Continuous-Stream Monitoring Advances Care of Critically Ill Patients
New technology in the intensive care units, select operating rooms and trauma bays of St. Louis Children’s Hospital (SLCH) allows physicians to rewind through hours, days or even months of vital signs for each patient. The Bedmaster System’s continuous-stream technology means clinicians may compare real-time data with data recorded earlier, thus gaining a clear window of understanding into evolving pathology.
Prior to the Bedmaster System launch in December 2011 at SLCH, bedside monitors displayed patient vital signs in 7-second intervals. Those brief slices of data were recorded hourly in patients’ charts. A bedside alarm sounded only if the data crossed a dangerous threshold.
“One hour is a long time in the ICU,” says Jose Pineda, MD, Washington University pediatric intensivist and director of the neurocritical care program at SLCH. “In the past if we wanted to make a decision based on a child’s blood pressure, we could review the readings charted at 9 a.m., 10 a.m., 11 a.m., noon—and so on. But what was the blood pressure at 12:15? Especially for critically ill children, physiological signs can fluctuate dramatically in a short period of time.”
Dr. Pineda compares the accuracy of the 7-second data interval to standing on a street, counting the number of yellow cars that pass in 7 seconds and adjusting the number to determine how many yellow cars passed in an hour.
“It’s a very limited picture,” he says. “In comparison, the Bedmaster System records trends for patients’ vital signs the entire length of their stay, allowing the medical team to review patterns over time and better recognize or anticipate a crisis.”
Jennifer Silva, MD, Washington University pediatric cardiologist and director of pediatric electrophysiology at SLCH, routinely cares for pediatric patients with heart rhythm abnormalities, pacemakers and intracardiac defibrillators. She personally has experienced how the ability to visualize a patient’s heart rhythm in real time has significantly affected patient care.
“For example, recently a 2-year-old girl with newly diagnosed dilated cardiomyopathy was transferred into our Cardiac ICU for a transplant evaluation. On admission she was noted to be very tachycardic, and the electrophysiology team assessed her as having ectopic atrial tachycardia,” explains Dr. Silva. “Critical to the management of her cardiomyopathy was rate control of her arrhythmia. Over the next 10 days, we loaded her with high doses of antiarrhythmics. Using the Bedmaster System, we were able to precisely titrate her medication given her heart rate and blood pressure responses to her medical management. Had the software not been available, we may not have been able to titrate her medication so accurately.”
The ability to control the patient’s heart rate resulted in her conversion to oral medications and discharge from the hospital.
Another advantage of the Bedmaster System is that it functions within a computer network, so specialists may review real-time data from a child’s bedside from elsewhere in the hospital—or anywhere in the world.
“If we are worried a patient may be having an arrhythmia, we can call a highly specialized electrophysiologist, who can instantly log-in, remotely check the monitor and say, ‘Yes, I recognize that arrhythmia, we need to try this medicine.’ We call this local telemedicine,” says Dr. Pineda.
The effectiveness of the medical intervention is evident within minutes through the real-time data streams now available. With the old system, physicians either had to wait for the next round of hourly data or physically stand at patients’ bedsides and watch the 7-second monitor for an extended period.
Beyond its use at the bedside, the Bedmaster System has potential as an important tool in research efforts. Avihu Gazit, MD, assistant professor of pediatrics at Washington University School of Medicine and medical director of SLCH’s cardiac ICU, is using the system as part of a prospective longitudinal study in neonates with congenital heart disease (CHD).
“In this study, we evaluate pre-operative heart rate variability in neonates with critical CHD in order to explore its ability to identify those infants with higher post-operative morbidity/mortality or inotrope requirements,” he says. “Heart rate variability measures the degree of HR modulation that occurs in response to autonomic and neuroendocrine inputs. It is dynamic, decreasing with illness and returning with clinical improvement. The Bedmaster System is being used to collect high-resolution physiologic data from our study participants, making this innovative research project possible.”
SLCH is the first children’s hospital in the area to use the advanced Bedmaster System. It was created by Excel Medical Electronics and purchased for $500,000 through a grant from an anonymous donor to the St. Louis Children’s Hospital Foundation. The system tracks all vital signs from the patient’s bedside monitor, including heart rate, blood pressure, oxygen saturation, carbon dioxide and intracranial pressure.
Looking to the future, Dr. Pineda and his team already have begun developing the next-generation application for the Bedmaster program—real-time computer analysis of each stream of data into an algorithm that will mathematically predict the patient’s clinical course in the ICU. SLCH is the first in the country to partner with IBM and Excel Medical Electronics to build a platform that interprets physiological data trends into predictive medicine.
“What if you could use this data to know whether a child in the ICU is likely to have a cardiac arrest in the next 12 hours, or to predict how a child will do after respiratory support with a breathing tube is discontinued?” says Dr. Pineda. “What we’re doing with the new technology being developed by IBM is trying to predict catastrophic, life-threatening events.”
The idea is that if physicians can predict life-threatening events, they can better anticipate and quickly implement appropriate therapies and save more lives.
“Until now we could only look at the trees. We couldn’t zoom out and look at the forest,” says Dr. Pineda. “With this tool, we can. It makes things so much clearer for everyone. We are finding that this type of data display and analysis also helps parents understand their child’s condition in the ICU.”