Mayo Registry for Telemetry Efficacy in Arrest Study: An Assessment of the Utility of Telemetry in Predicting Clinical Decompensation.

INTRODUCTION: Our study assesses the utility of telemetry in identifying decompensation in patients with documented cardiopulmonary arrest. METHODS: A retrospective review of inpatients who experienced a cardiopulmonary arrest from May 1, 2008, until June 30, 2014, was performed. Telemetry records 24 hours prior to and immediately preceding cardiopulmonary arrest were reviewed. Patient subanalyses based on clinical demographics were made as well as analyses of survival comparing patients with identifiable rhythm changes in telemetry to those without. RESULTS: Of 242 patients included in the study, 75 (31.0%) and 110 (45.5%) experienced telemetry changes at the 24-hour and immediately preceding time periods, respectively. Of the telemetry changes, the majority were classified as nonmalignant (n = 50, 66.7% and n = 66, 55.5% at 24 hours prior and immediately preceding, respectively). There was no difference in telemetry changes between intensive care unit (ICU) and non-ICU patients and among patients stratified according to the American Heart Association telemetry indications. There was no difference in survival when comparing patients with telemetry changes immediately preceding and at 24 hours prior to an event (n = 30, 27.3% and n = 15, 20.0%) to those without telemetry changes during the same periods (n = 27, 20.5% and n = 42, 25.2%; P = .22 and .39). CONCLUSION: Telemetry has limited utility in predicting clinical decompensation in the inpatient setting.

Cost-Effectiveness of Remote Cardiac Monitoring With the CardioMEMS Heart Failure System.

Heart failure (HF) is a leading cause of cardiovascular mortality in the United States and presents a substantial economic burden. A recently approved implantable wireless pulmonary artery pressure remote monitor, the CardioMEMS HF System, has been shown to be effective in reducing hospitalizations among New York Heart Association (NYHA) class III HF patients. The objective of this study was to estimate the cost-effectiveness of this remote monitoring technology compared to standard of care treatment for HF. A Markov cohort model relying on the CHAMPION (CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III Heart Failure Patients) clinical trial for mortality and hospitalization data, published sources for cost data, and a mix of CHAMPION data and published sources for utility data, was developed. The model compares outcomes over 5 years for implanted vs standard of care patients, allowing patients to accrue costs and utilities while they remain alive. Sensitivity analyses explored uncertainty in input parameters. The CardioMEMS HF System was found to be cost-effective, with an incremental cost-effectiveness ratio of $44,832 per quality-adjusted life year (QALY). Sensitivity analysis found the model was sensitive to the device cost and to whether mortality benefits were sustained, although there were no scenarios in which the cost/QALY exceeded $100,000. Compared with standard of care, the CardioMEMS HF System was cost-effective when leveraging trial data to populate the model.

Performance Analysis of IEEE 802.15.6 CSMA/CA Protocol for WBAN Medical Scenario through DTMC Model.

The newly drafted IEEE 802.15.6 standard for Wireless Body Area Networks (WBAN) has been concentrating on a numerous medical and non-medical applications. Such short range wireless communication standard offers ultra-low power consumption with variable data rates from few Kbps to Mbps in, on or around the proximity of the human body. In this paper, the performance analysis of carrier sense multiple access with collision avoidance (CSMA/CA) scheme based on IEEE 802.15.6 standard in terms of throughput, reliability, clear channel assessment (CCA) failure probability, packet drop probability, and end-to-end delay has been presented. We have developed a discrete-time Markov chain (DTMC) to significantly evaluate the performances of IEEE 802.15.6 CSMA/CA under non-ideal channel condition having saturated traffic condition including node wait time and service time. We also visualize that, as soon as the payload length increases the CCA failure probability increases, which results in lower node's reliability. Also, we have calculated the end-to-end delay in order to prioritize the node wait time cause by backoff and retransmission. The user priority (UP) wise DTMC analysis has been performed to show the importance of the standard especially for medical scenario.

Standardized accuracy assessment of the calypso wireless transponder tracking system.

Electromagnetic (EM) tracking allows localization of small EM sensors in a magnetic field of known geometry without line-of-sight. However, this technique requires a cable connection to the tracked object. A wireless alternative based on magnetic fields, referred to as transponder tracking, has been proposed by several authors. Although most of the transponder tracking systems are still in an early stage of development and not ready for clinical use yet, Varian Medical Systems Inc. (Palo Alto, California, USA) presented the Calypso system for tumor tracking in radiation therapy which includes transponder technology. But it has not been used for computer-assisted interventions (CAI) in general or been assessed for accuracy in a standardized manner, so far. In this study, we apply a standardized assessment protocol presented by Hummel et al (2005 Med. Phys. 32 2371-9) to the Calypso system for the first time. The results show that transponder tracking with the Calypso system provides a precision and accuracy below 1 mm in ideal clinical environments, which is comparable with other EM tracking systems. Similar to other systems the tracking accuracy was affected by metallic distortion, which led to errors of up to 3.2 mm. The potential of the wireless transponder tracking technology for use in many future CAI applications can be regarded as extremely high.

Telemedicine: what framework, what levels of proof, implementation rules.

The concept of telemedicine was formalised in France in the 2009 "Hospital, patients, health territories" (loi hôpital, patients, santé, territoire) law and the 2010 decree through which it was applied. Many experiments have been carried out and the regulatory institutions (Ministry, Regional Health Agency [Agence régionale de santé, ARS], French National Health Authority [Haute autorité de santé, HAS], etc.) have issued various guidance statements and recommendations on its organisation and on the expectations of its evaluation. With this background, the round table wanted to produce recommendations on different areas of medical telemonitoring (the role of telemonitoring, the regulatory system, the principles for assessment, methods of use and conditions for sustained and seamless deployment). Whilst many studies carried out on new medical telemonitoring approaches have led to the postulate that it offers benefit, both clinically and in terms of patient quality of life, more information is needed to demonstrate its impact on the organisation of healthcare and the associated medico-economic benefit (criteria, methods, resources). Similarly, contractual frameworks for deployment of telemonitoring do exist, although they are complicated and involve many different stakeholders (Director General fo the Care Offering [Direction générale de l'offre de soins, DGOS], ARS, HAS, Agency for Shared Health Information Systems [Agence des systèmes d'information partagés de santé, ASIP], French National Data Protection Commission [Commission nationale informatique et libertés, CNIL], French National Medical Council [Conseil national de l'Ordre des médecins, CNOM], etc.) that would benefit from a shared approach and seamless exchange between the partners involved. The current challenge is also to define the conditions required to validate a stable economic model in order to promote organisational change. One topical issue is placing the emphasis on its evaluation and operation. Access to patient data, particularly data from the health insurance funds and the use of these data, may enable the process to be more effective. In addition, the budgetary non-fungibility of the various financial envelopes for the different areas of work, restricts the consolidation of financial impact. Funding methods will need to be adapted to this new distribution of roles, both at the centre of the healthcare system and in the industrial ecosystem. All of these changes will help the leaders of our healthcare system to bring this new ambition closer to all of the people working in the health economy.

Implantable diagnostic monitors in the early assessment of syncope and collapse.

The implantable diagnostic monitor, or loop recorder (ILR) is a subcutaneous monitor capable of continuous ECG monitoring up to 3 years. It is an elegant investigative tool for the assessment of patients with recurrent, unexplained syncope in whom an arrhythmic cause needs to be excluded, and is now increasingly utilised very early in the diagnostic work-up of these patients, in line with current guidelines. This review examines the evidence underpinning these recommendations as well as the relevant clinical trials evaluating the use of the ILR in syncope. Continued research will be needed to validate its role as a first line investigation in a sub-select of syncopal patients, especially with the addition of remote monitoring capabilities.

Wireless physiological monitoring and ocular tracking: 3D calibration in a fully-immersive virtual health care environment.

Wireless physiological/neurological monitoring in virtual reality (VR) offers a unique opportunity for unobtrusively quantifying human responses to precisely controlled and readily modulated VR representations of health care environments. Here we present such a wireless, light-weight head-mounted system for measuring electrooculogram (EOG) and electroencephalogram (EEG) activity in human subjects interacting with and navigating in the Calit2 StarCAVE, a five-sided immersive 3-D visualization VR environment. The system can be easily expanded to include other measurements, such as cardiac activity and galvanic skin responses. We demonstrate the capacity of the system to track focus of gaze in 3-D and report a novel calibration procedure for estimating eye movements from responses to the presentation of a set of dynamic visual cues in the StarCAVE. We discuss cyber and clinical applications that include a 3-D cursor for visual navigation in VR interactive environments, and the monitoring of neurological and ocular dysfunction in vision/attention disorders.

Is telemetry overused? Is it as helpful as thought?

Cardiac telemetry is widely used in hospitals, but it is expensive and labor-intensive. Therefore, it should be used only in those most likely to benefit. The authors review the available evidence and offer their recommendations.

Diagnostic value and safety of long-term video-EEG monitoring.

This paper aimed to assess the usefulness and safety of video-EEG (video-electroencephalography) monitoring in patients with refractory epilepsy. We analysed the video-EEG recordings of consecutive patients over a 3-year period from 2002 to 2005. The pre-admission diagnosis, demographic information, number of ictal episodes, adverse events, and final diagnosis were recorded in all patients. The diagnostic labels before and after monitoring were compared in order to assess whether it had led to a change in diagnosis and management. Of the 100 patients who underwent video-EEG, 227 clinical events were recorded in 62 cases. The most common events were complex partial seizures followed by non-epileptic attacks. Video-EEG allowed a diagnosis to be made in 81 patients and the diagnosis at discharge was altered in 19 cases. Major injuries and status epilepticus did not occur during monitoring. In our experience video-EEG is safe and provides important clinical information in over 80% of patients.

Evaluating telemedicine systems and services.

The evaluation of telemedicine involves attempts to answer a wide range of questions involved in making decisions about safety, about practicality and about utility. Roughly speaking, if we wish to provide a telemedicine service we should first establish that it is safe, next that it is practical and finally that it is worthwhile. In establishing safety, most laboratory studies of telemedicine have a common structure, and consist of the following steps: (1) selection of cases; (2) interpretation; (3) comparison with a gold standard; (4) statistical analyses. Most of the studies to establish the practicality of telemedicine have been carried out as demonstrations, to show that a proposed application can be implemented in a chosen setting. In terms of utility, telemedicine has been used to improve the efficiency of an existing service or to make an existing service available to a new community. One of the difficulties is that the vendors of relatively expensive telemedicine systems and services disseminate much of the information on the topic. We have to focus not on the glamorous technology but on the underlying issue of how the participants in health care (patients, general practitioners, specialists) can communicate more effectively, using the range of technological options open to them. Ensuring that the most appropriate technology is used in the most effective way should be the primary aim of telemedicine research. There is now sufficient evidence for us to be confident that telemedicine is a safe alternative to conventional care in a variety of situations and for a number of clinical conditions. Reliable evidence that it is a practical and cost-effective alternative is, at the time of writing, harder to find.

Home informatics in healthcare: assessment guidelines to keep up quality of care and avoid adverse effects.

Due to an ageing population and improved treatment possibilities, a shortage in hospital beds is a fact in many countries. Home healthcare schemes using information technology (IT) are under development as a response to this and with the intention to produce a more cost-effective care. So far it has been shown that home healthcare is beneficial to certain patient groups. The trend is a widening of the criteria for admission to home healthcare, which means treatment in the home of more severe conditions that otherwise would require in-hospital care. Home informatics has the potential to become a means of providing good care at home. In this process, it is important to consider what new risks will be encountered when placing electronic equipment in the home care environment. Continuous assessment and guidance is important in order to achieve a safe and effective care. Based on a review of current knowledge this paper presents an inventory of risks and adverse events specific to this area. It was found that risks and adverse events could stem from technology in itself, from human-technology interaction conditions or from the environment in which the technology is placed. As a result from the risk inventory, this paper proposes guidelines for the planning and assessment of IT-based hospital-at-home schemes. These assessment guidelines are specifically aimed at performance improvement and thus to be considered a complement to the more general guidelines on telehomecare adopted by the American Telemedicine Association (ATA) in October 2002.

A health monitoring system for elderly people living alone.

We have developed a health monitoring system for elderly people living alone. We monitored the in-house movements of eight subjects (average age 81 years) by placing infrared sensors in each room of their homes. Because their movements were unrestricted, monitoring could last longer than other forms of monitoring. Continuous monitoring was performed for 80 months in total. We found that each subject had a specific pattern of movements. We estimated their health condition by comparing the duration of stays in specific rooms, such as the lavatory, with previously recorded data. If after analysis an unusual state was detected, we informed the family of the incident. Final decisions should be made by the family members, not automatically by computer software. For example, after contacting the subject or a neighbour by telephone, family members could call for an ambulance or arrange a visit by a doctor or home help. Thus, this system reduced anxiety for both the elderly subjects living alone and their family members.

The role of telemedicine in the assessment of strabismus.

Thirty patients with strabismus were seen face to face by an ophthalmologist and an orthoptist. The patients were then presented by the same orthoptist to a second ophthalmologist via a telemedicine link. Twenty-six patients were seen using a bandwidth of 384 kbit/s and four using 128 kbit/s. There was agreement between the two ophthalmologists about diagnosis and management in 24 cases, partial agreement in one and no agreement in five (17%). Manifest strabismus was safely diagnosed and managed using telemedicine at 128 kbit/s, although 384 kbit/s was preferred because it obviated the need for repeated examination. Latent strabismus and micro-movements were difficult to diagnose using telemedicine even at 384 kbit/s. Young patients who are unable to sit still would not be suitable for strabismus assessment via telemedicine.

Are auditory warnings in the intensive care unit properly adjusted?

The purpose of this study was to determine whether auditory warnings in the intensive care unit (ICU) were properly adjusted. An intervention study (before- and-after assessment) was conducted in a 12-bed medical-surgical ICU of an acute-care teaching hospital in Barcelona, Spain. A total of 100 patients with stable haemodynamic and respiratory parameters were included. In the first 3-month phase of the study, minimum and maximum alarm parameters of breathing rate, expired volume/min, airway pressure, SaO(2), arterial blood pressure and heart rate were recorded. In the second 12-month phase of the study, the same alarm parameters were recorded every 4 hours in the patient's medical record. In the third 3-month phase of the study, alarm readings were recorded again as in the first phase. The change throughout coefficient of variation (CV) and the 95% confidence interval (CI) for each alarm were calculated. Following the intervention, there was a statistically significant improvement in alarm readings for expired volume, heart rate and systolic blood pressure, so that alarms had been more properly adjusted to the patient's real value. Nursing staff should be aware that auditory warnings in ICU stable patients are frequently set very far from suitable values. Recording of alarm parameters in the patient's medical record as a routine daily activity was an effective intervention for improving adjustment of auditory warnings.