1. Trends in the management of acute and critically ill patients
Monitoring TechnologyTelemetry-
is the monitoring and analyzing of data that are received at a distance from their source. Itusually refers
to a certain way of monitoring a hospital patient's heart activity
-
it allows the patient to get up and move around, at least within the device's transmittingrange.
-
To provide skilled cardiac monitoring to patients who require cardiac monitoring, but otherwisedo not
warrant ICU placement.Any patient who needs continuous EKG monitoring with no other need for
intensive level care,including, but not limited to:1. Symptomatic and/or chronic or potential for life-
threatening arrhythmias.2. CCU or ICU transfers, status-post MI.3. Post cardiothoracic surgery.4. Drug
toxicities limited to potential arrhythmogenic compounds such as digitalis andtricyclics.5. New onset
supraventricular arrhythmias (atrial fibrillation or flutter, PSVT, etc.)6. Suspected pacemaker
malfunction.7. Observation post pacemaker or defibrillator placement or post ablation.8. Syncope when
an arrhythmia or other cardiac disorder is a suspected etiology.9. Suspected defibrillator discharge.10.
Unstable angina of low or intermediate grade (new onset angina without EKG orenzymatic changes,
crescendo angina in patient with history of coronary disease).11. Study drug protocols requiring cardiac
monitoring as a part of the protocol.
Prior to discharge from the Telemetry Unit, patients shall meet the following criteria:1. Physician shall
order the discontinuation of Telemetry monitoring.2. Patient shall be free of chest pain for 24 hours
prior to discharge.3. Patient's vital signs shall be stable.4. Patient does not require intravenous
vasoactive medications.5. Patient shall be able to perform minimal ADLs without shortness of breath.6.
Patient shall have normal sinus rhythm, stable rhythm, or controlled arrhythmia for thepast 24
hours.Diagnostic information systemToday s physicians and other caregivers have access to more than
5,000 different patient tests to helpthem evaluate, diagnose, and treat patients. The problem is that
physicians receive these test resultsfrom a wide range of disparate sources that use vastly different
reporting formats.Displaying test results in fragmented, variable and incomplete formats prevents
physicians fromefficiently reviewing and analyzing vital patient information. This can lead to:

2. Clinicians spending far too much time (an estimated 30%) gathering and organizing data.
critical information being missed which can cause medical errors
Redundant testing (an estimated 14% to 30% of the 30 billion diagnostic tests done annually inthe US
are non-contributory and avoidable)
The inability to share or exchange vital clinical information among providers
Underutilization of EH
R
s and other health IT applications and an unnecessary reliance on paper,telephones, and fax machinesIn
order to provide cost-effective, high quality care, physicians and other caregivers need immediateaccess
to accurate, timely, and comprehensive clinical information.The patented DIS
SM
Solution provides rapid access to cumulative patient information in an easy to readand analyze format
that increases the accuracy and efficiency of patient care and improves theproductivity of physicians,
nurses and others at all points of care
.
The patented DIS
SM
Solution provides rapid access to cumulative patient information in an easy to readand analyze format
that increases the accuracy and efficiency of patient care and improves theproductivity of physicians,
nurses and others at all points of care.DIS
SM
can aggregate and collate more than 5,000 different patient test results and display them all inone place
in the same user-friendly format. Its ease of access and use adds immediate value to thehealthcare
delivery process:1.

3. Converts raw patient test results data into organized, meaningful information for easy access,viewing,
and analysis2.
Provides a standardized reporting format that unifies test results from all data sources for usersat all
points of care3.
Integrates test results data on all levels (data, application, system and network) increasingefficiency,
accuracy and productivity4.
R
educes the number of pages and screens on which results are displayed by an average of 80percent5.
Saves time and helps physicians minimize duplicate and non-contributory testing
The DIS
SM
Technology solution was specifically designed for immediate use by all test results data usersin physician
offices, hospital inpatient facilities and outpatient clinics and community health centers.
Itsimplementation will depend on collaborative innovation among a number of
interdependentstakeholders. These include all the test results data providers in hospital and
community-based clinicallaboratories and in imaging and other testing facilities and the vendors of EH
R
s and PH
R
s, as well as thevendors of HIE data integration and exchange platforms and the
R
HIOs/HIEs that they serve.A

4. mechanical ventilator
is a machine that generates a controlled flow of gas into a patient s airways.Oxygen and air are
received from cylinders or wall outlets, the gas is pressure reduced and blendedaccording to the
prescribed inspired oxygen tension (FiO2), accumulated in a receptacle within themachine, and
delivered to the patient using one of many available modes of ventilation.The mechanics of inspiratory
support are more complex than previously considered. It has beenestablished that cyclical inflation and
deflation injures lung parenchyma and worsens outcome (1). Large tidal volume ventilation, to
normalize blood gases has been shown to worsen outcome in lunginjury (2), presumably due to
excessive pressure induced stretch injury of the parenchyma. Modernventilation strategy involves
attempting to achieve an adequate minute volume with the lowest possibleairway pressure (as this
relates to the degree of alveolar distension). The pressure that we areinterested in minimizing is at the
level of the alveolus, the plateau pressure.Ventilator cycling refers to the mechanism by which the
phase of the breath switches frominspiration to expiration. Modes of ventilation are time cycled,
volume cycled or flow cycled. Timecycling refers to the application of a set controlled breath rate.
In controlled ventilation a number of mandatory breaths are delivered to the patient at a
predetermined interval.The respiratory rate may be controlled by the operator or the patient. The
patient may breathespontaneously, and with modern ventilators these breaths are supported either by
delivering facsimilesof the controlled breaths synchronously with the patient s effort or by allowing
the patient moresubjective control. Pressure support is a form of flow cycled ventilation in which the
patient triggers theventilator and a pressure limited flow of gas is delivered. The patient determines the
duration of thebreath and the tidal volume, which may vary from breath to breath.CT scans are a
specialized type of x-ray. The patient lies down on a couch which slides into a largecircular opening. The
x-ray tube rotates around the patient and a computer collects the results. Theseresults are translated
into images that look like a "slice" of the person.Sometimes a radiologist will decide that contrast agents
should be used. Contrast agents are iodinebased and are absorbed by abnormal tissues. They make it
easier for the doctor to see tumors withinthe brain tissue. There are some (rare) risks associated with
contrast agents and you should make surethat you discuss this with the doctor before arriving for the
examination.CT is very good for imaging bone structures. In fact, it's usually the imaging mode of choice
whenlooking at the inner ears. It can easily detect tumors within the auditory canals and can
demonstratethe entire cochlea on most patients.M
R
I is a completely different animal! Unlike CT it uses magnets and radio waves to create the images.No x-
rays are used in an M
R
I scanner.The patient lies on a couch that looks very similar the ones used for CT. They are then placed in
a verylong cylinder and asked to remain perfectly still. The machine will produce a lot of noise
andexaminations typically run about 30 minutes.The cylinder that you are lying in is actually a very large
magnet. The computer will send radio wavesthrough your body and collect the signal that is emitted

5. from the hydrogen atoms in your cells. Thisinformation is collected by an antenna and fed into a
sophisticated computer that produces the images.These images look similar to a CAT scan but they have
much higher detail in the soft tissues.Unfortunately, M
R
I does not do a very good job with bones.One of the great advantages of M
R
I is the ability to change the contrast of the images. Small changes inthe radio waves and the magnetic
fields can completely change the contrast of the image. Differentcontrast settings will highlight different
types of tissue Another advantage of M
R
I is the ability to change the imaging plane without moving the patient. If youlook at the images to the
left you should notice that they look very different. The top two images arewhat we call axial images.
This is what you would see if you cut the patient in half and looked at themfrom the top. The image on
the bottom is a coronal image. This slices the patient from front to back.Most M
R
I machines can produce images in any plane. CT can not do this.Contrast agents are also used in M
R
I but they are not made of iodine. There are fewer documentedcases of reactions to M
R
I contrast and it is considered to be safer than x-ray dye. Once again, youshould discuss contrast agents
with your physician before you arrive for the examination.ICUThe ICU environment should focus on
thesetherapeutic elements:
y
W
indows and art that provide natural views; views of naturecan reduce stress, hasten recovery, lower
blood pressure andlower pain medication needs Family participation, including facilities for overnight
stay andcomfortable waiting rooms Providing familiarity in the ICU environment through person-
alization, warmer colors, natural materials, and artwork Providing a measure of privacy and personal
control throughadjustable lighting, adjustable curtains and blinds, accessiblebed controls, and TV, VC

6. R
and CD players Noise reduction through computerized pagers and silentalarms Medical team
continuity that allows one team to follow thepatient through his or her entire stayA tele-ICU system
involves a command center with the technological capability to remotely monitorpatients in off-site
intensive care units. The command center is staffed with intensivist physicians andcritical care nurses
who use two-way audio-visual monitoring systems to provide support and guidanceto the bedside staff
in those ICUs.And critical care nurses play a major role in the success of a tele-ICU. They have a great
deal of potential when it comes to bridging distance barriers, influencing patient safety and even
mentoringbedside nurses, noted Karen Harvey, MSN,
R
N, certification programs specialist for the corporation.
Laboratory testingWhat are the indicators of test reliability?
F
our indicators are most commonly used to determine the reliability of a clinical laboratory test. Two of
these,accuracy and precision, reflect how well the test method performs day to day in a laboratory. The
other two,sensitivity and specificity, deal with how well the test is able to distinguish disease from
absence of disease.The accuracy and precision of each test method are established and are frequently
monitored by the professionallaboratory personnel. Sensitivity and specificity data are determined by
research studies and are generally found inmedical literature. Although each test has its own
performance measures and appropriate uses, laboratory tests aredesigned to be as precise, accurate,
specific, and sensitive as possible. These basic concepts are the cornerstonesof reliability of your test
results and provide the confidence your health care provider has in using the clinicallaboratory.
Accuracy and Precision
Statistical measurements of accuracy and precision reveal a lab test's basic reliability. These terms,
which describesources of variability, are not interchangeable. A test method can be precise (reliable
reproducibility) without beingaccurate (measuring what it is supposed to measure and its true value) or
vice versa.Precision (Repeatability) A test method is said to be precise when repeated analyses on the
same sample give similar results. When a testmethod is precise, the amount of random variation is
small. The test method can be trusted because results arereliably reproduced time after time Accuracy
(Trueness) A test method is said to be accurate when the test value approaches the absolute ³true´
value of the substance(analyte) being measured. Results from every test performed are compared to
known "control specimens" that haveundergone multiple evaluations and compared to the "gold"
standard for that assay, thus analyzed to the best testingstandards available. Although a test that is
100% accurate and 100% precise is ideal, in practice, test methodology, instrumentation, andlaboratory
operations all contribute to small but measurable variations in results. The small amount of variability

7. thattypically occurs does not usually detract from the test¶s value and statistically is insignificant. The
level of precisionand accuracy that can be obtained is specific to each test method but is constantly
monitored for reliability throughcomprehensive quality control and quality assurance procedures.
Therefore, when your blood is tested more thanonce by the same laboratory, your test results should
not change much unless your condition has changed. Theremay be some differences between
laboratories in precision and accuracy due to different analytical instrumentation or methodologies,
however, the test results are reported with standardized reference intervals specific for thatlaboratory.
This helps your health care provider to correctly interpret the information and its relevance to
thatreference interval.
S
ensitivity and
Sp
ecificity
The tests that a provider chooses in order to diagnose or monitor a medical condition are based on
their inherentability to distinguish whether you have the condition or do not have the condition.
Depending on the symptoms andmedical history, a provider will order tests to confirm a condition (tests
with high sensitivity) or tests to rule out thecondition (tests with high specificity).SensitivitySensitivity is
the ability of a test to correctly identify individuals who have a given disease or condition.
F
or example, acertain test may have proven to be 90% sensitive. If 100 people are known to have a
certain disease, the test that identifies that disease will correctly do so for 90 of those 100 cases (90%).
The other 10 people (10%) tested will notshow the expected result for this test.
F
or that 10%, the finding of a "normal" result can be misleading and istermed false-negative. A test's
sensitivity becomes particularly important when you are seeking to exclude a dangerous disease, such
astesting for the presence of the HIV antibody. Screening for HIV antibody often utilizes an ELISA test
method, whichhas sensitivity over 99%. However, a person may get a false-negative if tested too soon
after the initial infection (lessthan 6 weeks). Thus, the result of a false-negative gives a person the sense
of being disease-free when in fact theyare not. The more sensitive a test, the fewer false-negative
results will be produced.SpecificitySpecificity is the ability of a test to correctly exclude individuals who
do not have a given disease or condition.
F

8. or example, a certain test may have proven to be 90% specific. If 100 healthy individuals are tested with
that method,only 90 of those 100 healthy people (90%) will be found "normal" (disease-free) by the
test. The other 10 people (whodo not have the disease) will appear to be positive for that test.
F
or that 10%, their "abnormal" findings are amisleading false-positive result. When it is necessary to
confirm a diagnosis that requires dangerous therapy, a test'sspecificity is one of the crucial indicators. A
patient who has been told that he is positive for a specific test yet trulydoes not have that disease may
be subjected to potentially painful or dangerous treatment, additional expense, andunwarranted
anxiety. The more specific a test, the fewer false-positive results it produces.The
F
DA requires that developers and manufacturers of a new test provide target values for test results and
provideevidence for the expected ranges as well as information on test limitations and other factors that
could generate falseresults. Thus it is critical for the health care provider to correlate the laboratory
results with an individual's clinicalcondition to determine if repeat testing would be needed.
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