John R. Zaleski, PhD, CPHIMS, Chief Informatics Officer & EVP

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Nuvon Vital Charting System
(NVCS)
Medical Device Integration (MDI) with Clinical
Rules and Decision Support
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Migrating Focus of Medical Device
Integration (MDI)
• MDI for charting & Electronic Health Records /
Electronic Medical Records (EHRs/EMRs) is the
starting point, but not the ultimate objective
– Use of data for near-real-time clinical use
– Data availability outside of EMR/EHR framework, for
research, real-time early warning notifications
– Provides a more direct route to support early
notification of higher acuity & higher risk patients
• Nuvon is taking steps in this direction, and
working with existing and new clients
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Nuvon Medical Device Integration
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Nuvon Vitals Charting System
• Overlays existing medical device integration framework
• Provides capability to store data for recall, export for a posteriori
analysis.
• Active rules & thresholds can operate on one or more of the medical
device parameters or complex methods involving multiple parameters.
• Tailored, role-based notifications and integrates with alarm management
systems
• The following policies apply to rules:
– Simple expressions and conditions that apply to parameters so as to notify on
occurrence of a condition.
– Rules can be stored / recalled and used to notify on email, HL7 when certain
conditions are met.
– Notifications can be displayed on occurrence of a condition of one or more
parameter observations received from medical devices.
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Configuration & Components
Real-Time
Information Sources
Vitals
Specialty Medical
Devices
• Real-time feed from existing data sources;
• Provides user-defined & default rules that can be created and
managed by end users;
• Can communicate to existing EHR or alarm management system;
• Can provide notification visualization via Web to support call
centers, handheld appliances, desktop computers
Labs
Rx
ADT
Notes
Informatics
Engine
Enterprise EHR /
Alarm Management
KEY:
Currently Supported
Future
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Example Use Cases
•
•
•
•
Rapid Response Notification
Shock index in medical / surgical patients
Capnography monitoring for PCA
Head-of-Bed angle compliance in
mechanically ventilated patients
• Rapid shallow breathing monitoring to
determine viability to wean
• …
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Earlier Intervention in General Wards
• “Research indicates that up to 40% of unexpected deaths in hospitals
occur on the general floor. While the signs of clinical instability typically
occur six to eight hours prior to an adverse event, large patient volumes
and limited staffing can make it difficult for care providers in the medical
surgical areas of the hospital to anticipate which patients to watch more
closely.” [1]
• “Up to 17% of patients in the medical surgical areas of the hospital will
face an unexpected complication …in two-thirds of cases, patients
demonstrate abnormal signs and symptoms within six hours of cardiac
arrest, while an MD is notified only 25% of the time. [2]
[1] http://healthcaresolutions.philips.com/earlier-intervention-on-thegeneral-ward#clinical
[2] Bellomo R, Goldsmith D, Russell S, Uchino S. Postoperative serious
adverse events in a teaching hospital: a prospective study. Med J Aust.
2002: 176:216-218
NUVON CONFIDENTIAL
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Rapid Response Criteria
NUVON CONFIDENTIAL
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Rapid Response Notification Methods
• Rapid Response Notification when patient meets
multiple criteria
– Superposition of multiple parameter values
simultaneously, or
– Additive or sum total of scoring system requirements
• Rapid Response Notification based on single
criteria
– Individual parameters thresholds, or
– Notification upon cascaded criteria (e.g.: when SpO2 <
92%, check ETCO2, …)
NUVON CONFIDENTIAL
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Rule for Rapid Response
hrScore=IF(HR<=40, 2, IF(HR>40 & HR<=50, 1,
IF(HR>50 & HR<=100, 0, IF(HR>100 & HR<=110,
1, IF(HR>110 & HR<=130, 2, 3)))))
rrScore=IF(RR<8, 2, IF(RR>=8 & RR<=11, 1,
IF(RR>11 & RR<=20, 0, IF(RR>20 & RR<=25, 1,
IF(RR>25 & RR<=30, 2, 3)))))
allScore=hrScore + rrScore
IF(allScore>=3, 1, 0)
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Rules for Rapid Response Scoring
NUVON CONFIDENTIAL
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Weaning, Head-of-Bed (HoB) angle
management, ARDS management
• On-board predictive analytics software
trained on source data and subject to
algorithms developed by end users.
• Provide notifications and warnings
based on near real-time data state in
comparison with algorithmic
expectations.
• Provide web-based access to
algorithms, data and results and tailored
view of output in end-user desired
formats.
Note: have developed
relationships (including driver)
with vendor partners such as
Covidien, Sizewise (beds) to
support more complex
workflows involving critical
patient data
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Increasing Rates of HoB Compliance
Linked to Reduced VAP
Ventilator-associated pneumonia (VAP) is the most common hospital-acquired
infection in the intensive care unit (ICU). [1] It occurs in 9% to 40% of all ICU patients
and has an incidence of 5 to 35 cases per 1000 ventilator days. [2] The consequences of
VAP are severe: a three-fold increased duration of mechanical ventilation, a two- to
six-fold increase in ICU stay, a 2- to 3-day increase in hospital stay. [3] Each case of VAP
increases hospital costs by $40,000 to $50,000 and results in a 15% to 45% increase in
attributable mortality. [2,4]
Elevation of the head-of-bed (HOB) of intubated patients is an effective method for
reducing rates of aspiration pneumonia. In a randomized two-period crossover study,
Torres et al. [5] demonstrated that the semirecumbent position decreased rates of
aspiration of gastric contents four-fold. Kollef [6]
A Simple Device to Increase Rates of Compliance in Maintaining 30-Degree Headof-bed Elevation in Ventilated Patients
Zev Williams, MD, PhD, Rodney Chan, MD, Edward Kelly, MD
DisclosuresCrit Care Med. 2008;36(4):1155-1157.
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Modified Shock Index
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Rapid Shallow Breathing Index
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Chart View
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Chart View, Trending, Thresholds
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John R. Zaleski, Ph.D., CPHIMS
Chief Informatics Officer
Nuvon, Inc.
4801 S. Broad Street
Suite 120
Philadelphia, PA 19112
E: [email protected]
T: @johnrzaleski
O: 215-600-2627 x102
THANK YOU
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References
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Vincent JL, Bihari D, Suter PM, et al: The prevalence of nosocomial infection in intensive care units in Europe: Results of the European Prevalence
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Ibrahim EH, Tracy L, Hill C, et al: The occurrence of ventilator-associated pneumonia in a community hospital: Risk factors and clinical outcomes.
Chest 2001; 120:555-561
Rello J, Ollendorf DA, Oster G, et al: Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest 2002;
122:2115-2121
Tablan OC, Anderson LJ, Besser R, et al: Guidelines for preventing health-care-associated pneumonia, 2003: Recommendations of CDC and the
Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep 2004; 53:1-36
Torres A, Serra-Batlles J, Jos E, et al: Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: The effect of body
position. Ann Intern Med 1992; 116:540-543
Kollef MH: Ventilator-associated pneumonia: A multivariate analysis. JAMA 1993; 270:1965-1970
Drakulovic MB, Torres A, Bauer TT, et al: Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: A
randomised trial. Lancet 1999; 354:1851-1858
Critical Care. http://www.ihi.org/IHI/Topics/CriticalCare/ . Accessed October 26, 2007
Curtis JR, Cook DJ, Wall RJ, et al: Intensive care unit quality improvement: A how-to guide for the interdisciplinary team. Crit Care Med 2006;
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Evans D: The use of position during critical illness: Current practice and review of the literature. Aust Crit Care 1994; 7:16-21
Grap MJ, Munro CL, Bryant S, et al: Predictors of backrest elevation incritical care. Intensive Crit Care Nurs 2003; 19:68-74
van Nieuwenhoven CA, Vandenbroucke-Grauls C, van Tiel FH, et al: Feasibility and effects of the semirecumbent position to prevent ventilatorassociated pneumonia: A randomized study. Crit Care Med 2006; 34:396-402
McMullin JP, Cook DJ, Meade MO, et al: Clinical estimation of trunk position among mechanically ventilated patients. Intensive Care Med 2002;
28:304-309
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