A transition is underway from technology that passively monitors patients to those that actively trigger interventions and even follow patients after discharge.
According to Maxime Cannesson, MD, PhD, professor of anesthesiology at the University of California, Los Angeles (UCLA), the days when medical devices simply provided measurements for clinicians are over as physicians collaborate with departments, institutions and industry partners to harness technology to drive improvements in care quality and patient outcomes.
As Dr. Cannesson reported at the American Society of Anesthesiologists’ INSIGHTS + INNOVATIONS 2017 Conference, the combination of physiologic observation and technology to redesign care processes is exemplified by Prof. William Shoemaker’s work with trauma patients at the University of Southern California in the 1980s. Despite normalizing mean arterial pressure, heart rate and systemic resistance in several thousand critically ill patients, 76% of them died. Separating survivors from nonsurvivors required the incorporation and optimization of specific flow-directed cardiopulmonary parameters: cardiac index, oxygen delivery and oxygen consumption. Although ultimately unsuccessful in trauma patients, Dr. Cannesson noted that the concept of goal-directed therapy was born.
Building on this research, Emanuel Rivers, MD, introduced the concept of early goal-directed therapy in the management of severe sepsis and septic shock, and between 2000 and 2015, sepsis-related mortality decreased from approximately 35% to 20%. Furthermore, Dr. Cannesson said this improvement came about without major advancements in drugs or medical devices; instead, it is the redesigned process of care that is responsible for the progressive increase in survival.
“Today with sepsis, we know that what improves outcome is not the drugs or the devices that we use but a multidisciplinary approach—cooperation between the emergency department, intensive care unit and surgeons,” Dr. Cannesson pointed out. “We are trying to achieve similar results with anesthesia and surgery: the whole team working together, quickly and efficiently, to improve patient outcomes.”
As Dr. Cannesson noted, this concerted effort in monitoring, process of care and outcome also exists for pulse oximetry and anesthesia; brain oxygenation and multidisciplinary work in cardiac surgery; depth of anesthesia monitoring and postoperative delirium awareness; glucose monitoring and diabetes; and use of electronic health records (EHRs) and clinical decision support (CDS) tools.
EHR as Technological Hub
Despite these improvements, Dr. Cannesson said, the operating room (OR) still consists largely of devices that do not communicate with one another. In the future, providers must work to consolidate this environment, he observed, but in the meantime, the EHR has replaced the monitor as the technological hub. “That’s where all the data are. The EHR is becoming increasingly important for quality improvement initiatives because we can only change things if we measure them.”
According to Dr. Cannesson, a high-functioning EHR requires substantial investment of people and resources to develop the metrics and skills necessary to modify these data within it, but once these data are available, the effects on outcome can be compelling. He mentioned a few examples:
- At Vanderbilt University Medical Center, clinicians used a mobile phone application to apply cardiovascular guidelines and dramatically improved compliance with protocol.
- A study from the University of Washington highlighted the use of a near real-time decision support module to manage intraoperative hypotension and hypertension. Patients who fall below or rise above a specific blood pressure will trigger a pop-up notification on their anesthesia provider’s computer screen. When the system was applied, durations of both hypotension and hypertension decreased because of changes in physician behavior.
- A perioperative data warehouse developed at the anesthesia department at UCLA was applied to reduce postoperative nausea and vomiting (PONV). When a patient presents with two or more risk factors for PONV, their physician receives an on-screen alert. The physician will then have access to a protocol for care developed by the department. After implementing the system, the incidence of PONV fell from 30% to 15%.
In addition, once the EHR is working properly, providers can move from decision support to closed-loop systems. While the latter might sound like high-level science, Dr. Cannesson said, a closed-loop system is no longer a novel concept, with variations having existed since the 1950s. Recently, the combination of multiple independent physiologic closed-loop systems was tested to evaluate the feasibility of automated anesthesia and fluid management in a patient undergoing high-risk surgery (A A Case Rep 2016;7:260-265).
“Systems like this place physicians in a position where we can orchestrate care and supervise the machine delivering care,” Dr. Cannesson said. “Everything is working independently, with the physician setting the target and checking protocol.”
When Technology Fails
Peggy Naas, MD, MBA, a physician volunteer in Minneapolis and former chief medical officer of health care performance improvement at Vizient, raised the issue of alarm fatigue. “How do providers stay awake and alert to failures when working with systems that are fully automated?”
“Complacency is definitely a concern when dealing with automated and closed-loop systems, as it’s been shown that skills tend to erode when using automated technology,” Dr. Cannesson acknowledged. “One way to compensate for the tendency to be complacent is through false alarms. False positives can help maintain vigilance of people, but avoiding complacency should be the highest priority for developers of automated systems. In medicine, people are trying to automate skills that can be easily reproduced.”
“The issue of whether [providers] can take over in the event of system failure is vitally important and very complicated,” added Julian Goldman, MD, medical director of Partners HealthCare Systems Biomedical Engineering (part of Massachusetts General Hospital), in Boston, and a member of the Anesthesiology News advisory board. “Even in a simple closed-loop control for blood pressure, if the pump or algorithm fails, it’s very difficult for us to take over the device if we don’t know what it was doing. In the international standard for closed-loop control systems, it’s written that the operator must be provided enough information to take over safely if the system fails.”