, et al., Patients alter power of breathing as the primary response to changes in pressure suppor... more , et al., Patients alter power of breathing as the primary response to changes in pressure support ventilation,
The usually more controlled circumstances of airway management in the operating room (OR) often p... more The usually more controlled circumstances of airway management in the operating room (OR) often provide better conditions, better monitoring, and more experienced personnel, particularly when a problem occurs, than is available in other critical care environments or the emergency department. While the detection of CO2 by capnography after completion of a difficult intubation procedure may suggest success, it may more precisely indicate only that the tube tip is somewhere in the respiratory path, although perhaps not exactly where the intubationist desires. A capnography pattern indicating declining CO2 in each subsequent breath over several breaths will help identify esophageal intubation. Unilateral pathophysiologic conditions that cause unilateral hypoventilation or high airway resistances would result in a biphasic waveform. Many techniques to facilitate blind nasal tracheal intubation use the detection of significant exhaled gas flow from a spontaneously breathing patient to indicate the proximity of the tube tip to the glottic opening.
International journal of clinical monitoring and computing, Feb 1, 1993
Decision analysis is a powerful methodology that can help clinicians make good decisions. Because... more Decision analysis is a powerful methodology that can help clinicians make good decisions. Because it is not practical to place a decision analyst at the bedside in critical care units, the application of this methodology will require leveraging the analyst through computer-based systems. A decision class analysis is a collective analysis of a group of decisions that provides the high-level specification for such a computer system. This paper presents a decision class analysis of critical care life-support decisions. Key elements of this analysis are: the simplification of an otherwise extremely complex multistage sequential decision problem by using a sequence of two-stage models, and the use of six generic knowledge maps that capture the extremely complex relevant medical knowledge.
Background: The advent of highly sensitive End-Tidal CO2 (ETCO2) sensors allows effective monitor... more Background: The advent of highly sensitive End-Tidal CO2 (ETCO2) sensors allows effective monitoring of intubated patients in EMS. Previous work has explored the use of ETCO2 monitoring in non-intubated patients with sensors placed in the nares. However, little is known about the effect of passive O2 delivery [nasal cannula (NC) or high-flow, non-rebreather mask (NRB)] on ETCO2 measurement. Objective: To compare ETCO2 measurements in non-intubated Traumatic Brain Injury (TBI) patients receiving O2 via NC vs. NRB in the field. Methods: A subset of cases from the EPIC EMS TBI Study (NIH-1R01NS071049) were evaluated (4/13-4/18). Non-intubated cases from 5 EMS agencies providing monitor data, including continuous ETCO2. Start and end segments were excluded to remove artifact from initiation (“ramp-up”) or termination of monitoring. Statistics: Wilcoxon rank-sum test, two-sample t-test, and Chi-squared test were used as appropriate. Linear regression compared continuous variables in adju...
INTRODUCTION We sought to characterize H1N1 clinical findings and interventions together with dem... more INTRODUCTION We sought to characterize H1N1 clinical findings and interventions together with demographic associations across 13 ICU’s in 10 medical centers belonging to the Sutter Health system. Sutter Health ICU’s are monitored by a telemedicine (eICU) center. The eICU covers a geographic area from the Oregon border to South of San Jose and from the Pacific to the Sierra Foothills, allowing us to characterize H1N1 over a large part of Northern California METHODS After receiving IRB approval we conducted an observational study, recording data from July 1, 2009, to December 6, 2009. The study was limited to patients admitted to an ICU. On admission to ICU, data from patients who were suspected to have H1N1 was captured using a custom Excel database. This included fields for elements of clinical course and laboratory results (see below). Data was collected both during ICU stay and post discharge. Chart reviews were conducted at regular intervals to obtain missing data elements. Crite...
"Damage control" in severe abdominal trauma, abdominal compartment syndrome, ne... more "Damage control" in severe abdominal trauma, abdominal compartment syndrome, necrotizing fasciitis of the abdominal wall, and necrotizing pancreatitis often preclude closure of the fascia after laparotomy. Many techniques have been reported for temporary coverage of the exposed viscera, but most have had documented problems. We report the successful use, since 1989, of a temporary sutureless coverage. The viscera are covered with omentum when possible, then with a clear plastic sheet. Sump drains are placed over this layer. The entire abdomen is then covered with two layers of iodophor-impregnated adhesive plastic drape. The last 50 patients managed with this technique are reported. The most common indication (27 patients) was for treatment of severe abdominal trauma. There were no wound infections, fasciitis, or bowel obstruction. Eighteen patients died; no deaths were related to abdominal closure. Temporary abdominal covering with adhesive plastic sheeting is a rapid, safe, and readily available method for managing the open abdomen. This technique provides a physiologic milieu for the abdominal viscera, simplifies nursing care, and promotes safe closure of the abdomen at a later time.
Proceedings / the ... Annual Symposium on Computer Application [sic] in Medical Care. Symposium on Computer Applications in Medical Care, 1995
Managing information is necessary to support clinical decision making and action in critical care... more Managing information is necessary to support clinical decision making and action in critical care. By understanding the nature of information management and its relationship to sound clinical practice, we should come to use technology more wisely. We demonstrated that a new approach inspired by ethnographic research methods could identify useful and unexpected findings about clinical information management. In this approach, a clinician experienced in a specific domain (critical care), with advice from a medical anthropologist, made short-term observations of information management in that domain. We identified 8 areas in a critical care Unit in which information management was seriously in need of better support. We also found interesting differences in how these needs were viewed by nurses and physicians. Our interest in this approach was at two levels: 1. Identify and describe representative instances of sub-optimal information management in a critical care Unit. 2. Investigate t...
Reports from the Food and Drug Administration (FDA) and the Joint Commission on Accreditation of ... more Reports from the Food and Drug Administration (FDA) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) have emphasized the potential for injury to patients caused by failures in oxygen supply systems. This article presents a model of patient risk related to the process of supplying oxygen at a single university hospital. One of the goals of the article is to illustrate how probabilistic risk analysis (PRA) can be used by hospitals to assess and mitigate risk and, therefore, to meet JCAHO requirements. PRA techniques are useful to 1) model the reliability of a complex system and 2) assess the cost-effectiveness of different risk mitigation measures. The authors focus on the risk estimation step, describing in detail their modeling of the oxygen supply system and analysis of the results. For the hospital that the authors study (20,000 admissions yearly), the total expected number of fatalities from oxygen system failure is 44 over a 30-year time horizon. The...
Distributed artificial intelligence (DAI) refers generally to systems in which decentralized, coo... more Distributed artificial intelligence (DAI) refers generally to systems in which decentralized, cooperative agents work synergistically to perform a task. Within this general description, however, there is considerable variability in the operational definitions of terms. "Agents" may refer to arbitrary numbers of more or less sophisticated computatational entities. "Decentralized" may refer to the distribution of knowledge, data, control, or computational resources among different agents. "Cooperative" may refer to a purely discretionary exchange of a small subset of available information or, at the other extreme, to an inevitable sharing of most information. These alternative definitions of terms entail a space of DA1 system models, many of which bear metaphorical resemblances to biological or social systems, such as neural networks [6, 191, complex problem-solvers [S, 11, 131, teams [l, 2, 41, con tract nets 13, 201, and societies [16, 181. None of these models is "correct" or "incorrect." Rather, they capture different, complementary kinds of intelligence, with each model supporting different design objectives and task requirements.
Objective: This article evaluates the feasibility of a tele-intensive care unit (ICU) nurse-drive... more Objective: This article evaluates the feasibility of a tele-intensive care unit (ICU) nurse-driven early identification and treatment process for severe sepsis patients in improving compliance to evidence-based practice. Materials and Methods: Florence Nightingale identified that by using science, logic, and compassion to manipulate the patient care environment nurses could create the best possible conditions for healing to occur. Nurses in a tele-ICU used this premise to initiate a standardized screening and data collection program using a custom-built document sharing application that conformed to the Surviving Sepsis Campaign (SSC) criteria for identification and treatment of severe sepsis. Results: The tele-ICU nurses performed 89,921 screens on 36,353 ICU admissions to 161 ICU beds across a geographical range of 500 miles. Between January 1, 2006 and December 31, 2008, tele-ICU nurses identified 5,437 patients as meeting the criteria for severe sepsis. Statistically significant increases in compliance with SSC's bundled care recommendations were realized during this study period with four initial elements: antibiotic administration increased from 55% in 2006 to 74% in 2008 (p = 0.001), serum lactate measurement increased from 50% to 66% (p = 0.001), the initial fluid bolus of ‡ 20 mL/kg increased from 23% to 70% (p = 0.001), and central line placement increased from 33% to 50% (p = 0.001). Conclusions: A tele-ICU nurse-driven process can prompt earlier identification and improve compliance to evidence-based practice bundles for complex disease states such as severe sepsis.
Healthy physiological systems exhibit irregular variability whereas diseased systems display decr... more Healthy physiological systems exhibit irregular variability whereas diseased systems display decreased signal variability or greater regularity. The objective of this article is to report a case series of critically ill adults who displayed ultra low-frequency periodic sinusoidal oscillations in cardiac output (ULF-CO) that were discovered during a clinical study testing software for continuous physiological monitoring. Data were collected from 13 critically ill surgical and trauma patients who required continuous cardiac output monitoring. Physiologic data were collected from clinical monitors. The computerized time series of cases displaying CO oscillations were manually reviewed. Ten patients with sepsis or the systemic inflammatory response syndrome exhibited 18 episodes of ultra low-frequency periodic oscillations (ULF-CO) with frequencies ranging from 0.0028 to 0.000053 Hz (periods, 6 to 316 min). Intensive care unit mortality rate was 50%. The amplitude and coefficient of variation of cardiac output during ULF-CO ranged from 0.1-4.6 L and 3.9-14.3%, respectively. Duration of ULF-CO ranged from 4-108.1 h. ULF-CO could not be explained as a result of patterned artifact from measurement error or therapeutic intervention. ULF-CO may be a pathophysiologic marker that might serve the diagnosis, prognosis, and treatment of critical illness.
The Wakefield roundtable discussion on complexity and variability at the bedside. ... Seely AJ, M... more The Wakefield roundtable discussion on complexity and variability at the bedside. ... Seely AJ, Macklem PT, Suki B, Goldberger A, Godin P, Batchinsky AI, Longtin A, Jones G, Seiver A, McGregor C, Norris P, Maksym G, Lake D, Costa MD, Marshall JC, Morris JA, Moorman ...
, et al., Patients alter power of breathing as the primary response to changes in pressure suppor... more , et al., Patients alter power of breathing as the primary response to changes in pressure support ventilation,
The usually more controlled circumstances of airway management in the operating room (OR) often p... more The usually more controlled circumstances of airway management in the operating room (OR) often provide better conditions, better monitoring, and more experienced personnel, particularly when a problem occurs, than is available in other critical care environments or the emergency department. While the detection of CO2 by capnography after completion of a difficult intubation procedure may suggest success, it may more precisely indicate only that the tube tip is somewhere in the respiratory path, although perhaps not exactly where the intubationist desires. A capnography pattern indicating declining CO2 in each subsequent breath over several breaths will help identify esophageal intubation. Unilateral pathophysiologic conditions that cause unilateral hypoventilation or high airway resistances would result in a biphasic waveform. Many techniques to facilitate blind nasal tracheal intubation use the detection of significant exhaled gas flow from a spontaneously breathing patient to indicate the proximity of the tube tip to the glottic opening.
International journal of clinical monitoring and computing, Feb 1, 1993
Decision analysis is a powerful methodology that can help clinicians make good decisions. Because... more Decision analysis is a powerful methodology that can help clinicians make good decisions. Because it is not practical to place a decision analyst at the bedside in critical care units, the application of this methodology will require leveraging the analyst through computer-based systems. A decision class analysis is a collective analysis of a group of decisions that provides the high-level specification for such a computer system. This paper presents a decision class analysis of critical care life-support decisions. Key elements of this analysis are: the simplification of an otherwise extremely complex multistage sequential decision problem by using a sequence of two-stage models, and the use of six generic knowledge maps that capture the extremely complex relevant medical knowledge.
Background: The advent of highly sensitive End-Tidal CO2 (ETCO2) sensors allows effective monitor... more Background: The advent of highly sensitive End-Tidal CO2 (ETCO2) sensors allows effective monitoring of intubated patients in EMS. Previous work has explored the use of ETCO2 monitoring in non-intubated patients with sensors placed in the nares. However, little is known about the effect of passive O2 delivery [nasal cannula (NC) or high-flow, non-rebreather mask (NRB)] on ETCO2 measurement. Objective: To compare ETCO2 measurements in non-intubated Traumatic Brain Injury (TBI) patients receiving O2 via NC vs. NRB in the field. Methods: A subset of cases from the EPIC EMS TBI Study (NIH-1R01NS071049) were evaluated (4/13-4/18). Non-intubated cases from 5 EMS agencies providing monitor data, including continuous ETCO2. Start and end segments were excluded to remove artifact from initiation (“ramp-up”) or termination of monitoring. Statistics: Wilcoxon rank-sum test, two-sample t-test, and Chi-squared test were used as appropriate. Linear regression compared continuous variables in adju...
INTRODUCTION We sought to characterize H1N1 clinical findings and interventions together with dem... more INTRODUCTION We sought to characterize H1N1 clinical findings and interventions together with demographic associations across 13 ICU’s in 10 medical centers belonging to the Sutter Health system. Sutter Health ICU’s are monitored by a telemedicine (eICU) center. The eICU covers a geographic area from the Oregon border to South of San Jose and from the Pacific to the Sierra Foothills, allowing us to characterize H1N1 over a large part of Northern California METHODS After receiving IRB approval we conducted an observational study, recording data from July 1, 2009, to December 6, 2009. The study was limited to patients admitted to an ICU. On admission to ICU, data from patients who were suspected to have H1N1 was captured using a custom Excel database. This included fields for elements of clinical course and laboratory results (see below). Data was collected both during ICU stay and post discharge. Chart reviews were conducted at regular intervals to obtain missing data elements. Crite...
"Damage control" in severe abdominal trauma, abdominal compartment syndrome, ne... more "Damage control" in severe abdominal trauma, abdominal compartment syndrome, necrotizing fasciitis of the abdominal wall, and necrotizing pancreatitis often preclude closure of the fascia after laparotomy. Many techniques have been reported for temporary coverage of the exposed viscera, but most have had documented problems. We report the successful use, since 1989, of a temporary sutureless coverage. The viscera are covered with omentum when possible, then with a clear plastic sheet. Sump drains are placed over this layer. The entire abdomen is then covered with two layers of iodophor-impregnated adhesive plastic drape. The last 50 patients managed with this technique are reported. The most common indication (27 patients) was for treatment of severe abdominal trauma. There were no wound infections, fasciitis, or bowel obstruction. Eighteen patients died; no deaths were related to abdominal closure. Temporary abdominal covering with adhesive plastic sheeting is a rapid, safe, and readily available method for managing the open abdomen. This technique provides a physiologic milieu for the abdominal viscera, simplifies nursing care, and promotes safe closure of the abdomen at a later time.
Proceedings / the ... Annual Symposium on Computer Application [sic] in Medical Care. Symposium on Computer Applications in Medical Care, 1995
Managing information is necessary to support clinical decision making and action in critical care... more Managing information is necessary to support clinical decision making and action in critical care. By understanding the nature of information management and its relationship to sound clinical practice, we should come to use technology more wisely. We demonstrated that a new approach inspired by ethnographic research methods could identify useful and unexpected findings about clinical information management. In this approach, a clinician experienced in a specific domain (critical care), with advice from a medical anthropologist, made short-term observations of information management in that domain. We identified 8 areas in a critical care Unit in which information management was seriously in need of better support. We also found interesting differences in how these needs were viewed by nurses and physicians. Our interest in this approach was at two levels: 1. Identify and describe representative instances of sub-optimal information management in a critical care Unit. 2. Investigate t...
Reports from the Food and Drug Administration (FDA) and the Joint Commission on Accreditation of ... more Reports from the Food and Drug Administration (FDA) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) have emphasized the potential for injury to patients caused by failures in oxygen supply systems. This article presents a model of patient risk related to the process of supplying oxygen at a single university hospital. One of the goals of the article is to illustrate how probabilistic risk analysis (PRA) can be used by hospitals to assess and mitigate risk and, therefore, to meet JCAHO requirements. PRA techniques are useful to 1) model the reliability of a complex system and 2) assess the cost-effectiveness of different risk mitigation measures. The authors focus on the risk estimation step, describing in detail their modeling of the oxygen supply system and analysis of the results. For the hospital that the authors study (20,000 admissions yearly), the total expected number of fatalities from oxygen system failure is 44 over a 30-year time horizon. The...
Distributed artificial intelligence (DAI) refers generally to systems in which decentralized, coo... more Distributed artificial intelligence (DAI) refers generally to systems in which decentralized, cooperative agents work synergistically to perform a task. Within this general description, however, there is considerable variability in the operational definitions of terms. "Agents" may refer to arbitrary numbers of more or less sophisticated computatational entities. "Decentralized" may refer to the distribution of knowledge, data, control, or computational resources among different agents. "Cooperative" may refer to a purely discretionary exchange of a small subset of available information or, at the other extreme, to an inevitable sharing of most information. These alternative definitions of terms entail a space of DA1 system models, many of which bear metaphorical resemblances to biological or social systems, such as neural networks [6, 191, complex problem-solvers [S, 11, 131, teams [l, 2, 41, con tract nets 13, 201, and societies [16, 181. None of these models is "correct" or "incorrect." Rather, they capture different, complementary kinds of intelligence, with each model supporting different design objectives and task requirements.
Objective: This article evaluates the feasibility of a tele-intensive care unit (ICU) nurse-drive... more Objective: This article evaluates the feasibility of a tele-intensive care unit (ICU) nurse-driven early identification and treatment process for severe sepsis patients in improving compliance to evidence-based practice. Materials and Methods: Florence Nightingale identified that by using science, logic, and compassion to manipulate the patient care environment nurses could create the best possible conditions for healing to occur. Nurses in a tele-ICU used this premise to initiate a standardized screening and data collection program using a custom-built document sharing application that conformed to the Surviving Sepsis Campaign (SSC) criteria for identification and treatment of severe sepsis. Results: The tele-ICU nurses performed 89,921 screens on 36,353 ICU admissions to 161 ICU beds across a geographical range of 500 miles. Between January 1, 2006 and December 31, 2008, tele-ICU nurses identified 5,437 patients as meeting the criteria for severe sepsis. Statistically significant increases in compliance with SSC's bundled care recommendations were realized during this study period with four initial elements: antibiotic administration increased from 55% in 2006 to 74% in 2008 (p = 0.001), serum lactate measurement increased from 50% to 66% (p = 0.001), the initial fluid bolus of ‡ 20 mL/kg increased from 23% to 70% (p = 0.001), and central line placement increased from 33% to 50% (p = 0.001). Conclusions: A tele-ICU nurse-driven process can prompt earlier identification and improve compliance to evidence-based practice bundles for complex disease states such as severe sepsis.
Healthy physiological systems exhibit irregular variability whereas diseased systems display decr... more Healthy physiological systems exhibit irregular variability whereas diseased systems display decreased signal variability or greater regularity. The objective of this article is to report a case series of critically ill adults who displayed ultra low-frequency periodic sinusoidal oscillations in cardiac output (ULF-CO) that were discovered during a clinical study testing software for continuous physiological monitoring. Data were collected from 13 critically ill surgical and trauma patients who required continuous cardiac output monitoring. Physiologic data were collected from clinical monitors. The computerized time series of cases displaying CO oscillations were manually reviewed. Ten patients with sepsis or the systemic inflammatory response syndrome exhibited 18 episodes of ultra low-frequency periodic oscillations (ULF-CO) with frequencies ranging from 0.0028 to 0.000053 Hz (periods, 6 to 316 min). Intensive care unit mortality rate was 50%. The amplitude and coefficient of variation of cardiac output during ULF-CO ranged from 0.1-4.6 L and 3.9-14.3%, respectively. Duration of ULF-CO ranged from 4-108.1 h. ULF-CO could not be explained as a result of patterned artifact from measurement error or therapeutic intervention. ULF-CO may be a pathophysiologic marker that might serve the diagnosis, prognosis, and treatment of critical illness.
The Wakefield roundtable discussion on complexity and variability at the bedside. ... Seely AJ, M... more The Wakefield roundtable discussion on complexity and variability at the bedside. ... Seely AJ, Macklem PT, Suki B, Goldberger A, Godin P, Batchinsky AI, Longtin A, Jones G, Seiver A, McGregor C, Norris P, Maksym G, Lake D, Costa MD, Marshall JC, Morris JA, Moorman ...
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