sign error detail 9126. This
information however relates to communications of vital sign data
that are deemed "errors" as noted above.
[0200] Care Net patient location 9132 is recorded and associated
with a particular hospital ID and location ID for the particular
patient. Carenet is a proprietary product designation of
Hewlett-Packard and is kept by the system of the present invention
since it identifies the equipment from which measurements come. The
ICU bed information 9038 is associated with the Care Net patient
location 9132.
[0201] Referring to FIG. 9, the distributed architecture of the
present invention is shown. In concept, the distributed
architecture comprises a headquarters component 200, a command
center/remote location 202, and a hospital ICU 204, which, while
represented as a single hospital in this illustration, in the
preferred embodiment comprises several hospital ICUs at different
locations. The headquarters unit 200 comprises a database server
and data warehouse functionality, together with a patient
information front end. The patient information front end 206
provides patient specific information to the command center/remote
location. The database server/warehouse function 208 comprises the
amassed information of a wide variety of patients, in their various
conditions, treatments, outcomes, and other information of a
statistical nature that will assist clinicians and intensivists in
treating patients in the ICU. The headquarters' function also
serves to allow centralized creation of decision support algorithms
and a wide variety of other treatment information that can be
centrally managed and thereby standardized across a variety of
command center/remote locations. Further, the database server/data
warehousing functionality 208 serves to store information coming
from command center/remote locations replicating that data so that,
in the event of a catastrophic loss of information at the command
center/remote location, the information can be duplicated at the
command center/remote location once all systems are up and
running.
[0202] At the hospital ICU 204, each patient room 232, 234 has a
series of bedside monitors and both video and audio monitoring of
each patient in the patient room. Each ICU further has a nurse's
station with a video camera and monitor 230 so that
videoconferencing can go on between the nurses and doctors at the
nursing station and those intensivists at the command center/remote
location. The monitoring equipment at the ICU is served by a
monitor server 236, which receives and coordinates the transmission
of all bedside monitoring and nurses station communication with the
command center/remote location. Finally, each ICU has a patient
information front end 228, which receives and transmits to the
command center/remote location information concerning the identity
and other characteristics of the patient.
[0203] Command center/remote location 202 comprises its own video
capture and monitoring capability 212 in order to allow the
intensivists to view the patients and information from the bedside
monitoring as well as to have videoconferencing with the nursing
station and with patients as the need arises. Information from the
monitor server 236 at the hospital ICU is served to an HL7 (the
language for transmitting hospital/patient/diagnostic data) gateway
214 to a database server 222. In this fashion, information from the
bedside monitors can be stored for current and historical analysis.
Monitor front ends 216 and 218 allow technicians and command
center/remote location personnel to monitor the incoming data from
the patient rooms in the ICU. Information from the patient
information front end 228 is provided to an application server 224,
having its own patient information front end 226 for aggregating
and assembling information in the database 222 that is associated
with individual patients in the ICU.
[0204] It is expected that there will be a great deal of concurrent
hospital data that is necessary to the implementation of the
present invention. It is therefore expected that there will be a
legacy database system 210 having a front end 220 from which
intensivists and command center/remote location personnel can
retrieve legacy database information.
[0205] Referring to FIG. 10, a system architecture of one
embodiment of the present invention is illustrated. Headquarters
200 comprises an application server 238, an NT file server 240, and
Sun SPARC Enterprise 250242 and Enterprise network management
system 244, a Cisco 3600 router 246, a Cisco 2924 switch 248, and a
hot phone 250. The application server 238 is designed to monitor
and update those applications used at the command center/remote
location. The NT file server serves to monitor, store, and
replicate information coming from the command center/remote
locations. The SPARC Enterprise 250 server 242 is a disc storage
server, for storing and serving information, such as practice
guidelines, algorithms, patient information, and all matter of
other information records that must be stored in order to support
the present invention. As explained below, the SPARC Enterprise 250
server and other components are such as routers and switches are
commonly used in the ICU, the command center/remote location, and
the headquarters. For example: [0206] The Cisco 3600 router is a
multi-function device that combines dial access, routing, and local
area network (LAN) to LAN services, as well as the multi-service
integration of voice, video, and data in the same device. This is
necessary, since the various command center/remote locations,
headquarters, and intensive care units all must integrate and
transmit video, audio, and data among the various entities. [0207]
The Cisco 7204 is a router which provides high speed LAN
interconnect, virtual private networks, and Internet access, all of
which is required for providing the communication in the network of
the present invention; and [0208] The Cisco 2924 switch is an
autosensing fast ethernet switch, allowing networked multimedia and
virtual LAN support. Multi-level security is also offered in the
switch to prevent unauthorized users from gaining access and
altering switch configuration. These components are also identified
in the figures (below).
[0209] The particular commercial systems named here are given as
but some examples of equipment available today. The function of
these equipment is the important factor. Other similar or improved
equipment can also be utilized.
[0210] The network management system 244 allows the entire traffic
and condition of the network to be monitored and to allow
maintenance to take place. The router 246 and switch 248 is used
for communication with the various command center/remote locations
that are served by the Headquarters component. The Headquarters
component interacts via frame relay with the command center/remote
location 202.
[0211] Command center/remote location 202 comprises an applications
server 262 for the purpose of running various applications for the
intensivists and command center/remote location staff. The NT file
server 264 at the command center/remote location allows patient
files, historical files, algorithms, practice standards, and
guidelines, to be served to the clinicians and intensivists to
assist in monitoring the patients. The Sun SPARC Enterprise 250266
is used to for storage purposes as noted above. The Enterprise
network management system 268 monitors the overall health of the
network of command center/remote locations and intensive care units
as well as the functionality of the individual pieces of equipment
within the command center/remote location. A Cisco 2924 switch 256
and Cisco 7204 router 258, combined with the Cisco 3600 router 260
allows for point to point communication over a Ti line, with a
plurality of intensive care units located remotely from the command
center/remote location. Hot phones 252 and 254 allow communication
with the headquarters and the intensive care unit.
[0212] Intensive care unit 204 comprises a Cisco 2924 switch 272
for the purpose of interfacing with the various audio-video feeds
274, 276 from the various patient rooms and the nursing station. A
local work station 280 is connected to a scanner 282 which allows
data to be input, scanned, and communicated via the point to point
T1 communications to the command center/remote location. Further,
the workstation 280 provides for textual advice and patient orders
to be delivered to the intensive care unit for execution. The
intensive care unit also comprises a laser printer 284 for the
printing of patient orders and other information relevant to the
care of intensive care patients. Referring to FIG. 11, the
videoconferencing/surveillance/imaging components of the present
invention are illustrated. The hospital ICU 204 comprises a series
of video cameras 290, which are located in patient rooms and at the
nurse's station. Control for the cameras is provided through an
RS424 to RS232 converter 288, with instructions for imaging
emanating from the workstation at the command center/remote
location 252 through the ICU workstation 280 through a multi-port
serial controller 286. Video feed from the video cameras 290 is
provided to an audio-video switcher 292, which in turn provides its
output to the multi-port serial controller 286 for subsequent
viewing at the nurse's station and at the command center/remote
location. Of equal importance is a microphone feed from the patient
and from the nurses. That microphone 296 provides its signal to an
audio line amplifier 294, which in turn provides an audio feed to
the audio-video switcher 292. In this way, a patient can provide
information, as can nurses who are visiting the patient during the
course of patient care. It is also important that information of an
audio nature be fed to the intensive care unit, both to the patient
rooms and to the nurse's station. To do this, the multi-port serial
controller 286 provides an audio signal to a reverse audio switcher
298, which in turn provides information to speakers 300 that are
located at the nurse's station as well as at the bedside of the
patients. Information to the reverse audio switcher is provided an
audio amplifier 302 from information from a video code 304, which
in turn is connected to the workstation at the ICU. As noted
earlier, a scanner 282 is provided, so that information can be
scanned and provided to the command center/remote location 202 and
a hot telephone 278 communicates with a telephone 252 at the
command center/remote location.
[0213] Referring to FIG. 12 the vital signs data flow is
illustrated. The monitoring system at each ICU bedside comprises a
monitoring system for monitoring the vital signs for the patient.
The vital sign monitoring system 450 captures vital sign data 452
and transmits that vital sign data 454 using the HL7 language (the
standard processing language for hospital data and information).
The processor at the ICU processes the vital sign data for
transmission and storage purposes and transmits that information to
the remote location. Vital sign data is then loaded into the data
base 458. The data base for each individual patient is then
reviewed and process rules are applied 460 to the vital sign data.
These process rules relate to certain alarming conditions which, if
a certain threshold is reached, provides an alarm to the
intensivist on duty. The vital sign alarm 462 is then displaced to
the intensivist who can then take appropriate action. A typical
type of rule processing of the vital sign data might be if blood
pressure remains at a certain low level for an extended period of
time, or if heart rate remains high for an extended period of time.
In addition a wide range of other rules are provided which will
provide an audible alarm to the intensivist before a critical
situation is reached.
[0214] In addition to the information being provided to the
alarming system for the intensivist, the vital sign data 464 is
also transmitted 466 into a database warehouse 468 comprising vital
sign data 470 from not only the individual patient but from all of
the patients being cared for in the ICU. This database warehouse
provides the ability to do data mining for trends that can give
rise to additional process rules and vital sign thresholding. In
addition to the transmission of vital sign data 454 to the remote
site, the vital sign data is displayed in real time at the ICU
472.
[0215] Referring to FIG. 13A the diagnostic imaging interaction is
illustrated. X-rays for example, are created and transmitted to the
command center 472. Additionally, the information could be ACT
scan, MRI, or any other method of medical diagnostic imaging. The
x-ray image is captured at the command center 474 where it is
stored and in addition displayed on the image monitor 476 for the
intensivist to review.
[0216] Referring to FIG. 13B the interactive video session is
illustrated. A video conferencing session is established 478
regarding a particular patient in an ICU bed. Using the video
cameras in each room and/or at the nurses station at the ICU, the
patient and/or the nurse can be viewed 480. On the other end of the
video conferencing session is the intensivist who can then both
visually and orally communicate with the patient and/or nurse
482.
[0217] Referring to FIG. 14 the physician resources and order
writing data interface is illustrated. The user interface 484
allows the physicians to access physician resources 486. These
resources provide guidelines for the treatment of the critically
ill. In this example the intensivist is requested to enter the
antibiotic associated with colitis 488. The system then generates a
request for a fecal leukocyte test 490. This request is translated
into an order writing module 496 which results in the actual order
for the test 502. Since the order needs to be transmitted to the
appropriate organization for execution, an appropriate order is
generated to the microbiology laboratory 500 in this instance. The
order results are then achieved 506 and the completion of the order
is reported to the order writing assignment manager 496. In
addition, the order writing module 502 also results in a task list
504 of orders for various other individuals in laboratories. In
addition, user interface 484 allows the physician to re-enter the
physician resources module at any particular location with results
of the tests. These tests are then fed into the system to continue
with the diagnostic algorithm processing of the patient test
results 494. The user interface also allows interaction with the
resident database 498.
[0218] Referring to FIG. 15 the physician resources database data
interface is illustrated. User interface 508 allows the intensivist
to interact with the physician resources data base 510. In this
example, resident data base 524 which comprises the identification
and background of the resident admitting the patient causes an
admission diagnosis 526 to be created. In this example a diagnosis
of pancreatitis is illustrated. This diagnosis of pancreatitis 522
alerts the physician resources module 510 which causes an entry for
the topic pancreatitis 512. The diagnosis algorithm for
pancreatitis 514 is then retrieved and a request for an Apache II
score 516 is requested. The system also requests information for
operative data 528 describing what if any operations have taken
place with respect to this patient, vital sign data 530, request
for laboratory information 532, past medical history for the
patient 534 and patient demographics 536. All this information is
provided to the Apache II score assignment manager 538 which
assigns an Apache II score based upon weighted composite up to
twenty five different variables. This Apache II score is provided
to the Apache II score request module 516. If the severity based
Apache II score is greater than or equal to eight the diagnostic of
the system continue 520. If the Apache II score is less than eight,
the patient is triaged to a none ICU bed 518 since the patient will
not necessarily require intensive care thereby saving relatively
scarce resources of the ICU for those who are truly critically
ill.
[0219] Referring to FIG. 16 the automated coding/billing work flow
and data flow is illustrated. Clearly ICUs must be paid for the
care that they give. At the outset of the visit 540 the user
interface 542 allows for the input of International Classification
of Diseases, Ninth Revision (ICD 9) diagnosis code information
concerning complexity of the case, whether the patient is stable,
whether the physician involved is the attending physician or
consulting physician and all other manner of information required
for billing purposes. In addition, resident data 544 is input such
as patient demographics, insurance information, physician,
guarantor, the date that the service is provided. All this
information is provided to the data manager 546 which assembles the
required data element for subsequent processing. The data manager
sends the demographic, physician, guarantor, insurance and related
information to a bill generator 548 which begins to assemble of the
information to subsequently generate a bill. Clinical information
is provided to the current procedural terminology (CPT) code
assignment manager which assigns codes based upon the scores and
user input for bill generation purposes. A history of present
illness (HPI) score 560 is generated along with a review of systems
(ROS) score 562. A past, family, and/or social history (PFSH) score
564 is generated along with a score relating to the physical exam
566. A mortality prediction model (MPM) score 568 which is a score
relating to the severity of the illness is also generated. All of
these various scores are provided to the CPT assignment manager
558. Periodically information is downloaded for management reports
556. Once all of the information for the CPT code assignment is
generated that information is provided to the bill generator 548
which assembles all the data elements needed to generate a Health
Care Financing Administration (HCFA) 1500 claim form. The input for
the bill generator is then verified 550 where the physician can
disagree with code assignments return progress notes and generally
review the bill. This smart processing of the HCFA 1500 claim form
allows for fewer mistakes to be made. If there is any error or
additional information that is required, the verification process
fails the proposed claim form and information regarding that
failure is provided back to the resident data for completion of any
missing items. Once an invoice has been verified as having the
appropriate information to be submitted the HCFA 1500 claim form is
generated 554. Additional information is written to a billing data
file 552 for importation to the patient accounting system of the
present invention.
[0220] Referring to FIG. 17 the order writing data flow is
illustrated. Order entry user interface 600 allows the intensivist
to order procedures and medication to assist the patients in the
ICU. For example, the intensivist can order an ECG 604. Thereafter
the order is reviewed and a digital signature relating to the
intensivist is supplied 606. Once reviewed and signed off, the
order is approved 607 and sent to the data output system 610.
Thereafter the data output system prints the order to the printer
in the ICU 616. For record keeping purposes the order is exported
in the HL7 language to the hospital data system 618. In addition
the data output system adds an item to the data base that will
subsequently cause an intensivist to check the ECG results. This
notification to the task list is provided to the database 614. In
addition, as part of the database an orders file relating to the
specific patient is also kept. The fact that and ECG has been
ordered is entered in the orders file for that patient.
[0221] In a similar fashion using the order entry user interface
600 the intensivist can order medications 602 for a patient. The
medication order then is provided to an order checking system 608.
The order checking system retrieves information from the database
614 relating to allergies of the patient and medication list which
includes medications which are already being administered to the
patient. This allows for the order checking system to check for
drug interactions. Further laboratory data is extracted from the
database 614 and the order checking system checks to insure that
there will be no adverse impact of the recommended dosage upon the
renal function of the patient. Once the order checking system 608
is completed, the order is okayed and provided to the order review
and signature module 606. In this module the digital signature of
the intensivist is affixed to the order electronically and the
order is approved 607. Thereafter it is provided to the data output
system 610 where again the orders are printed for ICU and 616 and
for the hospital data system. In this case, any medications that
are ordered are then provided to the medications list file in the
database 614 so that the complete list of all medications that are
being administered to the ICU patient is current.
[0222] Referring to FIG. 18 the event log is illustrated. The
database 620 contains all manner of notes and data relating to the
particular patient that is admitted to the ICU. For example,
admission notes 622 are taken upon admission of the patient and
stored in the file that is specific to that patient. Progress notes
624 are created during the patients stay within the ICU to note the
progress the patient is making giving the various treatments.
Procedural notes 626 are also created by the intensivist to note
what procedures have taken place and what if any events have
occurred associated with those procedures. Laboratory data such as
positive blood cultures are also stored in the file 628 in the
database 620. Further x-ray data 630 and abnormal CT Scan results
are stored in the database.
[0223] The result of these individual files are then provided to an
event log manager 632. For example, admission notes might contain
operations performed. Progress notes 624 might relate to the
operations preformed. This information is provided to the event log
manager 632. Admission information is also input to the event log
manager as are a listing of the procedures administered to the
patient. To the extent there are positive blood cultures in the
laboratory data 628 those are provided to the event log manager 632
as are abnormal CT scan results. All of this information is made
available through the user interface 634. Thus the event log
presents in a single location key clinical information from
throughout a patients stay in the ICU. The event log user interface
provides caregivers with a snapshot view of all salient events
since admission. All relevant data on procedures and laboratory
tests, etc. are presented chronologically.
[0224] Referring to FIG. 19 the smart alarms of the present
invention are illustrated. The smart alarm system constantly
monitors physiologic data (collected once per minute from the
bedside monitors) and all other clinical information stored in the
database (labs, medications, etc). The periodicity of the
collection of data is stated for illustrative purposes only. It is
well within the scope of the present invention to collect
physiological data at more frequent time intervals. Thus, monitor
636 provides information in HL7 form to the interface engine 638.
The physiological data is then formatted by the interface engine
for storage in the database 640 where all patient information is
maintained. The rules engine 642 searches for patterns of data
indicative of clinical deterioration.
[0225] One family of alarms looks for changes in vital signs over
time, using pre-configured thresholds. These thresholds are
patient-specific and setting/disease-specific. For example,
patients with coronary artery disease can develop myocardial
ischemia with relatively minor increases in heart rate. Heart rate
thresholds for patients with active ischemia (e.g. those with
unstable angina in a coronary care unit) are set to detect an
absolute heart rate of 75 beats per minute. In contrast, patients
with known coronary artery disease in a surgical ICU have alarms
set to detect either an absolute heart rate of 95 beats per minute
or a 20% increase in heart rate over the baseline. For this alarm,
current heart rate, calculated each minute based on the median
value over the preceding 5 minutes, is compared each minute to the
baseline value (the median value over the preceding 4 hours).
Physiologic alarms can be based on multiple variables. For example,
one alarm looks for a simultaneous increase in heart rate of 25%
and a decrease in blood pressure of 20%, occurring over a time
interval of 2 hours. For this alarm, thresholds were initially
selected based on the known association between changes in these
two variables and adverse clinical events. Actual patient data were
then evaluated to determine the magnitude of change in each
variable that yielded the best balance between sensitivity and
specificity. This process was used to set the final thresholds for
the rules engine.
[0226] Alarms also track additional clinical data in the patient
database. One alarm tracks central venous pressure and urine
output, because simultaneous decreases in these two variables can
indicate that a patient is developing hypovolemia. Other rules
follow laboratory data (e.g. looking for need to exclude active
bleeding and possibly to administer blood).
[0227] The purpose of the rules engine is to facilitate detection
of impending problems and to automate problem detection thereby
allowing for intervention before a condition reaches a crisis
state.
[0228] Referring to FIG. 20 the procedural note-line log is
illustrated. This log allows clinicians to evaluate the likelihood
that a given procedure might result in further complications. In
this example presented in this FIG. 20 a catheter removal is
illustrated. When a new catheter is inserted in a patient 648 a
procedural note is created on the procedure note creation user
interface 646. The note is reviewed and a digital signature is
attached to the note to associate the note with a particular
intensivist 654. The procedure is then approved and is provided to
the data output system 656. The procedural note is then printed on
the printer in the ICU 658 and is exported in HL7 language to the
hospital data system 660. In addition, this also triggers a billing
event and the data output system provides appropriate output to the
billing module 662 to generate an invoice line item. In addition,
the note is stored in the emergency medical record associated with
the patient in the database 664. In addition, the line log is
updated in the database 664 to show what procedure was
administrated to a patient at what time. If there is an existing
catheter, that is displayed to the intensivist at the procedure
note creation user interface 646. This would show an existing
catheter changed over a wire 650. That information is provided to
the line id module 652 which extracts information from the line log
in the database 664. This information results in a note being
created and provided to the note review and signature module 664.
Thus the line log contains, for each patient, relevant information
about all in-dwelling catheters, including type and location of the
catheter, insertion date, the most recent date that the catheter
was changed over a wire, and the date the catheter was removed.
This information helps clinicians evaluate the likelihood that a
given catheter is infected and guides its subsequent management of
that procedure.
Evidence-based Guidelines, Algorithms, and Practice Standards
Decision Support Algorithms
[0229] In order to standardize treatment across ICUs at the highest
possible level, decision support algorithms are used in the present
invention. These include textural material describing the topic,
scientific treatments and possible complications. This information
is available in real time to assist in all types of clinical
decisions from diagnosis to treatment to triage.
[0230] All connections among components of the present invention
are presently with a high bandwidth T-1 line although this is not
meant as a limitation. It is anticipated that other existing and
future high bandwidth communication capabilities, both wired and
wireless, as well as satellite communications will be suitable for
the communications anticipated for the present invention.
[0231] As noted earlier, a key objective of the present invention
is to standardize care and treatment across ICUs. This is effective
in the present invention by providing decision support to
intensivists as well as information concerning the latest care and
practice standards for any given condition. As noted in Table I
below, a wide variety of conditions is noted. Each of the
conditions has an associated guideline of practice standard that
can be presented to the intensivist who might be faced with that
particular condition in a patient. These guidelines of practice
standards can be accessed at the command center/remote location or
at the ICU to assist in the treatment of the patient. Thus, the
general categories of cardiovascular, endocrinology, general,
gastrointestinal, hematology, infectious diseases, neurology,
pharmacology, pulmonary, renal, surgery, toxicology, trauma all
have guidelines and practice standards associated with them.
TABLE-US-00001 TABLE 1 EVIDENCE-BASED GUIDELINES ALGORITHMS &
PRACTICE STANDARDS DECISION SUPPORT CARDIOVASCULAR BRADYARRHYTHMIAS
CARDIOGENIC SHOCK CARDIO-PULMONARY RESUSCITATION GUIDELINES
CONGESTIVE HEART FAILURE EMERGENCY CARDIAC PACING FLUID
RESUSCITATION HYPERTENSIVE CRISIS IMPLANTABLE CARDIO-DEFIBRILLATORS
INTRA-AORTIC BALLOON DEVICES MAGNESIUM ADMINISTRATION IN PATIENTS
MANAGEMENT OF HYPOTENSION, INOTROPES MYOCARDIAL INFARCTION MI WITH
LEFT BUNDLE BRANCH BLOCK PA CATHETER GUIDELINES &
TROUBLE-SHOOTING PERMANENT PACEMAKERS & INDICATIONS PULMONARY
EMBOLISM DIAGNOSIS PULMONARY EMBOLISM TREATMENT SUPRA-VENTRICULAR
TACHYARRHYTHMIAS UNSTABLE ANGINA VENOUS THROMBOEMBOLISM PROPHYLAXIS
VENOUS THROMBOSIS: DIAGNOSIS & TREATMENT VENTRICULAR
ARRHYTHMIAS ENDOCRINOLOGY ADRENAL INSUFFICIENCY DIABETIC
KETOACIDOSIS HYPERCALCEMIA: DIAGNOSIS & TREATMENT
HYPERGLYCEMIA: INSULIN TREATMENT STEROID REPLACEMENT STRATEGIES
THYROID DISEASE GENERAL DEALING WITH DIFFICULT PATIENTS AND
FAMILIES END OF LIFE DECISIONS ETHICAL GUIDELINES PRESSURE ULCERS
ORGAN PROCUREMENT GUIDELINES GASTROINTESTINAL ANTIBIOTIC ASSOCIATED
COLITIS HEPATIC ENCEPHALOPATHY HEPATIC FAILURE MANAGEMENT OF
PATIENTS WITH ASCITES NUTRITIONAL MANAGEMENT ACUTE PANCREATITIS
UPPER GI BLEEDING: STRESS PROPHYLAXIS UPPER GI BLEEDING:
NON-VARICEAL UPPER GI BLEEDING: VARICEAL HEMATOLOGY HEPARIN
HEPARIN-INDUCED THROMBOCYTOPENIA THE BLEEDING PATIENT
THROMBOCYTOPENIA THROMBOLYTIC THERAPY TRANSFUSION GUIDELINES USE OF
HEMATOPOETIC GROWTH FACTORS WARFARIN INFECTIOUS DISEASES ACALCULUS
CHOLECYSTITIS ANTIBIOGRAMS BLOODSTREAM INFECTIONS CANDIDURIA
CATHETER RELATED SEPTICEMIA CATHETER REPLACEMENT STRATEGIES
ENDOCARDITIS PROPHYLAXIS ENDOCARDITIS DIAGNOSIS AND TREATMENT
FEBRILE NEUTROPENIA FUO HIV+ PATIENT INFECTIONS MENINGITIS
NECROTIZING SOFT TISSUE INFECTIONS NON-INFECTIOUS CAUSES OF FEVER
OPHTHALMIC INFECTIONS PNEUMONIA, COMMUNITY ACQUIRED PNEUMONIA,
HOSPITAL ACQUIRED SEPTIC SHOCK SINUSITIS SIRS TRANSPLANT INFECTION
PROPHYLAXIS TRANSPLANT-RELATED INFECTIONS NEUROLOGY AGITATION,
ANXIETY, DEPRESSION & WITHDRAWAL BRAIN DEATH GUILLAIN-BARRE
SYNDROME INTRACEREBRAL HEMORRHAGE MYASTHENIA GRAVIS NEUROMUSCULAR
COMPLICATIONS OF CRITICAL ILLNESS NON-TRAUMATIC COMA SEDATION
STATUS EPILEPTICUS STROKE SUB-ARACHNOID HEMORRHAGE PHARMACOLOGY
AMINOGLYCOSIDE DOSING AND THERAPEUTIC MONITORING AMPHOTERICIN-B
TREATMENT GUIDELINES ANALGESIA ANTIBIOTIC CLASSIFICATION &
COSTS DRUG CHANGES WITH RENAL DYSFUNCTION PENICILLIN ALLERGY
NEUROMUSCULAR BLOCKERS VANCOMYCIN THERAPEUTIC DRUG MONITORING
PULMONARY ARDS: HEMODYNAMIC MANAGEMENT ARDS: STEROID USE ARDS:
VENTILATOR STRATEGIES ASTHMA BRONCHODILATOR USE IN VENTILATOR
PATIENTS BRONCHOSCOPY & THORACENTESIS GUIDELINES COPD
EXACERBATION & TREATMENT CXR (INDICATIONS) NONINVASIVE MODES OF
VENTILATION ENDOTRACHEAL TUBES & TRACHEOTOMY TREATMENT OF
AIRWAY OBSTRUCTION VENTILATOR WEANING PROTOCOL RENAL ACUTE RENAL
FAILURE: DIAGNOSIS ACUTE RENAL FAILURE: MANAGEMENT & TREATMENT
DIALYSIS DIURETIC USE HYPERKALEMIA: ETIOLOGY & TREATMENT
HYPERNATREMIA: ETIOLOGY & TREATMENT HYPOKALEMIA: ETIOLOGY &
TREATMENT HYPONATREMIA: ETIOLOGY & TREATMENT OLIGURIA SURGERY
OBSTETRICAL COMPLICATIQNS DISSECTING AORTIC ANEURYSM POST-OPERATIVE
HYPERTENSION POST-OPERATIVE MYOCARDIAL ISCHEMIA (NON-CARDIAC
ARRHYTHMIAS AFTER CARDIAC SURGERY POST-OPERATIVE BLEEDING
POST-OPERATIVE MANAGEMENT OF ABDOMINAL POST-OPERATIVE MANAGEMENT OF
OPEN HEART POST-OPERATIVE MANAGEMENT OF THORACOTOMY POST-OPERATIVE
POWER WEANING POST-OPERATIVE MANAGEMENT OF CAROTID WOUND HEALING
STRATEGIES TOXICOLOGY ACETAMINOPHEN OVERDOSE ANAPHYLAXIS COCAINE
TOXICITY ALCOHOL WITHDRAWAL HYPERTHERMIA LATEX ALLERGY UNKNOWN
POISONING TRAUMA ABDOMINAL COMPARTMENT SYNDROME BLUNT ABDOMINAL
INJURY BLUNT AORTIC INJURY BLUNT CARDIAC INJURY DVT PROPHYLAXIS
EXTREMITY COMPARTMENT SYNDROME HEAD INJURY HYPOTHERMIA
IDENTIFICATION OF CERVICAL CORD INJURY SPINAL CORD INJURY OPEN
FRACTURES PENETRATING ABDOMINAL INJURY PENETRATING CHEST INJURY
[0232] Referring to FIGS. 21A-B, the acalculous cholecystitis
decision support algorithm of the present invention is illustrated.
If an intensivist suspects that acalculous cholecystitis may be
present, the intensivist may not be certain of all of the aspects
that would be indicative of this particular condition. Therefore,
the intensivist is lead through a decision support algorithm, which
first causes the intensivist to determine if the patient is
clinically infected, either febrile or leukocystosis 800. If this
criterion is not met, the intensivist is prompted that it is
unlikely that the patient has acalculous cholecystitis 802.
[0233] If the patient is clinically infected 800, the intensivist
is prompted to determine whether the patient has had a previous
cholesystectomy 804. If patient has had a previous cholesystectomy,
the intensivist is prompted that it is very unlikely that the
patient has acalculous cholecystitis 806. Alternatively, if a
patient has not had a previous cholesystectomy, the intensivist is
prompted to determine whether the patient has any of seven (7) risk
factors, specifically: 1) Prolonged intensive care unit (ICU) stay
(defined as greater than six (6) days); 2) recent surgery
(particularly aortic cross clamp procedures); 3) hypotension; 4)
positive end-expiratory pressure (PEEP) greater than ten (10)
centimeters (cm); 5) transfusion greater than six (6) units of
blood; 6) inability to use the gastrointestinal (GI) tract for
nutrition; or 7) immunosuppresssion (AIDS, transplantation, or
leukemia) 808. If the patient has none of these seven risk factors,
the intensivist is prompted that the patient probably does not have
acalculous cholecystitis 810.
[0234] If the patient has any of the seven risk factors 808, the
intensivist is prompted to determine whether the patient has any of
the following symptoms: right upper quadrant (RUQ) tenderness;
elevated alkalinephosphatase; elevated bilirubin; or elevated
livert transaminases 812. If the patient has none of these four (4)
symptoms 812, the intensivist is prompted to consider other more
likely sources of infection (see fever of unknown origin or FUO)
814. If the infection remains undiagnosed following an alternative
work-up, the intensivist is prompted to re-enter the algorithm
814.
[0235] If the patient has any of these four (4) symptoms 812, the
intensivist is prompted to determine whether alternative
intra-abdominal infectious sources are more likely 816. If
alternative intra-abdominal infectious sources are not more likely,
the intensivist is prompted to determine whether the patient is
sufficiently stable to go for a test 826. If the patient is
sufficiently stable to go for a test, the intensivist is prompted
to perform an mso4 Cholescintigraphy 836. The normal AC is excluded
838. If the test indicates an abnormality, the intensivist is
prompted to consider a cholecystectomy or precutaneous drainage
840. If the patient is not sufficiently stable to go for a test,
the intensivist is prompted to perform a bedside ultrasound 828. If
no other infectious etiologies are identified and no abnormalities
of the gall-bladder are noted but: a) the patient remains ill 830,
the intensivist is prompted to consider empiric cholecystostomy
832. If no other infectious etiologies are identified and no
abnormalities of the gall bladder are noted but: b) the patient is
improving 830, the intensivist is prompted to continue to observe
the patient 834.
[0236] If alternative intra-abdominal infectious sources are more
likely 816, the intensivist is prompted to determine whether the
patient is sufficiently stable to go for a test 818. If the patient
is sufficiently stable to go for a test 818, the intensivist is
prompted to perform an abdominal CT scan 820. If no other
infectious etiologies are apparent and the test: a) demonstrates
abnormalities of the gall-bladder but not diagnostic; or b) no
gall-bladder abnormalities are noted 822, the intensivist is
prompted to maintain continued observation of the patient 824.
Alternatively, if neither of these criteria is met 822, the
intensivist is prompted to perform an mso4 cholescintigraphy 836.
Normal AC is excluded 838. If the test is abnormal, the intensivist
is prompted to consider cholecystectomy or precutaneous drainage
840. If the patient is not sufficiently stable to go for a test,
the intensivist is prompted to perform a bedside ultrasound 828. If
no other infectious etiologies are identified and no abnormalities
of the gall-bladder are noted but: a) the patient remains ill 830,
the intensivist is prompted to consider empiric cholecystostomy
832. If no other infectious etiologies are identified and no
abnormalities of the gall bladder are noted but: b) the patient is
improving 830, the intensivist is prompted to continue to observe
the patient 834.
[0237] Referring to FIG. 22, the adrenal insufficiency decision
support algorithm of the present invention is illustrated. When an
intensivist suspects an adrenal problem may be presented in a
patient, the intensivist may initiate the adrenal insufficiency
decision support algorithm which prompts questions concerning all
aspects of the condition. First the intensivist is prompted to
determine whether the patient is either hypotensive and/or has been
administered pressors for forty-eight hours or longer 900. If
neither condition is met, the system advises the intensivist that
it is unlikely that an adrenal problem is present 902.
[0238] If one or both conditions are met, the intensivist is asked
whether an obvious cause for hypotensive blood pressure or
treatment with pressors are manifested, such as hypovolemia or low
blood volume, myocardial dysfunction, or spinal injury 904. If at
least one of these obvious causes is present, the intensivist is
alerted by the system that the underlying cause must first be
treated 906. If treatment of a suspected underlying cause is
reversed, yet the hypotension or pressor need persists, the
intensivist is further directed to determine whether other adrenal
problems have occurred in the patient's history 908, 910, 912.
[0239] In order to examine prior treatment issues, the intensivist
is first prompted by the system to determine if the patient has
been treated with steroids in the previous six months for at least
a two week period 908. Next, the intensivist is prompted to
determine whether the patient has hyponatremia or hyperkalemia 910.
The intensivist is also prompted to determine whether the patient
has experienced anticoagulation or become coagulopathic prior to
the hypotension or pressor treatment 912. According to the
responses provided by the intensivist to the system queries or
blocks 908, 910, and 912, the system calculates a treatment action
914 as follows: The array of possible responses to diagnosis
questions 908, 910, and 912 are given a Decision Code as shown in
Table 1A: Adrenal Insufficiency Considerations, below.
TABLE-US-00002 TABLE 1A Adrenal Insufficiency Considerations
Question 1 Question 2 Question 3 908 910 912 Decision Code N N N A
N N Y A N Y N B N Y Y C Y Y Y C Y N N D Y Y N B Y N Y D Y Y Y C
[0240] The possible decision codes of Table 1A are as follows:
TABLE-US-00003 Decision Code Treatment Action A Do cosyntropin stim
test B Consider possible Adrenal Insufficiency. Give decadron 5 mg
IV, so cosyntropin stim test and empirically treat with
hydrocortione 50 mg IV every 8 hours until stim test results
return. C Consider possible Adrenal Insufficiency, secondary to
adrenal hemorrhage. Give decadron 5 mg IV, so cosyntropin stim test
and empirically treat with hydrocortione 50 mg IV every 8 hours
until stim test results return. D Do cosyntropin stim test, may
empirically treat with hydrocortisone 25-50 mg IV every 8 hours
until stim test results return
[0241] Besides specialized treatment actions listed in the decision
codes above, the intensivist is directed to administer a
cosyntropin stimulation test 914 in order to see how much cortisone
the adrenal gland is producing.
[0242] After performing the cosyntropin stimulation test, the
intensivist is prompted to enter the patient's level of cortisol
before administering cosyntropin and thirty minutes afterwards 916.
The software analyzes the test results as follows: The results in
Table 2, shown below, are shown as having certain decision codes A
through F. TABLE-US-00004 TABLE 2 Cosyntropin Stimulation Test
Results basal (A) basal (B) basal (C) <15 .sup. .sup. 15-20
>25 stim (D) stim (E) stim (F) <5 .sup. 5-10 >10
[0243] Depending upon the outcome of the analysis of Table 2, one
of the treatment actions, shown below in Table 3, will be displayed
918. TABLE-US-00005 TABLE 3 Cosyntropin Test Result Treatment
Actions Decision Code Treatment Action A + D Adrenal insufficiency
diagnosed - treat with hydro- cortisone 50 mg IV every 8 hours and
consider endocrine consult A + E Probable Adrenal insufficiency-
treat with hydro- B + D cortisone 25-50 mg IV every 8 hours and
taper as intercurrent illness improves A + F Possible Adrenal
insufficiency- consider treatment B + E with hydrocortisone 25 mg
IV every 8 hours and taper as intercurrent illness improves A + F
Adrenal insufficiency unlikely- would not treat B + F C + E C +
F
[0244] Referring to FIG. 23, the blunt cardiac injury decision
support algorithm of the present invention is illustrated. If an
intensivist suspects that blunt cardiac injury may be present, the
intensivist may not be certain of all aspects that would be
critical to or indicative of this particular condition. Therefore,
the intensivist is lead through a decision support algorithm, which
first causes the intensivist to determine whether any of seven (7)
risk factors are present: 1) was thoracic impact greater than
fifteen (15) mph; 2) was the steering wheel deformed; 3) was there
precordial ecchymosis, contusions, or abrasions; 4) was marked
precordial tenderness present; 5) was there a fractured sternum; 6)
were bilateral rib/costal cartilage fractures present; 7) were
thoracic spine fractures present 1000. If none of the 7 risk
factors are present, the intensivist is prompted that no further
evaluation is necessary 1002. If any of the 7 risk factors are
present, the intensivist is prompted to obtain an electrocardiogram
(ECG) and chest X-ray (CXR) 1004.
[0245] Once the results of the ECG and CXR are obtained, the
intensivist is prompted to determine: whether the ECG results are
abnormal, with abnormal being defined as anything other than sinus
rhythm, including ectopy and unexplained sinus tachycardia (greater
than 100 beats/minute); and whether the CXR results are abnormal,
with abnormal being defined as any skeletal or pulmonary injury,
especially cardiac enlargement 1006. If either the ECG or CXR is
not abnormal, the intensivist is prompted that a monitored bed is
unnecessary for the patient 1008. If either the ECG or CXR is
abnormal, the intensivist is prompted to determine whether there is
any hemodynamic instability (hemodynamic instability being defined
as the absence of hypovolemia, spinal cord injury, or sepsis) that
cannot be explained by hypovolemia, spinal cord injury, or sepsis
1010.
[0246] If this criterion is not met, the intensivist is prompted:
that the patient should be in a monitored bed; that the ECG should
be repeated at 24 hours; that, at any time, if unexplained
hemodynamic instability is present, the intensivist should request
a stat echo; and that, if blunt thoracic aortic injury is also
suspected, a transesophogeal echocardiogram (TEE) is favored over a
transthoracic echocardiogram (TTE) 1012. Once the results of these
tests are obtained, the intensivist is prompted further to
determine whether ectopy, arrhythmia, or abnormality is present on
the ECG 1014. If none of these criteria are met, the intensivist is
prompted that cardiac injury is excluded 1016. If any of these
criteria are met, the intensivist is prompted that he should
consider monitoring the patient for an additional 24 hours
1018.
[0247] If the internist determines that there is any hemodynamic
instability that cannot be explained by hypovolemia, spinal cord
injury, or sepsis 1010, he is prompted: to perform a stat echo;
and, if blunt thoracic aortic injury is also suspected, that a
transesophogeal echocardiogram (TEE) is favored over a
transthoracic echocardiogram (TTE) 1020. Once the results of the
stat echo are obtained, the intensivist is prompted to determine
whether the echo is abnormal with possible causes for the
abnormality being: pericardial effusion (tamponade; hypokineses or
akinesis (wall motion); dilatation or reduced systolic function;
acute valvular dysfunction; and/or chamber rupture 1022. If the
stat echo is abnormal, the intensivist is prompted to treat as
indicated for the particular cause of the abnormality 1026. If the
stat echo is not abnormal, the intensivist is prompted to continue
to monitor the patient and repeat the ECG at 24 hours 1024.
[0248] Once the results of the ECG are obtained, the intensivist is
prompted to determine whether ectopy, arrhythmia, or abnormality
are present on the ECG 1014. If any of these criteria are not met,
the intensivist is prompted that cardiac injury is excluded 1016.
If any of these criteria are met, the intensivist is prompted that
he should consider monitoring the patient for an additional 24
hours 1018.
[0249] Referring to FIGS. 24A-B, the candiduria decision support
algorithm, which is yet another decision support algorithm of the
present invention is illustrated. In the candiduria decision
support algorithm, the intensivist is presented with the criteria
for diagnosing candiduria, or severe fungal infection. First, the
intensivist determines whether the patient has any medical
conditions that render the patient prone to fungal infections, such
as diabetes, GU anatomic abnormality, renal transplant, or pyuria
1100. If there are no such conditions, the intensivist is next
prompted by the system to look for dissemination or spreading of
the fungal infection 1102. If the infection does not seem to have
spread, the intensivist is prompted to change the patient's
catheter and test for pyuria after twenty four hours have passed
1104.
[0250] The intensivist is prompted by the system to determine
whether the patient can have P.O. 1106. If the patient can take
P.O., the system next prompts the intensivist to determine whether
azoles, an organic compound for inhibiting fungal growth, have been
administered in the past three days to fight the infection 1108. If
azoles have been previously administered, the systemic infection
diagnosis is confirmed and the intensivist is referred to the
systemic amphotericin dosing algorithm 1110. If azoles have not
been previously administered, directions for the proper treatment
dosage of fluconazole (a type of azole) is provided to the
intensivist along with adjustments for the species of fungus found
1112. Where the patient cannot take P.O., the intensivist is again
referred to the systemic amphotericin dosing algorithm 1114.
[0251] When the patient does have some condition prone to fungal
infection, the intensivist is prompted to determine what other
signs of dissemination are exhibited in the patient 1116. The
intensivist is prompted to see if the patient can take P.O. If the
patient cannot take P.O., the intensivist is referred to the
systemic amphotericin dosing algorithm 1120. If the patient can
take P.O., the intensivist is prompted to check whether azoles have
been administered in the previous three days 1122. If azoles have
been administered, the systemic infection is confirmed and the
intensivist is referred to the systemic amphotericin dosing
algorithm 1124. If no azoles have been administered previously, the
intensivist is given instructions for administering fluconazole to
treat the fungal infection 1126.
[0252] If there is no evidence of dissemination, the intensivist is
still prompted to determine whether the patient can take P.O. 1128.
Where the patient cannot take P.O., directions are provided to
administer amphotericin bladder washing procedures 1130. If the
patient cannot take P.O., the intensivist is prompted to determine
whether azoles have been administered in the previous three days
1132. If azoles have been administered, the systemic infection is
confirmed and the intensivist is referred to the systemic
amphotericin dosing algorithm 1134. If no azoles have been
administered previously, the intensivist is given instructions for
administering fluconazole to treat the fungal infection 1136.
[0253] Referring to FIGS. 25A-B, the Cervical Spine Injury decision
support algorithm of the present invention is illustrated. If an
intensivist suspects that a cervical spine injury may be present,
the intensivist may not be certain of all of the factors that would
be indicative of this particular condition. Therefore, the
intensivist is lead through a decision support algorithm, which
first prompts the intensivist to determine if the patient is awake,
alert, not intoxicated, and has no mental status changes 1200. If
these criteria are met, the intensivist is prompted to determine
whether the patient has any neck pain 1202. If the patient does not
have any neck pain, the intensivist is prompted to determine
whether the patient has any other pain which would distract from
his or her neck pain 1204. If this criterion is not met, the
intensivist is prompted to determine whether the patient has any
neurologic deficits 1206. If this criterion is not met, the
intensivist is prompted that a stable C-spine is present if the
patient can flex, extend, move neck left/right without pain and
without neck tenderness to palpitation 1208. The intensivist is
prompted further that he can remove the collar 1208.
[0254] Alternatively, if the patient does have neck pain 1202, the
intensivist is prompted to order 3 x rays 1210 consisting of: 1)
lateral view revealing the base of the occiput to the upper border
of the first thoracic vertebra; 2) anteroposterior view revealing
spinous processes of the second cervical through the first thoracic
vertebra; and 3) an open mouth odontoid view revealing the lateral
masses of the first cervical vertebra and entire odontoid process
1210. If the x rays are normal the intensivist is prompted to
consider extension then flexion lateral x rays; if normal he is
prompted that he can remove the collar; if abnormal, he is prompted
to obtain a surgical consult 1212. If the x rays are abnormal, the
intensivist is prompted to obtain a surgical consult and order a CT
scan 1214. If the x rays are indeterminate, the intensivist is
prompted to order a CT scan 1216.
[0255] Alternatively, if the patient has no other pain which would
distract from their neck pain 1204, the intensivist is prompted to
order 3 x rays (the same types of x rays described in 1210 above
with the same prompting based on normal, abnormal, or indeterminate
x rays) 1218.
[0256] If the patient does have neurologic deficits 1206, the
intensivist is prompted to determine whether the neurologic deficit
is referable to the cervical spine 1226. If this criterion is not
met, the intensivist is prompted to order 3 x rays (the same types
of x rays described in 1210 above with the same prompting based on
normal, abnormal, or indeterminate x rays) 1218. If the neurologic
deficit is referable to the cervical spine 1226, the intensivist is
prompted that the patient should obtain immediate spine trauma
surgery consult and CT or MRI (if available) 1228.
[0257] Alternatively, if the intensivist determines that the
patient does not pass the criteria of being awake, alert, not
intoxicated and having no mental status changes 1200, the
intensivist is prompted to determine whether the patient has severe
head trauma 1232. If this criterion is met, the intensivist is
prompted to order CT of the neck with head CT 1236. If this
criterion is not met, the intensivist is prompted to determine
whether the patient has any neurologic deficit referable to the
cervical spine 1234. If the intensivist determines that the patient
does have a neurologic deficit referable to the cervical spine, the
intensivist is prompted that the patient should obtain immediate
spine trauma surgery consult and CT or MRI (if available) 1228. If
the intensivist determines that the patient does not have a
neurologic deficit referable to the cervical spine 1234, he is
prompted to order 3 x rays (the same types of x rays described in
1210 above with the same prompting based on normal, abnormal, or
indeterminate x rays) 1218.
[0258] Referring to FIG. 26A-B, the Oliguria decision support
algorithm of the present invention is illustrated. If an
intensivist suspects that Oliguria may be present, the intensivist
may not be certain of all of the aspects that would be indicative
of this particular condition. Therefore, the intensivist is lead
through a decision support algorithm, which first causes the
intensivist to determine if the patient is oliguric, with the
criterion being passage of less than 25 cc of urine in a period of
2 hours 1300. If this criterion is met the intensivist is prompted
to determine whether the patient is anuric (the criterion for which
is passage of less than 10 cc of urine in a 2 hour period) in spite
of fluid administration 1302.
[0259] If this criterion is met, the intensivist is prompted to
determine whether the urinary catheter is working by flushing the
catheter 1304. The intensivist is then prompted to determine
whether the catheter is functioning 1306. If the catheter is not
functioning, the intensivist is prompted to replace or reposition
the catheter 1308. If the catheter is functioning, the intensivist
is prompted to determine whether the patient has a history of: 1)
renal stone disease; 2) abdominal, pelvic, or retroperitoneal
cancer; or 3) recent pelvic or retroperitoneal surgery 1310. If any
of these criteria are met, the intensivist is prompted to perform
the following actions: 1) do renal ultrasound emergently to rule
out obstruction; 2) while waiting for ultrasound, administer fluid
at the rate of 7-15 ml/kg of bodyweight; and 3) send urine for
specific gravity determination 1312. Based on the renal ultrasound
test results, the intensivist is prompted to determine whether an
obstruction is present 1314. If an obstruction is determined to be
present, the intensivist is prompted to consult a urologist
immediately 1316.
[0260] Alternatively, if the intensivist determines that the
patient does not have a history of: 1) renal stone disease; 2)
abdominal, pelvic, or retroperitoneal cancer; or 3) recent pelvic
or retroperitoneal surgery 1310, the intensivist is prompted to
determine whether: 1) the patient has a history of heart failure or
known ejection fraction of less than 30 percent; or 2) there are
rales on the physical exam 1318.
[0261] Alternatively, if following the renal ultrasound test, the
intensivist determines that there is no obstruction the intensivist
is prompted to determine whether: 1) the patient has a history of
heart failure or known ejection fraction of less than 30 percent;
or 2) there are rales on the physical exam 1318.
[0262] If the intensivist determines that the patient is not anuric
1302, then the intensivist is prompted to determine whether: 1) the
patient has a history of heart failure or known ejection fraction
of less than 30 percent; or 2) whether there are rales on the
physical examination 1318. If neither of these criteria is met, the
intensivist is prompted to administer fluids to the patient at the
rate of 10-20 ml/kg of bodyweight 1320 and send the patient's urine
sample for a specific gravity test 1322 as more fully described in
FIGS. 26B-C.
[0263] Alternatively, if the patient does: 1) have a history of
heart failure or known ejection fraction less than 30 percent; or
2) there are rales on the physical exam 1318, the intensivist is
prompted to determine whether there has been a chest x-ray (CXR) in
the last 6 hours 1324. If this criterion is not met, the
intensivist is prompted to determine whether there has been a
change in respiratory status 1326. If there has been no change in
the respiratory status, the intensivist is prompted to administer
7-15 ml of fluids per kg of bodyweight 1328 and to send the
patient's urine sample for a specific gravity test.
[0264] Alternatively, if the intensivist determines that there has
been a change in respiratory status 1326, the intensivist is
prompted to: 1) do a chest x-ray; and 2) determine whether there is
evidence of edema or congestion 1334. If there is evidence of edema
or congestion 1334, the intensivist is prompted to: 1) insert a PA
catheter to measure wedge pressure and liver function to direct
fluid replacement; and 2) send urine creatinine and sodium
1332.
[0265] If the intensivist determines that there has been a CXR in
the last 6 hours 1324, the intensivist is prompted to determine
whether there is evidence of edema or congestion 1330. If there is
no evidence of edema or congestion, the intensivist is prompted to
administer 7-15 ml of fluids per kg of bodyweight 1328 and send the
patient's urine for a specific gravity test 1322.
[0266] Alternatively, if the intensivist determines there is
evidence of edema or congestion 1330, the intensivist is prompted
to: 1) insert a PA catheter to measure wedge pressure and liver
function to direct fluid replacement; and 2) send urine creatinine
and sodium 1332.
[0267] Referring now to FIG. 26C-D, the oliguria algorithm
description continues. Following the specific gravity test of the
patient's urine, the intensivist is prompted to determine whether
the results indicate the specific gravity is less than 1.018. If
this criterion is met, the intensivist is prompted to: 1) send
blood and urine immediately to test for blood urea nitrogen (BUN),
creatinine, electrolytes, and Hgb, and spot urine for creatinine,
sodium, and sediment; and 2) administer 5-10 ml of fluid per kg of
bodyweight 1356. Once the results of these tests are obtained, the
intensivist is prompted to determine what is the Hgb 1338.
[0268] If the Hgb has increased by more than 1.5 gm/dl compared to
the previous Hgb 1340, the intensivist is prompted to: 1)
administer fluids 5-10 ml/kg of bodyweight and follow the urine
output closely 1342. Following this, the intensivist is prompted to
determine whether the labs confirm renal failure by use of the
formula FE.sub.Na=Urine Na.times.Serum Creatinine/Urine
Creatinine.times.Serum Na.times.100 1344.
[0269] If the Hgb is within 1.5 gm/dl from the previous Hgb or no
comparison 1352, the intensivist is prompted to determine what is
the mean blood pressure 1354. If the mean blood pressure is
determined to be within 20 percent or higher than the baseline
blood pressure 1356, the intensivist is prompted to determine
whether the labs confirm renal failure 1344. If the mean blood
pressure is determined to be greater than 20 percent below the
baseline pressure 1358, the intensivist is prompted to give
additional fluids and consider invasive hemodynamic monitoring
1360. Following this, the intensivist is prompted to determine
whether the labs confirm renal failure by use of the formula
FE.sub.Na=Urine Na.times.Serum Creatinine/Urine Creatinine.times.
Serum Na.times.100 1344.
[0270] Alternatively if the Hgb has decreased by 1.5 gm/dl compared
to the previous Hgb 1362, the intensivist is prompted to: 1)
transfuse PRBCs as needed; 2) look for source of bleeding and check
PT, aPTT, & platelet count 1364. Following this, the
intensivist is prompted to determine what is the mean blood
pressure 1354. If the mean blood pressure is determined to be
greater than 20 percent below the baseline pressure 1358, the
intensivist is prompted to give additional fluids and consider
invasive hemodynamic monitoring 1360. Following this, the
intensivist is prompted to determine whether the labs confirm renal
failure by use of the formula FE.sub.Na=Urine Na.times.Serum
Creatinine/Urine Creatinine.times.Serum Na.times.100 1344.
[0271] If the labs do not confirm renal failure, as indicated by
FE.sub.Na.1toreq.1 percent 1346, the intensivist is prompted to: 1)
continue to administer fluids and follow urine output; and 2)
recheck creatinine in 6-12 hours 1348.
[0272] Alternatively, if the labs do confirm renal failure, as
indicated by FE.sub.Na>1 percent 1350, the intensivist is
prompted to: 1) place central venous pressure (CVP); 2) Assure
adequate intravascular volume; 3) give trial of diuretics: 40 mg
lasix IV, if no response in 1 hour, give hydrodiuril 500 mg IV,
wait 20-30 minutes then give 100 mg lasix, if persistent oliguria,
restrict: 1) fluids; 2) potassium & phosphate; if diuresis
ensues, restrict only potassium & phosphate; in both
situations, adjust all renally excreted medications; and 4) see
acute renal failure 1350.
[0273] Referring now to FIG. 26E, the oliguria algorithm
description continues. Alternatively, following the specific
gravity test of the patient's urine, the intensivist is prompted to
determine whether the results indicate the specific gravity is
greater than or equal to 1.018 1336. If this criterion is not met
1364, the intensivist is prompted to determine whether the urine is
dark or tea colored 1366. If this criterion is met, the intensivist
is prompted to: 1) check creatinine phospho/kinase; and 2) force
fluids to induce diuresis 1368.
[0274] If the intensivist determines that the urine is not dark or
tea colored, the intensivist is prompted to: 1) administer 10-20 ml
of fluids per kg of bodyweight; and 2) check Hgb 1370. The
intensivist is then prompted to determine what is the Hgb 1372.
[0275] If the Hgb is determined to be greater than 1.5 gm/dl higher
than the previous Hgb 1374, the intensivist is directed to: 1)
force fluids; and 2) continue to follow the urine output 1376.
[0276] Alternatively, if the Hgb is determined to be within 1.5
gm/dl of the last Hgb or there is no Hgb for comparison 1378, the
intensivist is prompted to determine what is the mean blood
pressure 1380. If the mean blood pressure is determined to be 20
percent or higher than the baseline pressure 1382, the intensivist
is prompted to: 1) continue to administer fluids; 2) follow urine
output; and 3) check creatinine in 6-12 hours 1384. If the mean
blood pressure is determined to be greater than 20 percent below
the baseline pressure 1386, the intensivist is prompted to: 1)
continue to push fluids; 2) consider invasive hemodynamic
monitoring; and 3) if post-op abdominal trauma, consider abdominal
compartment syndrome 1388.
[0277] If the Hgb is determined to be greater than 1.5 gm/dl below
the previous Hgb 1390, the intensivist is prompted to: 1) transfuse
blood as needed; 2) look for bleeding source; 3) check PT, aPPT
& platelet count; 4) continue to push fluids; and 5) recheck
Hgb in 1-2 hours 1392.
[0278] Referring to FIG. 27A-B, the open fractures decision support
algorithm of the present invention is illustrated. Open fractures
are where bone, cartilage, or a tooth break and push through the
skin surface. The intensivist is first prompted by the system to
determine whether the patient has an open fracture 1500. If one has
occurred, the intensivist must then determine whether the wound is
contaminated with soil, or was inflicted in a barnyard 1502 in
order to address higher risk of infection. If the wound is
contaminated with soil, or was inflicted in a barnyard, the
intensivist is prompted to administer a high dose of penicillin to
the antibiotics prescribed 1504. The intensivist is also prompted
to take several treatment steps 1506. These treatment steps include
administering tetanus prophylaxis, such an antitoxin injection,
monitoring staphylococcus aureus until twenty-four hours after
surgery, caring for the wound within six hours, and where the
injury is found to be more severe during surgery, the intensivist
is prompted to administer aminoglycosides for seventy two
hours.
[0279] If the wound is not contaminated with soil, or was inflicted
in a barnyard, the intensivist is next prompted to determine the
severity of the wound 1508. To do so, the intensivist must
determine the length of the wound and corresponding soft tissue
damage. If the wound is either less than one centimeter and clean
or greater than a centimeter long without extensive soft tissue
damage, the intensivist is prompted to take several treatment steps
1506 as previously described. Where the soft tissue damage is
extensive or amputation has occurred, the intensivist is prompted
by the system to make further determinations 1510, 1512, 1514 about
the wound caused by the fracture. The intensivist is prompted to
determine if enough soft tissue coverage is remaining for the wound
to close and heal 1510, if any arterial repair is needed 1512, and
if extensive soft tissue damage with periostitial injury, and bone
exposure 1514. If there is adequate soft tissue coverage, the
intensivist is advised that risk of infection is low and directed
to take treatment actions 1516. If arterial damage requiring repair
is present, the intensivist is advised by the system that risk of
infection is moderate to high and given treatment instructions
1518. Where there is soft tissue injury with periostitial stripping
and bone exposure, the intensivist is alerted by the system that
risk of infection is high and given treatment instructions 1520.
The treatment instructions in each case 1516, 1518, 1520 include
administering tetanus prophylaxis, such an antitoxin injection,
caring for the wound within six hours, and performing: monitoring
for staphylococcus aureus, and administering aminoglycosides and
high doses of penicillin, all for seventy two hours before and
after any operative procedures.
[0280] If the intensivist has determined that no exposed fracture
has occurred, the system next prompts the intensivist to determine
whether there is any evidence of neuro-vascular damage 1522. If
there is evidence of neuro-vascular damage, the intensivist is
prompted to consult with a nerosurgeon or vascular surgeon
immediately 1524. If the intensivist determines there is no
evidence of neuro-vascular damage to the patient, the system next
prompts the intensivist to determine whether the patient has
compartment syndrome 1526. If there is evidence of compartment
syndrome seen in the patient, the intensivist is prompted to
consult orthopedics right away 1528. If there is no evidence of
compartment syndrome seen in the patient, the intensivist is still
prompted to consult orthopedics, but without any prompt for time
sensitivity 1530.
[0281] Referring to FIGS. 28A-B, the Pancreatitis diagnostic
algorithm of the present invention is illustrated. To evaluate
whether a patient has pancreatitis, the intensivist is first
prompted to examine whether severe epigastric abdominal pains and
amylase levels three times greater than normal are present in the
patient 1600. If neither or one of the conditions is present, the
intensivist is prompted to consider other causes of the abdominal
pain, such as mesenteric ischemia, a perforated ulcer, intestinal
obstruction, biliary colic, or an ectopic pregnancy 1602.
[0282] If severe epigastric abdominal pains and amylase levels
three times greater than normal are present, the intensivist is
next prompted to provide the Ranson Criteria which is a criteria
associated with the severity of pancreatitis and the potential
outcome or prognosis at that particular level of severity, or
Apache II score which is also a score associated with the severity
of the disease and the potential prognosis at a particular level of
the patient 1604. If the patient has a Ranson Criteria less than
three or an Apache II score of less than eight, the intensivist is
prompted by the system to consider removing the patient from the
Intensive Care Unit 1606. However, if the patient has a Ranson
Criteria greater than three or an Apache II score of greater than
eight, the intensivist is instructed to perform an abdominal
ultrasound test within twenty-four hours 1607. If the results of
the ultrasound test show a biliary obstruction, the intensivist is
instructed to consider performing an ERCP to find and remove any
gallstones 1608.
[0283] If the abdominal ultrasound results do not show any biliary
obstruction, intensivist is next prompted to perform more
diagnostic tests 1610. The intensivist is directed to perform a
Dynamic IV contrast and an abdominal Tomography (CT) scan. If the
intensivist does not suspect a surgical condition exists, such as a
perforated ulcer, mesenteric infarction or pancreatic infection,
the tests may be performed after three days have passed. If the
intensivist does suspect a surgical condition exists, the tests
should be performed within three days. In either case, if the
patient has creatinine levels greater than or equal to 2 miligrams
per dl, the intensivist should not perform the Dynamic IV contrast
test.
[0284] Once the CT scan is performed, the intensivist is prompted
to determine whether necrotizing pancreatitis is present 1612. The
intensivist is next required to determine whether the patient has
improved since admission 1614. If no improvement has been seen, the
intensivist is directed to perform percutaneous fluid aspiration
and do a gram stain culture the collected fluid 1616. If the
culture shows infection 1618, the intensivist is directed to
perform surgical debridement of the pancreas 1620. If the results
of the culture are sterile 1622, the intensivist is directed to
closely follow up on the patient's condition 1624 and watch for
clinical deterioration 1626. If the patient does further
deteriorate, the intensivist is then instructed to perform a
surgical debridement of the pancreas 1628. If the patient does not
deteriorate, the intensivist is still prompted to closely follow
the patient's condition 1630.
[0285] Where the CT scan does not show signs of necrotizing
pancreatitis 1612, the intensivist is prompted by the system to
closely observe the patient 1632. The intensivist is also prompted
to check whether clinical deterioration is occurring 1634. If no
deterioration is observed, the intensivist continues to observe the
patient's condition 1636. If clinical deterioration is occurring
1634, the intensivist is directed to perform percutaneous fluid
aspiration and do a gram stain culture the collected fluid 1616. If
the culture shows infection 1618, the intensivist is directed to
order surgical debridement of the pancreas 1620. If the results of
the culture are sterile 1622, the intensivist is directed to
closely follow up on the patient's condition 1624 and watch for
clinical deterioration 1626. If the patient does further
deteriorate, the intensivist is then prompted to order a surgical
debridement of the pancreas 1628. If the patient does not
deteriorate, the intensivist is still directed by the system to
closely follow the patient's condition 1630.
[0286] Referring to FIGS. 29A-B, the penicillin allergy diagnosis
algorithm of the present invention is illustrated. In order to
diagnose a penicillin allergy, the intensivist is first prompted to
determine whether the patient has a history suggestive of previous
penicillin or cephalosporin anaphylaxis 1700. Various known
reactions, including angioedema, flushing, pruritis, airway
obstruction, syncope, and hypertension, are displayed for the
intensivist's review. If the patient has previously had any of
these reactions, the intensivist is prompted to determine whether
the patient has ever taken synthetic or partially synthetic
antibiotics, such as ampicillin, amoxicillin, duricef or kefzol,
without any anaphylaxis symptoms 1702. If the patient has taken
synthetics without reaction, the intensivist is advised by the
system that penicillin or cephalosporin may be administered 1716.
If the patient has reacted to synthetic or partially synthetic
antibiotics, the intensivist is next prompted to determine whether
the patient needs penicillin or cephalosporin specifically
1704.
[0287] If the patient is not required to have penicillin or
cephalosporin, the intensivist is prompted to administer the
synthetic antibiotics 1706. If the patient does need penicillin or
cephalosporin, the intensivist is directed by the system to
consider consulting with an allergist or immunologist and perform
skin tests for reactions 1708. Next, the intensivist is prompted to
enter whether the skin test was positive 1710. If the results are
negative, the intensivist is further directed by the system to
administer penicillin or cephalosporin with caution, to consider
pretreatment with benadryl or prednisone to counter any reaction,
and to closely monitor the patient 1712. If the results of the skin
test are positive, the intensivist is prompted by the system to
perform desensitization procedures 1714.
[0288] If the patient does not have a history suggestive of
previous penicillin or cephalosporin anaphylaxis 1700, the
intensivist is prompted to determine whether the patient has
previously experienced skin-level reactions, such as exfoliative
dermatitis, Stevens Johnson Syndrome, or Toxic Epidernial
Necrolysis, when given penicillin or cephalosporin 1718. If the
patient has previously experienced one of these reactions, the
intensivist is directed by the system to administer an alternative
antibiotic 1720. If the patient has not experienced one of these
reactions, the intensivist is prompted to determine whether there
is a history of any rash when given penicillin or cephalosporin
1722. If the patient has not previously had a rash when given
penicillin or cephalosporin, the intensivist is advised that the
patient will most likely be able to take penicillin or
cephalosporin 1724.
[0289] If the patient has previously experienced a rash when given
penicillin or cephalosporin, the intensivist is prompted to
determine whether the rash presented when the patient was given
ampicillin or amoxycillin 1726. If the rash resulted from
ampicillin or amoxycillin, the intensivist is next prompted to
determine whether the rash was urticarial 1728. If the rash was not
urticarial, the intensivist is advised by the system that the
patient probably can take penicillin or cephalosporin, but should
be closely monitored 1730. If the rash was urticarial, the
intensivist is prompted to determine whether or not the patient
needs penicillin or cephalosporin 1704.
[0290] If the patient is not required to have penicillin or
cephalosporin, the intensivist is directed by the system to
administer the synthetic antibiotics 1706. If the patient does need
penicillin or cephalosporin, the intensivist is directed to
consider consulting with an allergist or immunologist and perform
skin tests for reactions 1708. Next, the intensivist is prompted to
enter whether the skin test was positive 1710. If the results are
negative, the intensivist is further directed to administer
penicillin or cephalosporin with caution, to consider pretreatment
with benadryl or prednisone to counter any reaction, and to closely
monitor the patient 1712. If the results of the skin test are
positive, the intensivist is directed to perform desensitization
procedures 1714.
[0291] Referring to FIG. 30A-B, the Post-Op Hypertension decision
support algorithm of the present invention is illustrated. If an
intensivist determines that there may be a possibility of post-op
hypertension, the intensivist may not be certain of all aspects
that would be involved in this particular condition. Therefore, the
intensivist is lead through a decision support algorithm which
prompts the intensivist to determine the appropriate care to be
given.
[0292] Initially, the intensivist is prompted to determine whether
the patient is hypertensive (BP greater than 20 percent above mean
baseline) 1800. If this criterion is met, the intensivist is
prompted to determine whether the patient has any of the causes of
reversible hypertension: 1) hypercapnia; 2) bladder distension; 3)
pain; 4) increased ICP; 5) drugs (pressors, cocaine, ketamine and
chronic MAO use with indirect acting vasopressors); 6) automatic
hyperreflexia; or 7) volume overload 1802. If any of these criteria
are met, the intensivist is prompted to first treat those specific
etiologies and, if pressure remains high, re-enter algorithm
1804.
[0293] Alternatively, if none of these criteria are met 1802, the
intensivist is prompted to determine whether the patient is at risk
of injury from post-op hypertension (i.e., vascular surgery,
coronary artery disease, neurosurgery, ocular surgery, etc.) 1806.
If this criterion is not met 1806, the intensivist is prompted to
determine whether the BP is greater than 40 percent above mean
baseline 1808. If this criterion is not met, the intensivist is
prompted that the patient may not need BP treatment 1810.
[0294] If the BP is greater than 40 percent above the mean baseline
1808, the intensivist is prompted to determine whether the patient
is in pain 1812. If this criterion is met 1812, the intensivist is
prompted to treat pain and continue 1814. Following this prompt
1814, the intensivist is prompted next to determine whether the
patient is actively bleeding or at significant risk for post-op
bleeding (i.e., "moist closure" or high drain output) 1816. If
either of these criteria is met 1816, the intensivist is prompted
to use only short acting agents including emolol and nitroprusside
as needed until bleeding has abated 1818.
[0295] Alternatively, if neither of these criteria is met 1816, the
intensivist is prompted to determine whether the patient is
tachycardic (absolute greater than 90 bpm or ((relative greater
than 15 percent over baseline)) 1820. If either of these criteria
is met 1820, the intensivist is prompted to go to Decision Table C,
which is programmed for the condition of a high heart rate. If
neither of these criteria is met 1820, the intensivist is prompted
to eliminate (NOT C) Table C and proceed to the next decision point
1820. TABLE-US-00006 HR.uparw.Table C CAD Y Y Y N N N RAD N Y Y N Y
N .dwnarw.EF N N Y N Y Y Treatment 1.sup.ST L E L L A E 2.sup.ND E
L A N N A
[0296] The intensivist is prompted next to determine whether the
patient is bradycardic (absolute less than 60 bpm) 1822. If this
criterion is met, the intensivist is prompted to go to Decision
Table B, which is programmed for the condition of a low heart rate.
TABLE-US-00007 HR .dwnarw. Table B CAD Y Y Y N N N RAD N Y Y N Y N
.dwnarw.EF N N Y N Y Y Treatment 1.sup.ST N N A N A A 2.sup.ND S S
S H H H
[0297] If this criterion is not met, the intensivist is prompted to
eliminate (NOT B) Table B and proceed to the next decision point
1822. [Note: If NOT C and NOT B, the intensivist is prompted to go
to Table A by default, i.e., If NOT C and NOT B Then A].
TABLE-US-00008 HR (nl) Table A CAD Y Y Y N N N RAD N Y Y N Y N
.dwnarw.EF N N Y N Y Y Treatment 1.sup.ST L E A N A A 2.sup.ND N N
E A N N
[0298] The intensivist is prompted next to determine, sequentially,
table input values for CAD, RAD, and EF.
[0299] In these decision tables, the letter references have the
following meanings: L=labetalol, E=esmolol, A=enalapril,
N=nicardipine, H=hyrdalazine, S=nitroprusside. The reference to
1.sup.st and 2.sup.nd means that treatment should begin with the
1.sup.st drug and add or substitute the 2.sup.nd drug as
needed.
[0300] Using the above decision tables, the intensivist is prompted
to determine whether the patient has known coronary artery disease
(CAD) or 3 or more risk factors for CAD 1824. If either of these
criteria is met 1824, the intensivist is prompted to enter a "Y" or
"YES" for CAD into the table selected above in 1820 and 1822. If
neither of these criteria is met, the intensivist is prompted to
enter a "N" or "NO" for CAD into the table selected above in 1820
and 1822.
[0301] Next, the intensivist is prompted to determine whether the
patient has known reactive airway disease (RAD)1826. If this
criterion is met 1826, the intensivist is prompted to enter a "Y"
or "YES" for RAD into the table selected above in 1820 and 1822. If
this criterion is not met, the intensivist is prompted to enter a
"N" or "NO" for RAD into the table selected above in 1820 and
1822.
[0302] Next, the intensivist is prompted to determine whether the
patient has known EF less than 30 percent or a history of systolic
heart failure 1828. If either of these criteria is met 1828, the
intensivist is prompted to enter a "Y" or "YES" for EF into the
table selected above in 1820 and 1822. If neither of these criteria
is met 1828, the intensivist is prompted to enter a "N" or "NO" for
EF into the table selected above in 1820 and 1822.
[0303] Based on the table selected in 1820 and 1822 above, and the
table inputs determined from 1824, 1826, and 1828, the intensivist
is prompted with the proper medication to administer for the
1.sup.st and 2.sup.nd treatment.
[0304] If the patient is not in pain 1812, the intensivist is
prompted to employ the procedures described above in 1816.
[0305] If the patient is at risk of injury from post-op
hypertension 1806, the intensivist is prompted to determine whether
the blood pressure is greater than 40 percent above baseline 1830.
If this criterion is met 1830, the intensivist is prompted to
employ the procedures described above in 1812.
[0306] Alternatively, if this criterion is not met 1830, the
intensivist is prompted to determine whether the patient is in pain
1836. If this criterion is met 1836, the intensivist is prompted to
treat pain and reevaluate following analgesia and, if still
hypertensive, to continue algorithm 1838. Following this action
1838, the intensivist is prompted to employ the procedures
described above in 1816. If the patient is not in pain 1836, the
intensivist is prompted to employ the procedures described above in
1816.
[0307] If the patient is determined not to be hypertensive 1800,
the intensivist is prompted to determine whether the patient
requires their BP controlled near baseline (i.e., neurosurgery,
carotid surgery, thoracic aorta surgery) 1832. If this criterion is
not met 1832, the intensivist is prompted that the patient probably
does not need treatment 1834.
[0308] Alternatively, if this criterion is met 1832, the
intensivist is prompted to employ the procedures described above in
1836.
[0309] Referring to FIG. 31A, the pulmonary embolism diagnosis
algorithm is illustrated. If a pulmonary embolism is suspected, the
intensivist is first prompted to determine whether the patient is
hemodynamically unstable 2900. If the patient is hemodynamically
unstable, the intensivist is directed by the system to consider
performing an immediate transthoracic echocardiogram, pulmonary
angiogram and treatment consistent with massive pulmonary embolism
2902. If the patient is not hemodynamically unstable, the
intensivist is prompted to perform a VQ scan and perform further
assessment of the patient 2904.
[0310] In order to further assess the patient, the intensivist is
prompted to respond to a series of questions 2906, 2908, 2910,
2912. The intensivist is prompted to determine whether any of the
following patient conditions are present: Dyspnea, Worsening
chronic dyspnea, Pleuritic chest pain, Chest pain that is non-retro
sternal & non-pleuritic, O.sub.2 saturation<92% on room air
that corrects with 40% O.sub.2 supplementation, Hemoptysis, or
Pleural rub 2906. The intensivist is also prompted to determine
whether any risk factors are in the patient's history, such as:
Surgery within 12 weeks, Immobilization (complete bed rest) for
>3 days within 4 weeks, Previous DVT or objectively diagnosed
PE, Lower extremity fracture & immobilization within 12 weeks,
Strong family history of DVT or PE(.gtoreq.2 family members with
objective proven events or 1.sup.st degree relative with hereditary
thrombophilia), Cancer (treatment within the last 6 months or
palliative stages), Postpartum, or Lower extremity paralysis 2908.
Further, the intensivist must determine whether the patient has any
of the following symptoms: Heart rate>90 beats/min,
Temp.gtoreq.38.0, CXR free of abnormalities (edema, pneumonia,
pneumothorax), or Leg symptoms c/w DVT, syncope, blood pressure
less than 90 mm Hg with heart rate greater than 100 beats/min,
receiving mechanical ventilation and/or oxygen supplementation
greater than 40%, and new onset or right heart failure (-JVP, new
S1, Q3, T3, or RBBB) 2910. The intensivist is also queried by the
system to consider alternative diagnosis that may be more likely
than pulmonary embolism. To do so, the intensivist is prompted to
consider conditions that simulate major pulmonary embolism, such as
myocardial infarction, acute infection with COPD, septic Shock,
dissecting aortic aneurysm, or occult hemorrhage. The intensivist
is additionally prompted to consider conditions that simulate minor
pulmonary embolism, such as acute bronchitis, pericarditis, viral
pleurisy, pneumonia, and esophageal spasm 2912.
[0311] Referring to FIG. 31B, the pulmonary embolism algorithm
description continues. The intensivist enters the answers to the
assessment queries posed 2906, 2908, 2910, 2912 into the system. If
two or more responses to the patient condition query 2906 were
answered yes and one or more questions were answered yes from:
Heart rate>90 beats/min, Temp.gtoreq.38.0, CXR free of
abnormalities, or Leg symptoms c/w DVT of the symptoms query 2910,
the intensivist is informed that a typical pulmonary embolism is
present 2914. Next, the system compares this response to the answer
to the alternative diagnosis query 2912. If an alternative
diagnosis is at least as likely as pulmonary embolism 2916, the
intensivist is also given a low probability 2918 to moderate
probability 2920 risk factor. If an alternative diagnosis is less
likely than pulmonary embolism 2922, the intensivist is given a
moderate 2924 to high 2926 probability risk factor.
[0312] If less than two yes answers resulted from the patient
conditions 2906, the intensivist is advised by the system that an
atypical pulmonary embolism may be present 2928. Next, the system
compares this response to the answer to the alternative diagnosis
query 2912. If an alternative diagnosis is at least as likely as
pulmonary embolism 2930, the intensivist is told there is no risk
and low probability 2932 or some risk with a low probability 2934
risk factor. If an alternative diagnosis is less likely than
pulmonary embolism 2934, the intensivist is given a no risk and low
probability 2938 to risk but moderate probability 2940.
[0313] If at least one answer to the symptoms of syncope, blood
pressure less than 90 mm Hg with heart rate greater than 100
beats/min, receiving mechanical ventilation and/or oxygen
supplementation greater than 40%, and new onset or right heart
failure 2910 is yes, the intensivist is prompted with a message
that severe pulmonary embolism is occurring 2942. Next, the system
compares this response to the answer to the alternative diagnosis
query 2912. If an alternative diagnosis is at least as likely as
pulmonary embolism 2944, the intensivist is told there is a
moderate probability of pulmonary embolism 2946. If an alternative
diagnosis is less likely than pulmonary embolism 2948, the
intensivist is notified that a high probability of pulmonary
embolism is present 2950.
[0314] Once the risk factors and probabilities are determined the
system compares this information to the VQ scan results. This
comparison is performed according to the following Table 4 below.
TABLE-US-00009 TABLE 4 Probability table Input Clinical Probability
V/Q Scan High Moderate Low High A A B Intermediate B C C Low B C E
Normal E E E
[0315] Where the VQ scan column and the risk column intersect, a
letter code is assigned to various treatment instructions. The
treatment instructions are as follows.
A=Pulmonary embolus diagnosed. Begin treatment
E=Pulmonary embolus excluded
B=Proceed with the following work-up:
[0316] 1) Perform spira CT(If patient has real insufficiency
[creatinine>2.0],consider going directly to pulmonary angiogram
to reduce the potential dye load). If positive begin treatment,
[0317] 2) If negative, assess for DVT using compression ultrasound
or venography. If positive begin treatment, [0318] 3) If negative,
perform pulmonary angiogram. If positive begin treatment, if
negative diagnosis excluded. C=Proceed with the following
work-up:
[0319] 1) Perform spiral CT. If positive begin treatment, [0320] 2)
If negative, assess for DVT using compression ultrasound or
venography. If positive begin treatment, [0321] 3) If negative
perform D-dimer assay(elisa only). If negative diagnosis excluded,
If positive, perform serial ultrasound of the lower
extremities.
[0322] Once the correlation is made, the instructions associated
with the letter code are displayed by the system to prompt the
intensivist with diagnosis and treatment instructions.
[0323] Referring to FIG. 32, the seizure decision support algorithm
of the present invention is illustrated. If an intensivist
encounters seizure in a patient, he may not be certain of all of
the aspects and the timelines that are critical to treating this
particular condition. Therefore, the intensivist is lead through a
decision support algorithm, which divides the treatment sequence
into three segments: 0-30 minutes; 30-60 minutes; and beyond 60
minutes.
[0324] At the onset of a seizure, in the 0-30 minute segment of the
algorithm, the intensivist is prompted to give the patient
lorazepam (0.1 mg/kg of bodyweight) in 2 mg boluses up to 8 mg
2000. Subsequently, the intensivist is prompted to give the patient
phenytoin (18-20 mg/kg of bodyweight) at 50 mg/min of fosphenytoin
(18-20 mg/kg of bodyweight) at 150 mg/min followed by 5 mg/kg of
bodyweight/day through separate IV line 2002.
[0325] During the 30-60 minute segment of the algorithm, the
intensivist is prompted to: reload additional phenytoin or
fosphenytoin (10 mg/kg of bodyweight) maintaining previous
infusion; and give additional lorazepam (0.05 mg/kg of bodyweight)
2004. Subsequently, the intensivist is prompted to begin continuous
EEG monitoring 2006.
[0326] The intensivist is then prompted to determine whether the
patient is hemodynamically stable 2008. If hemodynamically stable,
the intensivist is prompted to administer propofol 1-2 mg/kg of
bodyweight bolus followed by 2-10 mg/kg/hr 2010.
[0327] At the 60 minute segment of the algorithm, the intensivist
is prompted that if seizure activity stops, he should taper either
midazolam or propofol over the next 12-24 hours while maintaining
phenytoin but if seizures persist, he is prompted to move to the
pentobarbital coma block 2012.
[0328] Under pentobarbital coma, the intensivist is prompted to
administer 10-15 mg/kg/hr and to maintain until seizure control is
achieved on EEG 2014. The intensivist is prompted further that the
patient usually requires PA catheter and pressors to maintain
hemodynamic control 2014.
[0329] Alternatively, if the patient is determined to be
hemodynamically unstable 2016, the intensivist is prompted to
utilize fluids and pressors as needed (phynylephrine or dopamine)
midazolam 0.2 mg/kg bolus followed by 0.1-2.0 mg/kg/hr 2018.
[0330] At the 60 minute segment of the algorithm, the intensivist
is prompted that if seizure activity stops, he should taper either
midazolam or propofol over the next 12-24 hours while maintain
phenytoin but if seizures persist, he is prompted to move to the
pentobarbital coma block 2012.
[0331] Under pentobarbital coma, the intensivist is prompted to
administer 10-15 mg/kg/hr and to maintain until seizure control is
achieved on EEG 2014. The intensivist is prompted further that the
patient usually requires PA catheter and pressors to maintain
hemodynamic control 2014.
[0332] Referring to FIGS. 33A-B, the supra ventricular tachycardia
(SVT) decision support algorithm of the present invention is
illustrated. If an intensivist determines that SVT is present, the
intensivist may not be certain of all aspects that would be
involved in treating this particular condition. Therefore, the
intensivist is lead through a decision support algorithm which
prompts the intensivist to determine the appropriate care to be
given.
[0333] Initially, the intensivist is prompted to determine whether
SVT is stable or unstable 2100. If SVT is stable 2102, the
intensivist is prompted to determine whether the patient has a
regular or irregular rhythm 2102. If the patient has a regular
rhythm 2104, the intensivist is prompted to determine whether there
is a wide complex or a narrow complex 2104. If the intensivist
determines that there is a wide complex 2106, the intensivist is
prompted to administer adenosine 6 mg/12 mg (if needed) 2108.
Following the administering of adenosine 2108, the intensivist is
prompted to consider that if the patient converts to sinus rhythm
(SR) to--consider re-entrant junctional or WPW re-entrant. If the
wide complex recurs, treat the patient with esmolol or Ca+2
blockers.
[0334] Alternatively; if no effect, the intensivist is prompted to
consider V-tach 2112. Next, the intensivist is prompted to: 1) load
procainamide 150 mg over 10 min, then 1 mg/min infusion; and 2)
synchronized cardiovert 2114.
[0335] Alternatively, if the wide complex slows, the intensivist is
prompted to consider SVT w/aberrancy and continue to slow with
esmolol or Ca+2 blockers 2116.
[0336] The intensivist is prompted next to administer
esmolol/calcium blockers and link to ventricular rate control 2118.
The intensivist is prompted next to determine whether there has
been a conversion to SR 2120. If there is no conversion to SR in 24
hours, the intensivist is prompted to add antiarrhythmic agent and
consider anticoagulation 2122. The intensivist is prompted next to
determine whether there has been conversion to SR. If conversion to
SR, the intensivist is prompted to continue maintenance
antiarrhythmic agent during hospitalization 2124. If no conversion
to SR, the intensivist is prompted to cardiovert while on
antiarrhythmic & following heparinization 2126.
[0337] If the patient has a regular rhythm 2104, the intensivist is
prompted to determine whether there is a wide complex or a narrow
complex 2104. If the intensivist determines that there is a narrow
complex 2128, the intensivist is prompted to to administer
adenosine 6 mg/12 mg (if needed) 2130. If administering the
adenosine 2130 slows the ventricular rate only and the atrial rate
persists, the intensivist is prompted to consider atrial flutter
and continue to slow with esmolol or Ca+2 blockers 2132. The
intensivist is prompted next to employ the procedures described
above in 2118.
[0338] If administering the adenosine 2130 converts the patient to
SR, the intensivist is prompted to consider re-entrant sinus or
junctional and if recurs, treat with esmolol or Ca+2 blockers
2134.
[0339] If administering the adenosine 2130 slows both atrial and
ventricular rates the intensivist is prompted that there is a
probable sinus tachycardia 2136. The intensivist is prompted next
to continue to slow with esmolol 2138. The intensivist is prompted
next to employ the procedures described above in 2118.
[0340] If SVT is stable 2102, the intensivist is also prompted to
determine whether the patient has a regular or irregular rhythm
2102. If the patient has an irregular rhythm 2140, the intensivist
is prompted that if no p waves, there is probable Atrial
fibrillation 2142. The intensivist is prompted next to slow
ventricular response with esmolol or Ca+2 blockers 2144. The
intensivist is prompted next to employ the procedures described
above in 2118.
[0341] If the patient has an irregular rhythm 2140, the intensivist
is prompted to determine whether there are more than 3 p wave types
MAT--and to treat underlying lung dz. and avoid theophylline
compounds 2146. The intensivist is prompted next to slow rate with
Ca+2 blockers only 2148. The intensivist is prompted next to employ
the procedures described above in 2118.
[0342] Referring now to FIG. 33C, the description of the SVT
decision algorithm continues. If SVT is unstable 2101, the
intensivist is prompted to determine whether the patient has SBP
less than 80, ischemia, mental status changes 2150. The intensivist
is prompted next to perform synchronous cardioversion (100 J, 200
J, 300 J) 2152. The intensivist is prompted next that if sinus
rhythm: 1) correct reversible etiologies; 2) consider starting IV
antiarrhythmic for maintenance of sinus rhythm 2154. Alternatively,
following 2152, the intensivist is prompted next that if continued
SVT: 1) correct reversible etiologies; 2) load IV antiarrhythmic
(see dosing guidelines) and repeat DC cardioversion 2156.
[0343] For example, and without limitations, wide complex QRS
Tachycardia is also addressed in the decision support algorithm of
the present invention. Referring to FIGS. 34A-B, the wide complex
QRS tachycardia decision support algorithm is illustrated. If an
intensivist determines that there may be a possibility of wide
complex QRS tachycardia, the intensivist may not be certain of all
aspects that would be involved in this particular condition.
Therefore, the intensivist is lead through a decision support
algorithm which prompts the intensivist to determine the
appropriate care to be given.
[0344] Initially, the intensivist is prompted to determine whether
the patient is hemodynamically stable (no angina, heart failure, or
hypotension (systolic less than 80 mm)) 2200. If this criterion is
not met, the intensivist is prompted to go to the cardio-pulmonary
guidelines algorithm which is generally known to those skilled in
the art.
[0345] Alternatively, if this criterion is met, the intensivist is
prompted to determine whether the patient is within 7 days of a
myocardial infarction or at risk for myocardial ischemia 2202. If
the patient is not within 7 days of a myocardial infarction or at
risk for myocardial ischemia 2202, the intensivist is prompted to
determine whether the wide complex QRS rhythm is sustained (greater
than 30 seconds) 2234. If this criterion is not met, the
intensivist is prompted to determined whether the QRS is
monomorphic 2236. If the QRS is monomorphic 2236, the to
intensivist is prompted to determine whether the patient has
structural heart disease 2242. If the patient has structural heart
disease 2242, the intensivist is prompted to: 1) monitor closely;
2) look for reversible etiologies; and 3) consider antiarrhythmic
therapy 2244. If the patient does not have structural heart disease
2242, the intensivist is prompted to: 1) monitor closely; 2) look
for reversible etiologies; and 3) if recurs and symptomatic may
require further testing (prolonged holter or EP study) 2246.
[0346] If the QRS is not monomorphic 2236, the intensivist is
prompted to determine whether the QT is prolonged 2238. If this
criterion is met, the intensivist is prompted to: 1) check K; 2)
give Mg; and 3) consider overdrive pacing 2240. If the intensivist
determines that the QT is not prolonged, 2238, the intensivist is
prompted to employ the procedures described above in 2242.
[0347] If the wide complex QRS rhythm is sustained 2234, the
intensivist is prompted to determine whether the rhythm is
polymorphic or irregular 2208. If the rhythm is polymorphic or
irregular, the intensivist is prompted to consider atrial
fibrillation with accessory pathway conduction and load with
procainamide and get a cardiology consultation 2210. If the rhythm
is not polymorphic or irregular, the intensivist is prompted with
the question of whether he wishes to: 1) perform ECG diagnosis; or
2) administer adenosine diagnostically 2220. If the intensivist
makes the determination to perform an ECG diagnosis 2220, he is
prompted to go to the ECG diagnosis algorithm 2300.
[0348] If the intensivist makes the determination to administer
adenosine diagnostically 2220, he is prompted to go to the
administer adenosine branch of the algorithm 2222. If there is no
effect, the intensivist is prompted that there is probable VT and
to determine whether the VT is monomorphic 2224. If the VT is
monomorphic 2224, the intensivist is prompted to load with
procainamide and perform synchronous cardioversion 2226.
[0349] Alternatively, if the VT is not monomorphic 2224, the
intensivist is prompted to load with lidocaine and perform
immediate cardioversion 2228.
[0350] If the ventricular response is slowed after administering
adenosine 2222, the intensivist is prompted to consider SVT with
aberrancy and treat with esmolol or Ca blockers 2230.
[0351] If the ventricular response converts to sinus rhythm after
administering adenosine 2222, the intensivist is prompted: to
consider re-entrant mechanism with BBB or WPW; and, 1) if WPW
consult cardiology for possible ablation 2232.
[0352] If the patient is within 7 days of a myocardial infarction
or at risk for myocardial ischemia 2202, the intensivist is
prompted to determine whether the wide complex is sustained (30
seconds) 2204. If the wide complex is not sustained 2204, the
intensivist is prompted to determine whether the patient: 1)
symptomatic; 2) tachycardia runs are frequent; or 3) the
tachycardia rates are rapid (greater than 180) 2212. If none of
these criteria is met, the intensivist is prompted to observe 2216.
Alternatively, if any of these criteria is met 2212, the
intensivist is prompted to: 1) administer lidocaine 100-200 mg
& 1-4 mg/min infusion; and 2) amiodarone 2214.
[0353] If the wide complex is sustained 2204, the intensivist is
prompted to determine whether the rate is greater than 140/min
2206. If this criterion is not met 2206, the intensivist is
prompted: to consider accelerated idioventricular, and that in some
patients this can lead to hemodynamic compromise; and that 1) he
can perform overdrive pacing if needed 2218.
[0354] Alternatively, if this criterion is met, the intensivist is
prompted to follow the procedures in 2208.
[0355] If the intensivist makes the determination to perform ECG
Diagnosis 2220, he is prompted to go to the ECG Diagnosis branch of
the algorithm 2220. Referring now to FIG. 34C, in the ECG Diagnosis
branch, the intensivist is prompted to determine whether the
patient has known pre-excitation syndrome 2300. If this criterion
is met, the intensivist is prompted to determine whether the QRS
complexes are predominantly negative in leads V4-V62302. If the QRS
complexes are predominantly negative in leads V4-V6, the
intensivist is prompted that there is probable VT 2304.
[0356] If the QRS complexes are not predominantly negative in leads
V4-V62302, the intensivist is prompted to determine whether there
is a QR complex in one or more of leads V2-V62306. If this
criterion is met, the intensivist is prompted that there is
probable VT 2308.
[0357] Alternatively, if this criterion is not met 2306, the
intensivist is prompted to determine whether there are more QRS
complexes than P waves 2310. If there are more QRS complexes than P
waves 2310, the intensivist is prompted that there is probable VT
2312. If there are not more QRS complexes than P waves 2310, the
intensivist is prompted: to consider pre-excited SVT; and that he
may wish to perform EP study 2314.
[0358] If the intensivist determines that the patient does not have
known pre-excitation syndrome 2300, the intensivist is prompted to
determine whether there is an RS complex present in any precordial
lead 2316. If this criterion is not met 2316, the intensivist is
prompted that there is probable VT 2318.
[0359] Alternatively, if this criterion is met 2316, the
intensivist is prompted to determine whether the R to S interval is
greater than 100 MS in any one precordial lead 2320. If this
criterion is met, the intensivist is prompted that there is
probable VT 2322.
[0360] If the R to S interval is not greater than 100 MS in any one
precordial lead 2320, the intensivist is prompted to determine
whether there is evidence of atrioventricular dissociation 2324. If
this criterion is met, the intensivist is prompted that there is
probable VT 2326.
[0361] Alternatively, if there is no evidence of atrioventricular
dissociation 2324, the intensivist is prompted to determine whether
V-1 is negative and V-6 positive and QRS greater than 0.14 mSEC
2328. If these criteria are met, the intensivist is prompted that
there is probable VT 2330.
[0362] If none of these criteria is met 2328, the intensivist is
prompted that the situation may represent SVT with aberrancy or
underlying bundle branch block 2332.
[0363] Referring to FIG. 35A, the assessment of sedation algorithm
of the present invention is illustrated. If an intensivist
encounters a need for sedation, he may not be certain of all of the
aspects and the timelines that are critical to this particular
process. Therefore, the intensivist is lead through a decision
support algorithm, which prompts the intensivist to address a
number of factors in the process 3100.
[0364] The intensivist is prompted initially to go to the Scoring
section of the algorithm 3100. The intensivist is prompted to
proceed through a number of scorings 3102 and to first score the
patient's alertness with points being allocated in the following
manner: asleep/unresponsive=0; responsive to voice=1; and
hyperresponsive=2 3104.
[0365] The intensivist is prompted next to score the patient's
movement with points being allocated in the following manner: no
spontaneous movement=0; spontaneous movement=1; and pulls at lines,
tubes, dressings=2 3106.
[0366] The intensivist is prompted next to score the patient's
respiration based on whether the patient is mechanically ventilated
or spontaneously breathing with points being allocated as
subsequently discussed. If the patient is mechanically ventilated,
the intensivist is prompted to allocate points in the following
manner: no spontaneous ventilation=0; spontaneous ventilations and
synchronous with ventilator=1; or spontaneous ventilations with
cough or dysynchrony>10 percent of breaths=2 3108.
Alternatively, if the patient is spontaneously breathing, the
intensivist is prompted to allocate points in the following manner:
respiration rate (RR)<10=0; RR=10-30=1; or RR>30=2 3108.
[0367] The intensivist is prompted next to score the patient's
heart rate with points being allocated in the following manner:
>20 percent below mean for last 4 hr=0; within 20 percent mean
for last 4 hr=1; or >20 percent above mean for last 4 hr=2
3110.
[0368] The intensivist is prompted next to score the patient's
blood pressure with points being allocated in the following manner:
MAP>20 percent for last 4 hr=0; MAP within 20 percent mean for
last 4 hr=1; or MAP>20 percent above mean for last 4 hr=2
3112.
[0369] The intensivist is prompted next to determine the sedation
score by the following formula: SEDATION
SCORE=alertness+movement+respirations+heart rate+blood pressure
3114. In one embodiment, respiratory rate, heart rate, and BP can
be computer linked to monitor data thereby simplifying the sedation
scoring assessment. The nursing observations are deemed intuitive
and the nursing burden in sedation scoring can be minimal by using
this point scoring.
[0370] Referring now to FIG. 35B, the sedation assessment algorithm
description continues. The intensivist is prompted then to continue
the sedation assessment by moving to the Pain Assessment section of
the algorithm 3116.
[0371] In the Pain Assessment section, the intensivist is prompted
to determine whether the patient is conscious, communicative, and
acknowledging pain 3118. If any of these criteria is not met, the
intensivist is prompted to determine: whether the sedation score is
greater than 2 and the patient: is known to be in pain before
becoming uncommunicative; or S/p recent surgery; or having tissue
ischemia or infarct; or has wounds; or has large tumor possibly
impinging on nerves. If the answer to either of these two questions
is YES, the intensivist is prompted to treat for pain 3118. The
intensivist is prompted then to continue the assessment by moving
to the Delirium Assessment section of the algorithm 3118.
[0372] In the Delirium Assessment section, the intensivist is
prompted to determine whether the sedation score is greater than 2
AND the patient has: day/night reversal with increased agitation at
night OR eyes open and "awake" but disoriented; or eyes open and
"awake" but pulling at lines, tubes, or dressings OR difficult to
sedate prior to ventilator weaning OR paradoxical response to
benzodiazepines. If these criteria is met, the intensivist is
prompted to consider butyrophenone 3120.
[0373] Referring to FIG. 36, the Bolus sliding scale algorithm is
illustrated. If an intensivist encounters a need for sedation, the
algorithm for which may contain a reference to the bolus sliding
scale for midazolam, he nay not be certain of all of the aspects
which are critical to this scale. Therefore, the intensivist is
lead through a decision support algorithm, which prompts the
intensivist through the use of the scale 3200.
[0374] If lorazepam is less than 0-2 mg IV q 6 hr, then the
intensivist is prompted to give midazolam 1-2 mg q 5 min until
adequately sedated 3202.
[0375] Alternatively, if lorazepam equals 2-4 mg IV q 4 hr, then
the intensivist is prompted to give midazolam 2 mg q 5 min until
adequately sedated 3202.
[0376] Alternatively, if lorazapam is greater than 10 mg IV q 4 hr,
then the intensivist is prompted to give midazolam 5 mg q 5 min
until adequately AND consider fentanyl and/or droperidol or Haldol
for synergy despite delirium and pain assessment 3202.
[0377] Yet another decision support routine is the sedation
algorithm. Referng to FIG. 37, the sedation process decision
support algorithm is illustrated. If an intensivist determines that
a patient will require sedation, the intensivist may not be certain
of all aspects that would be involved in this particular process.
Therefore, the intensivist is lead through a decision support
algorithm, which prompts the intensivist to conduct a sedation
assessment based on: 1) scoring; 2) pain; and 3) delirium (see
Assessment of Sedation algorithm) 3300.
[0378] Following completion of the sedation assessment process
3300, the intensivist is prompted to determine whether the patient
is in pain 3302. If this criterion is met, the intensivist is
prompted to administer bolus morphine, fentanyl, other narcotic,
start patient controlled analgesic (PCA) or epidural analgesia as
indicated 3324. If the patient is not in pain 3302 or after
administering bolus morphine, fentanyl, other narcotic, start
patient controlled analgesic (PCA) or epidural analgesia as
indicated 3324, the intensivist is prompted to determine whether
the patient is delirious 3304.
[0379] If the intensivist determines that the patient is delirious
3304, he is prompted to administer droperidol 2.5-5 mg q 30 min pm
and that he may consider IV Haldol not to exceed 30 mg/24 hr 3326.
If the patient is not delirious or after following the procedures
in 3326, the intensivist is prompted to determine whether the
patient will need sedation for more than the next 24 hours 3306. If
the patient will not need sedation for more than the next 24 hours
3306, the process continues as described in FIG. 38.
[0380] Alternatively, if the patient will need sedation for more
than the next 24 hours 3306, the intensivist is prompted to
determine whether the sedation score is 8-10 3308. If this
criterion is met, the intensivist is prompted to employ the Bolus
sliding scale midazolam and increase lorazepam by 20 percent 3328
(see Bolus sliding scale midazolam algorithm--FIG. 36).
Subsequently, the intensivist is prompted to reassess sedation in 4
hr 3330.
[0381] Alternatively, if the patient will need sedation for more
than the next 24 hours 3306, the intensivist is prompted to
determine whether the sedation score is 8-10 3308. If this
criterion is met, the intensivist is prompted to employ the Bolus
sliding scale midazolam and increase lorazepam by 20 percent 3328
(see Bolus sliding scale midazolam algorithm--FIG. 42).
Subsequently, the intensivist is prompted to reassess sedation in 4
hr 3330.
[0382] If the sedation score is not 8-10, the intensivist is
prompted to determine whether the sedation score is greater than or
equal to the last Sed Scr after sedative bolus or increase 3310. If
this criterion is met, the intensivist is prompted to employ the
procedures described above in 3328 and 3330.
[0383] If the sedation score is not greater than or equal to the
last Sed Scr after sedative bolus or increase 3310, the intensivist
is prompted to determine whether four (4) or more midaz boluses
have been given since last q 4 hr assessment 3312. If this
criterion is met, the intensivist is prompted to employ the
procedures described above in 3328 and 3330.
[0384] Alternatively, if less than four (4) midaz boluses have been
given since last q 4 hr assessment 3312, the intensivist is
prompted to determine whether the patient is adequately sedated
3314. If this criterion is not met, the intensivist is prompted to
employ the procedure described in 3328 and 3330.
[0385] If the intensivist determines that the patient is adequately
sedated 3314, the intensivist is prompted to determine whether the
sedation score is 0-2 3316. If this criterion is met, the
intensivist is prompted to decrease lorazepam by 20 percent 3332
and reassess sedation in 4 hr 3334.
[0386] Alternatively, if the sedation score is not 0-2 3316, the
intensivist is prompted to determine whether the sedation score is
less than or equal to the last Sed Scr after sedative decrease
3318. If this criterion is met, the intensivist is prompted to
employ the procedure described in 3332 and 3334.
[0387] If the sedation score is not less than or equal to the last
Sec Scr after sedative increase 3318, the intensivist is prompted
to determine whether the patient is clinically oversedated 3320. If
the patient is clinically oversedated 3320, the intensivist is
prompted to employ the procedure described in 3332 and 3334. If the
patient is not clinically oversedated 3320, the intensivist is
prompted to reassess sedation in 4 hr 3322.
[0388] Referring to FIG. 38, the short term sedation process
decision support algorithm of the present invention is illustrated.
If an intensivist determines that a patient will not require
sedation past the next 24 hour period, the intensivist may not be
certain of all aspects that would be involved in this particular
process. Therefore, the intensivist is lead through a decision
support algorithm, which prompts the intensivist to conduct a
sedation assessment based on: 1) scoring; 2) pain; and 3) delirium
(see Assessment of Sedation algorithm) 3100.
[0389] Following completion of the sedation assessment process
3100, the intensivist is prompted to decrease lorazepam by 20
percent from baseline per day 3102. The intensivist is prompted
next to determine whether the patient is in pain 3104. If this
criterion is met, the intensivist is prompted to administer bolus
morphine or fentanyl 3122. If the patient is not in pain or after
administering bolus morphine or fentanyl 3122, the intensivist is
prompted to determine whether the patient is delirious 3106.
[0390] If the intensivist determines that the patient is delirious,
he is prompted to administer droperidol 2.5-5 mg q30 min pm 3124.
If the patient is not delirious or after administering droperidol
3124, the intensivist is prompted to determine whether the sedation
score is 8-10 3108.
[0391] If this criterion is met, the intensivist is prompted to
employ the Bolus sliding scale midazolam (see Bolus sliding scale
midazolam algorithm) and begin midazolam infusion or begin propofol
1-2 mg/kg bolus and 5-50 mcg/kg/min infusion 3126. Subsequently,
the intensivist is prompted to reassess sedation in 1 hr 3128.
[0392] If the sedation score is not 8-10, the intensivist is
prompted to determine whether the sedation score is greater than or
equal to the last Sed Scr after sedative bolus or increase 3110. If
this criterion is met, the intensivist is prompted to employ the
procedures described above in 3126 and 3128.
[0393] If the intensivist determines that the sedation score is not
greater than the last sedation score after sedative bolus or
increase 3110, the intensivist is prompted to determine whether the
patient is adequately sedated 3112. If this criterion is not met,
the intensivist is prompted to employ the procedures described
above in 3126 and 3128.
[0394] If the intensivist determines that the patient is adequately
sedated 3112, he is prompted to determine whether the sedation
score is 0-2 3114. If this criterion is met, the intensivist is
prompted to determine if the patient has been sedated for more than
72 hours 3130. If the patient has not been sedated for more than 72
hours 3130, the intensivist is prompted to hold midazolam or
propofol and hold or decrease lorazepam by 50 percent 3132. The
intensivist is prompted subsequently to reassess sedation in 1 hour
3134.
[0395] Alternatively, if the intensivist determines that the
patient has been sedated for more than 72 hours 3130, the
intensivist is prompted to hold midazolam or propofol and decrease
lorazepam by 20 percent per day 3136. The intensivist is prompted
subsequently to reassess sedation in 1 hour 3134.
[0396] Alternatively, if the intensivist determines that the
sedation score is not 0-2 3114, the intensivist is prompted to
determine whether the sedation score is less than or equal to the
last sedation screening after sedative decrease 3116. If this
criterion is met, the intensivist is prompted to determine whether
the patient has been sedated for more than 72 hours and to follow
the procedures described above in 3130.
[0397] If the intensivist determines that the sedation score is not
less than or equal to the last Sed Scr after sedative decrease
3116, the intensivist is prompted to determine whether the patient
is clinically oversedated 3118. If this criterion is met, the
intensivist is prompted to determine whether the patient has been
sedated for more than 72 hours and to follow the procedures
described above in 3130. If this criterion is not met, the
intensivist is prompted to reassess sedation in 1 hr 3120.
[0398] Referring to FIG. 39, the respiratory isolation decision
support algorithm is illustrated. If an intensivist determines that
there may be a need for respiratory isolation, the intensivist may
not be certain of all aspects that would be involved in this
process. Therefore, the intensivist is lead through a decision
support algorithm which prompts the intensiviat to determine the
need for respiratory isolation based upon: a) clinical assessment;
and/or b) smear/culture findings 3500.
[0399] Pursuing the clinical assessment branch of the decision
support algorithm, the intensivist is prompted to determine whether
the patient has known mTB (mycobacterium tuberculosis) 3502. If
this criterion is met, the intensivist is prompted to determine
whether the patient has been compliant with their medications for
over 2 weeks and is clinically responding 3512. If the patient has
not been compliant with their medications for over 2 weeks and is
not clinically responding 3512, the intensivist is prompted that
isolation is required 3514. If the patient has been compliant with
their medications and is clinically responding 3512, the
intensivist is prompted that no isolation is required 3516.
[0400] Alternatively, if the patient does not have known mTB 3502,
the intensivist is prompted to determine whether the patient has
known mycobacterial disease other than TB 3504. If this criterion
is met, the intensivist is prompted to determine whether the
patient has new CXR (chest x ray) findings and symptoms (cough 2
weeks, fever, weight loss) 3518. If the patient does not have new
CXR findings and symptoms 3518, the intensivist is prompted that no
isolation is required 3520. If the patient does have new CXR
findings and symptoms 3518, the intensivist is prompted that
isolation is required 3522.
[0401] If the patient does not have known mycobacterial disease
other than TB 3504, the intensivist is prompted to determine
whether there is a new cavitary lesion on CXR 3506. If this
criterion is met, the intensivist is prompted that isolation is
required 3524.
[0402] Alternatively, if there is no new cavitary lesion on CXR
3506, the intensivist is prompted to determine whether there are
pulmonary infiltrates or whether the patient is HIV (human
immunodeficiency virus) positive 3508. If neither of these criteria
is met, the intensivist is prompted that no isolation is required
3510. If either of these criteria is met, the intensivist is
prompted to determine whether the patient has new CXR findings and
symptoms (cough 2 weeks, fever, weight loss) and at high risk: 1)
known mTB exposure; 2) homeless; 3) prisoner; 4) travel to area
with multi-drug resistant TB 3526. If these criteria are met, the
intensivist is prompted that isolation is required 3528.
Alternatively, if these criteria are not met, the intensivist is
prompted that no isolation is required 3530.
[0403] Pursuing the smear/culture branch of the decision support
algorithm 3500, the intensivist is prompted to determine whether
the AFB (acid-fast bacilli) smear is positive 3532. If the AFB
smear is not positive, the intensivist is prompted that: no
isolation is required; await culture results; if culture negative,
no isolation required; if culture positive and patient has
mycobacterial disease other than TB (MOTT no isolation is required;
if the culture is positive and the patient does not have MOTT
consult ID 3534.
[0404] Alternatively, if the AFB smear is positive, the intensivist
is prompted to determine whether the patient has known
mycobacterial disease other than TB 3536. If this criterion is not
met, the intensivist is prompted that isolation is required 3538.
If this criterion is met, the intensivist is prompted: to isolate
until results of NAP test are in; if mTB positive isolate the
patient; if no mTB, no isolation is required 3540.
[0405] Referring to FIG. 40, the empiric meningitis treatment
decision support algorithm of the present invention is illustrated.
If the intensivist is treating a patient for meningitis, the
intensivist is prompted to answer a series of queries by the system
to properly address medication and dosage. First, the intensivist
is prompted to determine whether the patient has suffered a head
trauma or undergone neurosurgery 3700. The answer to this question
is input 1 to table x below. The intensivist is next prompted to
determine whether the patient is allergic to penicillin or is from
an area where penicillin resistant staphylococcus pneumoniae is
prevalent 3702. The answer to this question becomes input 2 to
table x below. The intensivist must also determine whether the
patient is immunocompromised 3704, and the answer becomes input 3
to table x below. The intensivist determines if the patient is over
fifty years of age 3706, with the answer being input 4 in table x
below. Lastly, the intensivist is prompted to determine whether the
patient has altered mental status 3708, and the answer becomes
input 5 in table x below. The inputs to each of these prompts 3702,
3704, 3706, 3708 is compared to a dosage database according to the
Table 5 below. TABLE-US-00010 TABLE 5 Meningitis Input-Output Table
Input Combinations Output 1 1 = yes A) vancomycin 2 = no 1.5-2 gm
IV q 12 h + ceftazedine 2 gm IV q 8 hr or cefapime 2 gm IV q 8 hr 2
1 = yes B) vancomycin 2 = no 1.5-2 gm IV q 12 h + aztreonam 0.5-2
gm IV q 6-8 hr 3 1 = no ampicillin 2 gm IV q 4 h 2 = no + 3 = no
ceftriaxone 2 gm IV q 12 4 = yes cefotaxime 2 gm IV q 6 h 4 1 = no
ceftriaxone 2 gm IV q 12 hr 2 = no or 3 = no cefotaxime 2 gm IV q 6
hr 4 = no 5 1 = no ampicillin 2 gm IV q 4 hr 2 = no + 3 = yes
ceftazidime 2 gm IV q 8 hr or cefipime 2 gm IV q 8 hr 6 1 = no
vancomycin 1.5-2 gm IV q 12 hr 2 = yes + 3 = no chloramphenicol 1
gm IV q 6 hr 4 = yes 7 1 = no 2 = yes 3 = no 4 = no 8 1 = no 2 =
yes 3 = yes 9 5 = yes add to output to inputs 3-8 consider
acyclovir 10 mg/kg IV q 8 h
[0406] In the Meningitis Input-Output Table, possible combinations
of the five inputs are listed. For the conditions manifested in the
patient, different drugs and dosages will be required. The proper
treatment for each combination is listed in the output column of
Table 5. After the algorithm runs the comparison, the output is
displayed on the computer screen, prompting the intensivist with
the proper treatment 3712.
[0407] Referring to FIG. 41A, the ventilator weaning decision
support algorithm of the present invention is illustrate The
ventilator weaning decision support algorithm is used to determine
whether an intensive care unit patient can return to breathing
unassisted, and discontinue use of a ventilator. Such a
determination weuires evaluation of the patient by the intensivist
over the course of several days.
[0408] To begin the decision process of whether to wean a patient
from ventilator use, the intensivist is prompted to conduct daily
screening, preferably during the hours of 06:00 a.m. to 10:00 a.m.
3800. The daily screen prompts the intensivist to determine
whether: the patients P/F ratio is greater than 200, the patient's
positive end-expiratory pressure (PEEP) is less than or equal to 5,
whether cough suctioning has been adequate and/or spontaneous,
infusions with vasopressors have been necessary, and continuous
infusions of sedatives or neuromuscular blocking agents have been
necessary 3800. If all conditions 3802 are answered no, the
intensivist is directed by the system to repeat the daily screen
3805 the following morning. If all the conditions of the daily
screen are met 3802, the intensivist is prompted to perform
additional tests.
[0409] If the patient has satisfied the daily screen, the
intensivist is next directed to conduct a rapid shallow breathing
test 3804. To perform the test, the intensivist is directed to
change the ventilator setting to continuous positive airway
pressure (CPAP) less than or equal to 5. In other words, there is
no intermittent mandatory ventilation or pressure support provided
for the patient. The patient is given one minute to reach a steady
state of breathing. Then the intensivist measures the ratio of
breaths per minute to tidal volume (f/V.sub.T). The intensivist
next is prompted to determine whether the patient's f/V.sub.T is
less than or equal to 105 breathes per minute 3806. If the
patient's f/V.sub.T is greater than 105 breathes per minute, the
intensivist is prompted to return to performing daily screening the
following morning 3808.
[0410] If the patient's f/V.sub.T is less than or equal to 105
breathes per minute, the intensivist is next directed to perform a
trial of spontaneous breathing. Here, the intensivist can either
insert a T-Piece in the patient's airway or reduce the patient's
CPAP to less than or equal to 5 over the course of two hours. The
intensivist is prompted to observe the patient periodically in
order to evaluate if the patient is breathing without assistance
3810. The intensivist is prompted to perform a periodic assessment
by determining whether: the patient's breathing characteristics are
greater than 35 breaths per minute for 5 minutes, or SpO.sub.2 is
less than 90%, or the patient's Heart Rate (HR) is grater than 140,
or HR deviates from the baseline breathing rate by more than 20%,
or the patient's SBP is outside the range of 90 to 180. If any of
the conditions are met, the intensivist is directed by the system
to terminate ventilator weaning 3812. If the conditions are not
met, the patient is further assessed.
[0411] In further assessment, the intensivist is prompted to
determine whether the patient has been able to breathe
spontaneously for two hours, keep a clear airway, and does not have
any procedures scheduled within twenty-four hours that would
require the patient to be intubated 3814. If the patient meets all
of these criteria 3814, the intensivist is notified by the system
that the patient may be extubated 3816. If the patient does not
meet one or more of the criteria 3814, the intensivist is prompted
to perform steps for progressive weaning 3818.
[0412] Referring to FIG. 41B, the ventilator weaning decision
support algorithm of the present invention is further illustrated.
The intensivist, at his or her discretion may choose either T-piece
progressive weaning or pressure support progressive weaning. In
order to perform T-piece progressive weaning, the intensivist is
directed to repeat the trial of spontaneous breathing (as
previously described 3810). The intensivist can either insert a
T-piece in the patient's airway or reduce the patient's CPAP to
less than or equal to 5 over the course of two hours. The
intensivist is prompted to perform periodic assessment of the
patient by either a two hour or 30 minute trial 3820.
[0413] In order to perform pressure support progressive weaning,
the intensivist is first prompted to observe whether the patient's
pressure support (PS) rating is equal to eighteen plus or minus the
positive end-expiratory pressure (PEEP). Next, the intensivist is
directed by the system to regulate the pressure values in order to
keep the patient's respiratory rate (RR) between twenty and thirty.
Next, the intensivist is directed by the system to decrease the
patient's pressure support by 2-4 centimeters of water two times
per day. Once the patient maintains pressure support for at least
two hours, the intensivist is prompted to further pursue extubating
the patient 3822.
[0414] After either T-Piece progressive weaning 3820 or pressure
support progressive weaning 3822, the intensivist is next prompted
to perform a periodic assessment of the patient. Here, the
intensivist must determine whether whether: the patient's breathing
characteristics are greater than 35 breaths per minute for 5
minutes, or SpO.sub.2 is less than 90%, or the patient's HR is
grater than 140, or HR deviates from the baseline breathing rate by
more than 20%; or the patient's SBP is outside the range of 90 to
180. Where the patient meets any of these criteria, the intensivist
is prompted to terminate weaning. If the patient meets none of
these criteria; the intensivist is prompted to further assess the
patient's ability to breath spontaneously 3824.
[0415] In further assessment, the intensivist is prompted to
determine whether the patient has been able to breathe
spontaneously for two hours, keep a clear airway, and does not have
any procedures scheduled within twenty-four hours that would
require the patient to be intubated 3826. If the patient meets all
of these criteria 3814, the intensivist is notified by the system
that the patient may be extubated 3828. If the patient does not
meet one or more of the criteria 3826, the intensivist is directed
by the system to allow the patient to rest for at least twelve
hours at A/C, the last level of pressure support the patient
achieved 3830. The intensivist is prompted to resume progressive
weaning the following day 3832.
[0416] Referring to FIG. 42, the Warfarin Dosing Algorithm of the
present invention is illustrated. The intensivist is first prompted
to give the initial dose and determine subsequent dosage each day
3900. When the intensivist determines subsequent dosage, he is
first prompted to determine the patient's target INR 3902. If the
patient's target INR ranges from 2.0 to 3.0, the intensivist is
prompted by the system to make further determinations relevant to
dosage. The intensivist is directed by the system to determine
whether the patient is taking drugs that effect prothrombin time
3904, the baseline INR value 3906, and whether rapid
anticoagulation is required 3908. Each answer is assigned a point
value, and the total points are tabulated. If the point value is
greater than one, the system refers to the 10 milligram load target
database for dosing. If the point value is less than one, the
system refers to the 5 milligram load target database for dosing
3910.
[0417] At the initial INR determination 3902, if the patient's INR
was initially between 1.5 and 2.0, the system refers to the 5
milligram load target database for dosing. If the patient's INR was
initially between 3.0 and 4.0, the system refers to the 10
milligram load target database for dosing 3910. Next the
intensivist is prompted to enter the day of treatment 3912 and the
patient's INR 3914. Depending on whether the system has been
directed to the 5 milligram load target or the 10 milligram load
target, a comparison is run 3916 according to the following tables.
TABLE-US-00011 TABLE 6 5 mg Load Target INR 1.5-2.0 Day <1.5
1.5-2 2-2.5 >2.5 2 5 1.25-2.5- 0- 0- 3 5-7.5 1.25-2.5 0-1.25 0 4
10-(Check to see 1.25-2.5 0-1.25 0 whether pt has received vit K) 5
10 2.5-5 0-2.5 0-1.25 (Check to see whether pt Has received vit K)
6 15 2.5-5 1.25-2.5 0-1.25 Obtain hematology consultation.
[0418] TABLE-US-00012 TABLE 7 10 mg Load Target INR 3.0-4.0 Day
<1.5 1.5-2 2-2.5 2.5-3 >3 2 10 7.5-10 5-7.5 2.5-5.0 0-2.5 3
10-15 7.5-10 5-7.5 2.5-5 2.5-5 4 10-15 7.5-12.5 5-10 5-7.5 2.5-5
(Check to see whether pt has received vit K) 5 15 .sup. 10-12.5
7.5-10 .sup. 5-7.5 2.5-5 (Check to see whether pt has received vit
K) 6 15-20 obtain 10-15 7.5-12.5 5-10 5-7.5 hematology
consultation.
[0419] The appropriate dosage and instructions is displayed on the
computer screen to the intensivist 3918.
[0420] Referring to FIG. 43, the heparin-induced thrombocytopenia
(HIT) decision support algorithm of the present invention is
illustrated. The intensivist is prompted to observe whether the
patient's platelet count has dropped 50% or more over seventy-two
hours while being treated with heparin, and whether any other
obvious causes of platelet reduction might be present 4100. If such
a drop has not occurred, the intensivist is notified by the system
that the patient most likely does not have HIT, but monitoring of
the platelet count should continue 4102. If the patient's platelet
count has drastically dropped, the intensivist is prompted to
determine whether the patient has been treated with heparin for
more than three days 4104. Regardless of the answer, the
intensivist is next prompted to determine if the patient has been
treated with heparin in the preceeding three months 4106. If the
patient has not received heparin in the proceeding three months,
the intensivist is notified by the system that HIT is not likely to
be the cause of the platelet drop. The intensivist is also prompted
to monitor platelet count for infection or other
thronbocytopenia-causing drugs, and to consider stopping heparin
therapy if the platelet count drops below 50,000 per cubic
millimeter 4108.
[0421] If the patient has received heparin in the last three days
4104, the intensivist is further prompted to look for signs of
thrombosis, or blood clotting 4110. If the patient shows signs of
thrombosis, the intensivist is notified by the system that the
patient is likely to have HIT. Accordingly, the intensivist is
prompted to stop administering heparin and flush any drug
administration equipment that would contain heparin traces. The
intensivist is also provided instructions by the system to treat a
patient still requiring anticoagulation treatment with alternate
drugs and methods 4112.
[0422] Where the patient does not show signs of thrombosis 4110,
the intensivist is prompted to check for heparin resistance 4114.
Signs of heparin resistance include inability to hold aPTT though
heparin doses have been increase. If the patient shows signs of
heparin resistance, the intensivist is prompted to consider
stopping heparin treatment and to consider treating a patient still
requiring anticoagulation treatment with alternate drugs and
methods 4116. If the patient does not show signs of heparin
resistance, the intensivist is notified by the system that the
patient possibly has HIT. The intensivist is accordingly prompted
to continue monitoring for thrombosis, consider infection or other
drugs that cause throbocytopenia, and to consider stopping heparin
therapy if the platelet count drops below 50,000 per cubic
millimeter 4118
RESULTS
[0423] The structure of the present invention and its efficacy have
yielded striking results in practice. In a research setting,
deployment of certain rudimentary aspects of the present the
invention designed to experimentally test the approach described
and developed in detail above, yielded unprecedented improvements
in clinical and economic outcomes: 50% improvement in severity
adjusted mortality, 40% improvement in clinical complication rates,
30% improvement in ICU length of stay, and 30% improvement in
overall ICU cost of care.
[0424] A remote command center for providing services to
geographically dispersed hospitalized patients has been shown. It
will be apparent to those skilled in the art that other variations
of the present invention are possible without departing from the
scope of the invention as disclosed. For example, one can envision
different ratios of command center/remote location to ICU's, other
decision support algorithms that would be used by intensivists,
other types of remote monitoring of not only geographically
dispersed hospitalized patients but other types of hospital
functions as well as industrial functions where critical expertise
is in limited supply but where that expertise must be applied to
ongoing processes. In such cases a system such as that described
can be employed to monitor processes and to provide standardized
interventions across a number of geographically dispersed locations
and operations. Further, any reference to claim elements in the
singular, for example, using the articles "a," "an," or "the" is
not to be construed as limiting the element to the singular.
* * * * *