US20120284053A1 - Remote command center for patient monitoring - Google Patents

Abstract

A remote command center for providing services to geographically dispersed hospitalized patients. A datastore accessible to the remote command center receives patient data from geographically dispersed hospitalized patients. Monitored data elements of geographically dispersed hospitalized patients are also received at the remote command center and stored in the datastore. A smart alert module generates and applies patient specific rules to data elements. If a patient-specific rule for a hospitalized patient has been contravened, an alert is issued from the remote command center. A patient care module displays selected data elements of the hospitalized patients. A decision support module applies decision support algorithms to selected data elements of a hospitalized patient and to user input to provide patient care advice. Patient care advice comprises a diagnosis, a method of treatment, and a laboratory protocol. The decision support module also writes orders for medication, laboratory protocols and surgical procedures.

Description

• This application is a continuation of application Ser. No. 11/072,359 filed Mar. 4, 2005, which is a continuation of application Ser. No. 09/443,072, now U.S. Pat. No. 6,804,656, filed Nov. 18, 1999. The 09/443,072 and 11/072,359 applications are hereby incorporated by reference in its entirety for all purposes and from which priority is claimed.
FIELD OF THE INVENTION
• This invention relates generally to the care of patients in Intensive Care Units (ICUs). More particularly this invention is a system and method for care of the critically ill that combines a real-time, multi-node telemedicine network and an integrated, patient care management system to enable specially-trained Intensivists to provide 24-hour/7-day-per-week patient monitoring and management to multiple, geographically dispersed ICUs from both on-site and remote locations.
BACKGROUND OF THE INVENTION
• While the severity of illness of ICU patients over the past 15 years has increased dramatically, the level of and type of physician coverage in most ICUs has remained constant. Most ICU patients receive brief minutes of attention during morning rounds from physicians with limited critical care experience. During the remainder of the day and night, nurses are the primary caregivers, with specialists called only after patient conditions have started to deteriorate. The result of this mismatch between severity of illness and physician coverage is an unacceptably high ICU mortality rate (10% nationwide), and a high prevalence of avoidable errors that result in clinical complications. In 1998, an Institute of Medicine Roundtable determined that avoidable patient complications were the single largest problem in medical care delivery. In another prominent 1998 study of 1000 patients, 46% experienced an avoidable adverse event in care, with 40% of these errors resulting in serious disability or death.
• The physicians who can remedy this situation are in critically short supply. Numerous studies have shown that Intensivists (physicians who have trained and board certified in Critical Care Medicine) can markedly improve patient outcomes. However, only one-third of all ICU patients ever has an Intensivist involved in their care, and the number of Intensivists would need to increase tenfold (nationally) to provide 24-hour coverage to all ICU patients. With the rapid aging of the population, this shortfall of expertise is going to increase dramatically.
• Even where Intensivists are present (and especially where they are not), patients suffer from unnecessary variation in practice. There is little incentive for physicians to develop and conform to evidence-based best practices (it takes significant work and a change in behavior to develop and implement them). This variation contributes to sub-optimal outcomes, in both the quality and cost of care delivered to ICU patients.
• What is needed is a redesigning of the critical care regimen offered to patients in an ICU. Rather than the consultative model where a periodic visit takes place and the doctor then goes away, a more active 24-hour intensivist managed care is required. Further, technology that leverages the intensivists' expertise and standardizes the care afforded to patients in an ICU is required. Further, continuous feedback to improve the practice of intensivists in an ICU is necessary to provide the intervention required to minimize adverse events. This invention seeks to provide new methods for managing and delivering care to the critically ill.
• Attempts to automate various aspects of patient care have been the subject of various inventions. For example, U.S. Pat. No. 5,868,669 to Iliff was issued for “Medical Diagnostic and Treatment Advice System.” The disclosed invention is for a system and method for providing knowledge based medical diagnostic and treatment advice to the general public over a telephone network.
• U.S. Pat. No. 5,823,948 to Ross, Jr. et al was issued for “Medical Records Documentation, Tracking and Order Entry System”. The disclosed invention is for a system and method that computerizes medical records, documentation, tracking and order entries. A teleconferencing system is employed to allow patient and medical personnel to communicate with each other. A video system can be employed to videotape a patient's consent.
• U.S. Pat. No. 4,878,175 to Norden-Paul et al. was issued for “Method for Generating Patient-Specific Flowsheets By Adding/Deleting Parameters.” The disclosed invention is for an automated clinical records system for automated entry of bedside equipment results, such as an EKG monitor, respirator, etc. The system allows for information to be entered at the bedside using a terminal having input means and a video display.
• U.S. Pat. No. 5,544,649 to David et al. was issued for “Ambulatory Patient Health Monitoring Techniques Utilizing Interactive Visual Communications.” The disclosed invention is for an interactive visual system, which allows monitoring of patients at remote sites, such as the patient's home. Electronic equipment and sensors are used at the remote site to obtain data from the patient, which is sent to the monitoring site. The monitoring site can display and save the video, audio and patient's data.
• U.S. Pat. No. 5,867,821 to Ballantyne et al. was issued for “Method and Apparatus for Electronically Accessing and Distributing Personal Health Care Information and Services in Hospitals and Homes.” The disclosed invention is for an automated system and method for distribution and administration of medical services, entertainment services, and electronic health records for health care facilities.
• U.S. Pat. No. 5,832,450 to Myers et al. issued for “Electronic Medical Record Using Text Database.” The disclosed invention is for an electronic medical record system, which stores data about patient encounters arising from a content generator in freeform text.
• U.S. Pat. No. 5,812,983 to Kumagai was issued for “Computer Medical File and Chart System.” The disclosed invention is for a system and method which integrates and displays medical data in which a computer program links a flow sheet of a medical record to medical charts.
• U.S. Pat. No. 4,489,387 to Lamb et al. was issued for “Method and Apparatus for Coordinating Medical Procedures.” The disclosed invention is for a method and apparatus that coordinates two or more medical teams to evaluate and treat a patient at the same time without repeating the same steps.
• U.S. Pat. No. 4,731,725 to Suto et al. issued for “Data Processing System which Suggests a Pattern of Medical Tests to Reduce the Number of Tests Necessary to Confirm or Deny a Diagnosis.” The disclosed invention is for a data processing system that uses decision trees for diagnosing a patient's symptoms to confirm or deny the patient's ailment.
• U.S. Pat. No. 5,255,187 to Sørensen issued for “Computer Aided Medical Diagnostic Method and Apparatus.” The disclosed invention is for an interactive diagnostic system which relies on color codes which signify the presence or absence of the possibility of a disease based on the symptoms a physician provides the system.
• U.S. Pat. No. 5,553,609 to Chen et al. issued for “Intelligent Remote Visual Monitoring System for Home Health Care Service.” The disclosed invention is for a computer-based remote visual monitoring system, which provides in-home patient health care from a remote location via ordinary telephone lines.
• U.S. Pat. No. 5,842,978 to Levy was issued for “Supplemental Audio Visual Emergency Reviewing Apparatus and Method.” The disclosed invention is for a system which videotapes a patient and superimposes the patient's vital statistics onto the videotape.
• While these inventions provide useful records management and diagnostic tools, none of them provides a comprehensive method for monitoring and providing real time critical care at disparate ICUs. In short, they are NOT designed for critical care. Further, none of these inventions provide for the care of a full time intensivist backed by appropriate database and decision support assistance in the intensive care environment. What would be useful is a system and method for providing care for the critically ill that maximizes the presence of an intensivist trained in the care of the critically ill. Further such a system would standardize the care in ICUs at a high level and reduce the mortality rate of patients being cared for in ICUs.
SUMMARY OF THE INVENTION
• The present invention provides a core business of Continuous Expert Care Network (CXCN) solution for hospital intensive care units (ICUs). This e-solution uses network, database, and decision support technologies to provide 24-hour connectivity between Intensivists and ICUs. The improved access to clinical information and continuous expert oversight leads to reduced clinical complications, fewer medical errors, reduced mortality, reduced length of stay, and reduced overall cost per case.
• The technology of the present invention as explained below can be implemented all at once or in stages. Thus the technology, as more fully explained below is available in separate components to allow for the fact that hospitals may not be able to implement all of the technology at once. Thus modular pieces (e.g. videoconferencing, vital sign monitoring with smart alarms, hand-held physician productivity tools, etc.) can be implemented, all of which can add value in a stand-alone capacity. First amongst these offerings will be an Intensivist Decision Support System, a stand-alone software application that codifies evidence-based, best practice medicine for 150 common ICU clinical scenarios. These support algorithms are explained more fully below.
• The “Command Center” model, again as more fully set forth below, will ultimately give way to a more distributed remote management model where Intensivists and other physicians can access ICU patients and clinicians (voice, video, data) from their office or home. In this scenario, the present invention will be available in hospital applications that centralize ICU information, and offer physicians web-based applications that provide them with real-time connectivity to this information and to the ICUs. This access and connectivity will enable physicians to monitor and care for their patients remotely. These products will be natural extensions and adaptations of the present invention and the existing applications disclosed herein that those skilled in the art will appreciate and which do not depart from the scope of the invention as disclosed herein.
• The present invention addresses these issues and shortcomings of the existing situation in intensive care, and its shortfalls via two major thrusts. First, an integrated video/voice/data network application enables continuous real-time management of ICU patients from a remote setting. Second, a client-server database application—integrated to the remote care network—provides the data analysis, data presentation, productivity tools and expert knowledge base that enables a single Intensivist to manage the care of up to 40 patients simultaneously. The combination of these two thrusts—care management from a remote location and new, technology-enhanced efficiency of Intensivist efforts—allows health care systems to economically raise the standard of care in their ICUs to one of 24.times.7 continuous Intensivist oversight.
• It is therefore an object of the present invention to reduce avoidable complications in an ICU.
• It is a further object of the present invention to reduce unexplained variations in resource utilization in an ICU.
• It is a further objective of the present invention to mitigate the serious shortage of intensivists.
• It is yet another objective of the present invention to reduce the occurrence of adverse events in an ICU.
• It is a further objective of the present invention to standardize the care at a high level among ICUs.
• It is yet another objective of the present invention to reduce the cost of ICU care.
• It is yet another objective of the present invention to dramatically decrease the mortality in an ICU.
• It is yet another objective of the present invention to bring information from the ICU to the intensivist, rather than bring the intensivist to the ICU.
• It is a further objective of the present invention to combine tele-medical systems comprising two-way audio/video communication with a continuous real time feed of clinical information to enable the intensivist to oversee care within the ICU.
• It is a further objective of the present invention to allow intensivists to monitor ICUs from a site remote from each individual ICU.
• It is a further objective of the present invention to bring organized detailed clinical information to the intensivist, thereby providing standardized care in the ICU.
• It is yet another objective of the present invention to utilize knowledge-based software to use rules, logic, and expertise to provide preliminary analysis and warnings for the intensivists.
• The present invention comprises a command center/remote location, which is electronically linked to ICUs remote from the command center/remote location. The command center/remote location is manned byintensivists 24 hours a day, seven days per week. Each ICU comprises a nurse's station, to which data flows from individual beds in the ICU. Each patient in the ICU is monitored by a video camera, as well as by clinical monitors typical for the intensive care unit. These monitors provide constant real time patient information to the nurse's station, which in turn provides that information over a dedicated T-1 (high bandwidth) line to the ICU command center/remote location. As noted earlier, the command center/remote location is remote from the ICU, thereby allowing the command center/remote location to simultaneously monitor a number of patients in different ICUs remote from the command center/remote location.
• At each command center/remote location, video monitors exist so that the intensivist can visually monitor patients within the ICU. Further, the intensivist can steer and zoom the video camera near each patient so that specific views of the patient may be obtained, both up close and generally. Audio links allow intensivists to talk to patients and staff at an ICU bed location and allow those individuals to converse with the intensivist.
• Clinical data is constantly monitored and presented to the command center/remote location in real time so that the intensivist can not only monitor the video of the patient but also see the vital signs as transmitted from the bedside. The signals from the clinical data and video data are submitted to a relational database, which comprises 1) standardized guidelines for the care of the critically ill, 2) various algorithms to support the intensive care regimen, 3) order writing software so that knowledge-based recommendations and prescriptions for medication can be made based upon the clinical data, and 4) knowledge-based vital-sign/hemodynamic algorithms that key the intensivist to engage in early intervention to minimize adverse events.
• The advantage of the present invention is that intensivists see all patients at a plurality of ICU's at all times. Further, there is a continuous proactive intensivist care of all patients within the ICU, thereby minimizing adverse events. Intervention is triggered by evidence-based data-driven feedback to the intensivist so that standardized care can be provided across a plurality of ICUs.
• The economic benefits of the present invention are manifold. For the first time, 24-hour a day, seven day a week intensivist care for patients in an ICU can be obtained. Further, more timely interventions in the care of the patients can be created by the knowledge-based guidelines of the present invention, thereby minimizing complications and adverse events. This in turn will lead to a reduced mortality within the ICU, and hence, a reduced liability cost due to the dramatic reduction in avoidable errors in health care.
• By providing timely interventions, the length of stay within the ICU can be greatly reduced, thereby allowing more critically ill patients to be cared for in the ICU.
• In addition, by reviewing and standardizing the care afforded to patients in an ICU, a more standardized practice across a variety of ICUs can be achieved. This will lead to more cost-effective care within the ICU, and reduced ancillary cost for the care of the critically ill.
• The overall architecture of the present invention comprises a “pod.” The pod comprises a tele-medicine command center/remote location connected to a plurality multiple ICUs at various locations. The connection between the command center/remote location and the ICUs is via a dedicated wide-area network linking the ICUs to the command center/remote location and a team of intensivists who integrate their services to provide 24-hour, seven day a week care to all of the pod ICUs.
• The pod is connected via a wide-area network using dedicated T-1 lines, for example, with redundant backup. This network provides reliable, high speed secure transmission of clinical data and video/audio signals between each patient room and the command center/remote location. The use of a T-1 line is not meant as a limitation. It is expected that more and higher bandwidth networks will become available. Such high bandwidth networks would come within the scope of the invention as well.
• Each patient room is equipped with a pan/tilt/zoom video camera with audio and speaker to enable full videoconferencing capability. In addition, computer workstations are dedicated for exclusive physician use in each ICU, preferably at the nurse's station. Intensivists use the workstations to view patient information, consult decision support information, record their notes, and generate patient orders.
• The patient management software used by intensivists is provided across the pod. Updates and changes made to the record are available at both the ICU and the command center/remote location for any given patient.
• Each command center/remote location contains at least three workstations: one for the intensivist, one for the critical care registered nurse, and one for a clerk/administrative person.
• The intensivist workstation comprises separate monitors for displaying ICU video images of patients and/or ICU personnel, output from bedside monitoring equipment, patient clinical data comprising history, notes, lab reports, etc., and decision support information. The staff at the command center/remote location are able to activate and control the cameras in each patient's room so that appropriate visual views of the patient can be generated.
• Intensivists are able to switch between rooms and patients and can monitor at least two rooms simultaneously via the video screens. Patient data such as X-ray and ECG images are scanned and transmitted to the command center/remote location upon request of the intensivist.
• Remote patient management is utilized in the present invention's critical care program to supplement traditional onsite care. The rationale underlying the remote patient management of the present invention is that critically ill patients are inherently unstable and require continuous expert care that is not now offered in existing ICU monitoring regimens. Further, remote monitoring allows a single intensivist to care for patients in multiple ICU locations, thereby creating an efficiency that makes continuous care feasible.
• Remote intensivist care of the present invention is proactive. Intensivists will order needed therapies and check results of tests and monitor modalities in a more timely fashion than is currently offered. Patients can be observed visually when needed using the ceiling-mounted cameras in each room.
• Command center/remote location personnel communicate with ICU staff through videoconferencing and through “hot phones,” which are dedicated telephones directly linked between the command center/remote location and the ICU. These communications links are used to discuss patient care issues and to communicate when a new order has been generated.
• Intensivists document important events occurring during their shift in progress notes generated on the command center/remote location computer terminal.
• Intensivists detect impending problems by intermittently screening patient data, including both real time and continuously stored vital sign data. Patient severity of illness determines the frequency with which each patient's data is reviewed by the intensivists.
• Embodiments of the present invention provide a system for providing continuous, expert network health care services from a remote location. The system comprises a plurality of health care locations, at least one remote command center for managing healthcare at said plurality of health care locations, and at least one network. The plurality of health care locations are electronically connected to said at least one remote command center by the network. The at least one remote command center provides intensivist monitoring of the plurality ofhealth care locations 24 hours per days seven days per week.
• The remote command center further comprises a patient care management system for monitoring and treating individual patients at any of said plurality of healthcare locations. The patient care management system further comprises a data server/data warehouse for storing and analyzing data from the at least one remote command center.
• Each of the plurality of health care locations further comprises patient monitoring equipment electronically connected to the at least one remote command center over the network. In another embodiment of the present invention each health care location further comprises a nurses' station electronically connected to said monitoring equipment and to the at least one remote command center over the network. In still another embodiment of the present invention, the healthcare locations comprise intensive care units (ICU's).
• Optionally, the patient care management system further comprises a relational database for storing a plurality of decision support algorithms and for prompting intensivists to provide care to patients based upon any of the decision support algorithms. The algorithms are selected from the group consisting of algorithms for treating Acalculous Cholecystitis, Acute Pancreatitis Algorithms, Acute Renal Failure-Diagnosis, Acute Renal Failure-Management & Treatment, Adrenal Insufficiency. Agitation and Anxiety, Depression & Withdrawal, Aminoglycoside Dosing and Therapeutic Monitoring, an Amphotericin-B Treatment Guidelines, Analgesia, Antibiotic Classification & Costs, Antibiograms Algorithm, Antibiotic associated Colitis Algorithm, ARDS: Hemodynamic Management, ARDS: Steroid Use, ARDS: Ventilator Strategies, Asthma, Bleeding Patient, Bloodstream Infections, Blunt Cardiac Injury, Bradyarrhythmias, Brain Death, Bronchodilator Use in Ventilator Patients, Bronchoscopy & Thoracentesis Guidelines, Candiduria, Cardiogenic Shock, CardioPulmonary Resuscitation Guideline, Catheter Related Septicemia, a Catheter Replacement Strategies, Cervical Cord Injury, Congestive Heart Failure, COPD Exacerbation & Treatment, CXR (Indications), Dealing with Difficult patients and families, Diabetic Ketoacidosis, Dialysis, Diuretic Use, Drug Changes with Renal Dysfunction, Emergency Cardiac Pacing, Endocarditis Diagnosis and Treatment, Endocarditis Prophylaxis, End of Life Decisions, Endotracheal Tubes & Tracheotomy, Ethical Guidelines, Febrile Neutropenia, FUO, Fluid Resuscitation, Guillain-Barre Syndrome, Heparin, Heparin-Induced Thrombocytopenia, Hepatic Encephalopathy, Hepatic Failure, HIV+Patient Infections, Hypercalcemia Diagnosis and Treatment, Hyperglycemia Insulin Treatment, Hyperkalemia: Etiology & Treatment, Hypernatremia: Etiology & Treatment, Hypertensive Crisis, Hypokalemia: Etiology & Treatment, Hyponatremia: Etiology & Treatment, Hypothermia, Identification of Cervical Cord Injury, Implantable Cardio-defibrillator, Intra-Aortic Balloon Device, Intracerebral Hemorrhage, Latex Allergy, Magnesium Administration, Management of Hypotension, Inotropes, Management of Patients with Ascites, Empiric Meningitis, Meningitis, a Myasthenia Gravis, Myocardial Infarction, Myocardial Infarction with left bundle branch block, Necrotizing Soft Tissue Infections, Neuromuscular Blockers, Neuromuscular Complications of Critical Illness, Non-Infectious Causes of Fever, Non-Traumatic Coma, Noninvasive Modes of Ventilation, Nutritional Management, Obstetrical Complication, Oliguria, Open Fractures, Ophthalmic Infections, Organ Procurement Guidelines, PA Catheter Guideline and Troubleshooting, Pancreatitis, Penetrating Abdominal Injury, Penetrating Chest Injury, Penicillin Allergy, Permanent Pacemaker and Indications, Pneumonia Community Acquired, Pneumonia Hospital Acquired, Post-Op Bleeding, Post-Op Hypertension, Post-Op Management of Abdominal Post-Op Management of Carotid, Post-Op Management of Open Heart, Post-Op Management of Thoracotomy, Post-Op Myocardial Ischemia (Non-Cardiac Arrhythmias after Cardiac Surgery), Post-Op Power Weaning, Pressure Ulcers, Pulmonary Embolism Diagnosis, Pulmonary Embolism Treatment, Respiratory Isolation, Sedation, Seizure, Status Epilepticus, Stroke, Sub-Arachnoid Hemorrhage, Supra-Ventricular Tachyarrhythmia, Supra-Ventricular Tachycardia, Wide Complex QRS Tachycardia, Therapeutic Drug Monitoring, Thrombocytopenia, Thrombolytic Therapy, Transfusion Guidelines, Traumatic Brain Injury, Assessment of Sedation, Sedation, Septic Shock, Bolus Sliding, Scale Midazolam, Short Term Sedation Process, Sinusitis, SIRS, Spinal Cord Injury, Steroid Replacement Strategy, Thyroid Disease, Transplant Infection Prophylaxis, Transplant Related Infections, Treatment of Airway Obstruction, Unknown Poisoning, Unstable Angina, Upper GI Bleeding Stress Prophylaxis, Vancomycin, Upper GI Bleeding Non-Variceal, Upper GI Bleeding Variceal, Use of Hematopoietic Growth Factors, Ventilator Weaning, Ventilator Weaning Protocol, Venous Thrombosis Diagnosis and Treatment, Venous Thromboembolism Prophylaxis, Ventricular Arrhythmia, Warfarin, Warfarin Dosing, and Wound Healing Strategies.
• In yet another embodiment of the present invention, the patient care management system further comprises order writing software for providing knowledge-based recommendations and prescriptions for medication based upon the clinical data. In another embodiment of the present invention, the patient care management system further comprises knowledge-based vital sign/hemodynamic algorithms that prompt said intensivist to engage in early intervention.
• Embodiments of the present invention provide methods for continuous expert critical care. Patients are monitored in a plurality of ICU's. Information from the patient monitoring is communicated to at least one command center over a first network. The information from the patient monitoring is received and analyzed at the command center over the first network; and guidance is provided from the command center to the plurality of ICU's to take actions regarding patient care. In another embodiment of the present invention, providing guidance from the command center further comprises an intensivist reviewing decision support algorithms that provide guidance for treating a plurality of critical care conditions. The algorithms are taken from the group consisting of algorithms for treating Acalculous Cholecystitis, Acute Pancreatitis Algorithm, Acute Renal Failure-Diagnosis, Acute Renal Failure-Management & Treatment, Adrenal Insufficiency, Agitation and Anxiety, Depression & Withdrawal, Aminoglycoside Dosing and Therapeutic Monitoring, an Amphotericin-B Treatment Guidelines, Analgesia, Antibiotic Classification & Costs, Antibiograms Algorithm, Antibiotic associated Colitis Algorithm, ARDS: Hemodynamic Management, ARDS: Steroid Use, ARDS: Ventilator Strategies, Asthma, Bleeding Patient, Bloodstream Infections, Blunt Cardiac Injury, Bradyarrhythmias, Brain Death, Bronchodilator Use in Ventilator Patients, Bronchoscopy & Thoracentesis Guidelines, Candiduria, Cardiogenic Shock, CardioPulmonary Resuscitation Guideline, Catheter Related Septicemia, a Catheter Replacement Strategies, Cervical Cord Injury, Congestive Heart Failure, COPD Exacerbation & Treatment, CXR (Indications), Dealing with Difficult patients and families, Diabetic Ketoacidosis, Dialysis, Diuretic Use, Drug Changes with Renal Dysfunction, Emergency Cardiac Pacing, Endocarditis Diagnosis and Treatment, Endocarditis Prophylaxis, End of Life Decisions, Endotracheal Tubes & Tracheotomy, Ethical Guidelines, Febrile Neutropenia, FUO, Fluid Resuscitation, Guillain-Barre Syndrome, Heparin, Heparin-Induced Thrombocytopenia, Hepatic Encephalopathy, Hepatic Failure, HIV+Patient Infections, Hypercalcemia Diagnosis and Treatment, Hyperglycemia Insulin Treatment, Hyperkalemia: Etiology & Treatment, Hypernatremia: Etiology & Treatment, Hypertensive Crisis, Hypokalemia: Etiology & Treatment, Hyponatremia: Etiology & Treatment, Hypothermia, Identification of Cervical Cord Injury, Implantable Cardio-defibrillator, Intra-Aortic Balloon Device, Intracerebral Hemorrhage, Latex Allergy, Magnesium Administration, Management of Hypotension, Inotropes, Management of Patients with Ascites, Empiric Meningitis, Meningitis, a Myasthenia Gravis, Myocardial Infarction, Myocardial Infarction with left bundle branch block, Necrotizing Soft Tissue Infections, Neuromuscular Blockers, Neuromuscular Complications of Critical Illness, Non-Infectious Causes of Fever, Non-Traumatic Coma, Noninvasive Modes of Ventilation, Nutritional Management, Obstetrical Complications, Oliguria, Open Fractures, Ophthalmic Infections, Organ Procurement Guidelines, PA Catheter Guideline and Troubleshooting, Pancreatitis, Penetrating Abdominal Injury, Penetrating Chest Injury, Penicillin Allergy, Permanent Pacemaker and Indications, Pneumonia Community Acquired, Pneumonia Hospital Acquired, Post-Op Bleeding, Post-Op Hypertension, Post-Op Management of Abdominal, Post-Op Management of Carotid, Post-Op Management of Open Heart, Post-Op Management of Thoracotomy, Post-Op Myocardial Ischemia, (Non-Cardiac Arrhythmias after Cardiac Surgery), Post-Op Power Weaning, Pressure Ulcers, Pulmonary Embolism Diagnosis, Pulmonary Embolism Treatment, Respiratory Isolation, Sedation, Seizure, Status Epilepticus, Stroke, Sub-Arachnoid Hemorrhage, Supra-Ventricular Tachyarrhythmia, Supra-Ventricular Tachycardia, Wide Complex QRS Tachycardia, Therapeutic Drug Monitoring, Thrombocytopenia, Thrombolytic Therapy, Transfusion Guidelines, Traumatic Brain Injury, Assessment of Sedation, Sedation, Septic Shock, Bolus Sliding Scale Midazolam, Short Term Sedation Process, Sinusitis, SIRS, Spinal Cord Injury, Steroid Replacement Strategy, Thyroid Disease, Transplant Infection Prophylaxis, Transplant Related Infections, Treatment of Airway Obstruction, Unknown Poisoning, Unstable Angina, Upper GI Bleeding Stress Prophylaxis, Vancomycin, Upper GI Bleeding Non-Variceal, Upper GI Bleeding Variceal, Use of Hematopoietic Growth Factors, Ventilator Weaning, Ventilator Weaning Protocol, Venous Thrombosis Diagnosis and Treatment, Venous Thromboembolism Prophylaxis, Ventricular Arrhythmia, Warfarin, Warfarin Dosing, and Wound Healing Strategies.
• In another embodiment, a method further comprises a data server/data warehouse storing and analyzing patient data from the at least one command center and providing analysis in results over a second network to the at least one command center.
BRIEF DESCRIPTION OF THE FIGURES
• FIG. 1A illustrates the logical data structure for billing, insurance and demographic information.
• FIG. 1B illustrates the logical data structure for billing, insurance and demographic information (cont).
• FIG. 2A illustrates the command center logical data structure.
• FIG. 2B illustrates the command center logical data structure (cont).
• FIG. 3 illustrates the logical data structure for creating a medical history.
• FIG. 4A illustrates the logical data structure for creating notes relating to patient treatment and diagnosis.
• FIG. 4B illustrates the logical data structure for creating notes relating to patient treatment and diagnosis (cont).
• FIG. 4C illustrates the logical data structure for creating notes relating to patient treatment and diagnosis (cont).
• FIG. 5 illustrates the logical data structure for entry of medical orders.
• FIG. 6A illustrates the logical data structure for patient care, laboratory testing and diagnostic imaging.
• FIG. 6B illustrates the logical data structure for patient care, laboratory testing and diagnostic imaging (cont).
• FIG. 7A illustrates the logical data structure for categories of information that are permitted to be presented to intensivists and other care givers by the system.
• FIG. 8A illustrates the logical data structure for documenting patient vital signs.
• FIG. 8B illustrates the logical data structure for documenting patient vital signs (cont).
• FIG. 9 illustrates the distributed architecture of the present invention.
• FIG. 10 illustrates the system architecture of the present invention.
• FIG. 11 illustrates the decision support algorithm for diagnosis and treatment of pancreatitis.
• FIG. 12 illustrates the vital signs data flow.
• FIG. 13A illustrates capture and display of diagnostic imaging.
• FIG. 13B illustrates establishing videoconferencing in the present invention.
• FIG. 14 illustrates the physician resources order writing data interface of the present invention.
• FIG. 15 illustrates the physician resources database data interface of the present invention.
• FIG. 16 illustrates the automated coding and billing system integrated with the workflow and dataflow of the present invention.
• FIG. 17 illustrates the order writing data flow of the present invention.
• FIG. 18 illustrates the event log flow of the present invention.
• FIG. 19 illustrates the smart alarms implementation of the present invention.
• FIG. 20 illustrates the procedure note creation and line log for the present invention.
• FIGS. 21A-B illustrate the acalculous cholecystitis decision support algorithm.
• FIG. 22 illustrates the adrenal insufficiency decision support algorithm.
• FIG. 23 illustrates the blunt cardiac injury decision support algorithm.
• FIGS. 24A-B illustrate the candiduria decision support algorithm.
• FIGS. 25A-B illustrate the cervical spine injury decision support algorithm.
• FIGS. 26A-B illustrate the oliguria decision support algorithm.
• FIGS. 26C-D illustrate the oliguria decision support algorithm (cont).
• FIG. 26E illustrates the oliguria decision support algorithm (cont).
• FIGS. 27A-B illustrate the open fractures decision support algorithm.
• FIGS. 28A-B illustrate the pancreatitis decision support algorithm.
• FIGS. 29A-B illustrate the penicillin allergy decision support algorithm.
• FIGS. 30A-B illustrate the post-op hypertension decision support algorithm.
• FIG. 31A illustrates the pulmonary embolism decision support algorithm.
• FIG. 31B illustrates the pulmonary embolism decision support algorithm (cont).
• FIG. 32 illustrates the seizure decision support algorithm.
• FIGS. 33A-B illustrate the SVT determination decision support algorithm.
• FIG. 33C illustrates the SVT unstable decision support algorithm.
• FIGS. 34A-B illustrate the wide complex QRS Tachycardia decision support algorithm.
• FIG. 34C illustrates the wide complex QRS Tachycardia decision support algorithm (cont).
• FIG. 35A illustrates the assessment of sedation decision support algorithm.
• FIG. 35B illustrates the assessment of sedation decision support algorithm (cont).
• FIG. 36 illustrates the bolus sliding scale midazolam decision support algorithm.
• FIG. 37 illustrates the sedation assessment algorithm decision support algorithm.
• FIG. 38 illustrates the short term sedation process, decision support algorithm.
• FIG. 39 illustrates the respiratory isolation decision support algorithm.
• FIG. 40 illustrates the empiric meningitis treatment decision support algorithm.
• FIG. 41A illustrates the ventilator weaning decision support algorithm.
• FIG. 41B illustrates the ventilator weaning decision support algorithm (cont).
• FIG. 42 illustrates the warfarin dosing decision support algorithm.
• FIG. 43 illustrates the HIT-2 diagnostic decision support algorithm.
DEFINITIONS OF TERMS AND DATA
• In the following Detailed Description of the Invention, a number of modules and procedures are described. For purposes of definitions, the following module definitions apply and are more fully amplified in the descriptions of the figures that follow.
Term Definitions
• Following are a series of definitions for certain terms used in this specification:

• Insurance carrier:	This is a table of all the valid insurance carriers listed in the
  	system of the present invention.
  Patient guarantor:	Provides the insurance guarantor information for a given
  	patient.
  Patient information:	Provides demographic information for each patient.
  Medical event date history:	This contains the various disorders of the patient and the
  	dates associated with major medical events relating to those
  	disorders.
  Medical history:	Contains non-major system medical history of a patient.
  Drug:	Contains what medication and allergies have been
  	identified for a patient at admission.
  Address:	Contains the address or addresses for a given patient.
  Patient visit:	There may be multiple records for any given patient, since
  	the patient may visit the ICU on more than one occasion.
  	This file contains a record of each visit to an ICU by a
  	patient.
  Physician-patient task:	Contains the task that had been defined for each patient.
  Present illness:	This contains a textural description of the patient illness for
  	the specific ICU visit.
  Physical exam:	This contains the information gathered as a result of a
  	physical examination of the patient during the admission to
  	the ICU.
  Surgical fluids:	This provides all the information related to the fluids
  	provided during surgery.
  Surgery:	This contains all information pertaining to any surgical
  	procedure performed on a patient while the patient is at the
  	ICU.
  Patient admit:	This provides general information that needs to be gathered
  	when a patient is admitted into the ICU.
  Medical orders:	This provides the general information for all types of
  	medical orders associated with a given patient.
  Daily treatment:	This contains the treatment provided for a given patient on
  	a given day.
  Daily diagnosis:	This contains the daily diagnosis for a given patient, which
  	includes neurological, cardiological, pulmonary, renal,
  	endocrinological, and any other diagnosis that may be
  	associated with a patient.

• Vital sign information is also critical to the administration of care in the ICU. A number of different modules collect information relating to patient vital signs. For example:

• Patient admit:	This provides the general information that needs to
  	be gathered when a patient is admitted to the ICU
  Patient visit:	This contains a record of each visit to an ICU by
  	a patient.
  Patient:	Provides demographic information for each patient.
  Vital sign header:	This contains general information related to the
  	vital sign data for the particular patient.
  Vital sign:	Contains the vital sign data taken at specific
  	intervals for a given patient.
  Hospital:	This contains identifying information for a
  	particular hospital where the care is given.
  ICU bed:	Contains the association for identifying which
  	beds are in a given ICU

• Command center/remote location definitions and modules have also been created for the present invention to allow for the orderly storage and retrieval and entering of data. For example:

• Physician-physician	Contains the names of all of the physicians and
  (such as nurses and	physician extenders for the command center/remote
  LPN and the like):	location as well as for ICUs associated with the
  	command center/remote location.
  Communication:	Contains all of the various types of communication
  	vehicles used to contact an individual physician
  	or physician extender.
  Physician role:	Contains the role a physician is playing for a given
  	patient, (i.e., primary care, consultant, etc.)
  Patient:	Provides demographic information for each patient.
  Command center/	Provides identifying information for a particular
  remote location:	command center/remote location.
  Hospital:	Contains identifying information for a particular
  	hospital wherein an ICU is located.
  ICU:	Contains identifying information for an ICU at
  	a hospital.
  ICU bed:	Contains the association for identifying which
  	beds are in a given hospital.
  ICU patient	Provides the association between an ICU and a
  location:	patient and identifies where a patient is located
  	within an ICU in a particular hospital.

• The order entry functionality of the present invention provides a critical service for obtaining information on the patient during admission, medical orders, and procedures provided to the patient during the ICU stay. For example:

• Radiology:	Contains all radiology performed on a particular
  	patient.
  Radiology results:	Contains the results of each radiology test
  	performed on the particular patient.
  Drugs:	Contains all relevant information for all the drugs
  	that a patient has been administered.
  Laboratory:	Contains all laboratory tests ordered for a patient.
  Microbiology result:	Contains the results of microbiology organisms
  	taken on a patient.
  Laboratory result:	Contains the results for a laboratory test ordered
  	for a particular patient.

DETAILED DESCRIPTION OF THE INVENTION
• The present invention is a system and method for remote monitoring of ICU's from a distant command center/remote location. By monitoring a plurality of ICU's remotely, intensivists can better spread their expertise over more ICU beds that heretofore achievable. The presence of 24-hour a day/7 day-per-week intensivist care dramatically decreases the mortality rates associated with ICU care.
• Referring toFIGS. 1A and 1B, the Billing and Demographic data structure of the present invention is illustrated. Patientdemographic information9010 is collected on the particular patient. This information comprises all the typical kinds of information one would normally gather on a patient such as first name, last name, telephone number, marital status, and other types of information.Patient insurance information9012 is collected and associated with the patientdemographic information9010.Patient insurance information9012 relates to information on the type of accident and related information such as employment, employer name, place of service, and other information that would relate to the accident that actually occurred (if at all) and which would have to be reported to an insurance agency. This information is associated with the patient demographic information which assigns the unique patient ID to the particular patient.
• Insurance plan information9008 is also created and stored and comprises insurance carrier ID's, the plan name, policy number, and group number. This information on theinsurance plan9008 is also associated with the patient ID anddemographic information9010.
• Physician information9002 is also created and stored for each physician associated with the system of the present invention. Information such as first and last name, credentials, and other information concerning the physician is saved. In addition, the physician's role is identified9004 and information concerning the physician and the physician's role is associated with the particular patient via the patient ID stored in thedemographic information9010.
• Patients are entered into the hospital by ahospital representative9006 who has a representative ID which also is ultimately associated with the patient ID. In addition,communications data9000 is stored concerning how a representative can be reached (cell phone, home phone etc.).
• Referring now toFIG. 1B, the Overall Billing and Insurance data structure is illustrated. Aninsurance provider number9014 is also stored in the system. Each physician is given a provider number and provider ID by each insurance company. Thus data must be stored regarding the ID that is given to a particular physician by each insurance provider. This information is also stored and can be associated ultimately with treatment of the patient.
• Each patient admitted to the hospital and to the ICU has a patient visit ID associated with thepatient9017. This visit ID has patient ID information, ICU information, admission date, and other information relevant to the specific visit. This information is illustrated inFIG. 1B. Thevisit ID9017 is associated with thepatient ID9010 so that each visit can be tracked by patient.
• Insurance carrier information9018 is stored by the system and is associated with theinsurance plan information9008 as appropriate. Thus the particular insurance carrier with its name, address, and other identifyinginformation9018 is associated with the type ofplan9008 carried by the patient. Theinsurance carrier information9018 together with theinsurance plan information9008 is associated with the patient via thepatient ID information9010.
• Patient address information9020 and9022 are collected for each individual patient and associated with the patientdemographic information9010. If there is a patient guarantor, this information is obtained and stored with information on theguarantor9026. Such information as the guarantor's first and last name, date of birth, and other information is stored and is illustrated inFIG. 1B. Further, the guarantor'saddress9024 is also collected and ultimately associated with the patientdemographic information9010.
• Referring toFIGS. 2A and 2B, the Command Center logical data structure is illustrated. The various information associated with demographic and insurance information is again used to manage the care and operations of the command center. Therefore,communications information9000 is combined with physician and physician extender (i.e. nurse, LPN and the like)information9002 andphysician role9004 to be associated with thedemographic information9010. Thepatient visit information9017 together with this information is associated with the patient's location which has aunique identifier9030. Each location ID has patient ID information and visit ID information associated with it.
• Referring now toFIG. 2B, the Command Center logical data structure illustration continues. Each ICU bed has an associated location ID which comprises hospital ICU information, room number, andbed number9038. In addition, and as described earlier, instrumentation such as cameras are also associated with the particular patient. Therefore thecamera setting9040 will have a location ID relating to the ICU bed as well as have camera value settings and associated camera identifier information.
• EachICU bed9038 is associated with anICU9032. Each ICU has information associated with it that uniquely identifies the ICU as being associated with the particular hospital, and having particular phone numbers, fax numbers, work space addresses, and other information, that help to identify the ICU.
• As noted above, each ICU is associated with ahospital9034. Each hospital has a unique identifier, as well as its own name, address, and other identifying information. Further, since each hospital ICU is to be coordinated through a remote command center, information on theremote command center9036 is associated with the hospital information. Each command center has a unique ID and has associated address information stored as well.
• Thus in the Command Center logical data structure,patient ID information9010 is linked to apatient location9030 which in turn is associated with anICU bed9038 each of which beds are uniquely associated anICU9032 which is associated with ahospital9034 which in turn has the ICU managed by acommand center9036.
• An integral part of the system of the present invention is the recording of medical history. Referring toFIG. 3, the logical relationship among data elements for medial history is illustrated.Patient visit information9017 combined with the physician-physician extender information9002 is combined with specific note-taking information9042. The note information comprises the date and time the notes are taken as well as the note type. The note ID is fed information from themedical history item9044, which has its own unique medical ID associated with it. This information comprises medical text, category of information, and other information relevant to the medical history. As noted, this information formedical history9044 is associated with anote ID9042, which in turn is associated with the patient visit andphysician information9017 and9002.
• Referring toFIGS. 4A,4B, and4C, the note-keeping logical data structure of the present invention is illustrated. As noted earlier, thenote ID9042 combines information from visit ID, treating physician, and other information relating to the time the note was entered. Other information is associated with the note ID. Referring first toFIG. 4A, thepatient visit information9017, is associated with thenote ID9042. Variousprocedural information9046 is kept by the system of the present invention and is associated with thevisit ID9017. Physicians are able to create free textpatient illness notations9048 and associate them with thenote9042. Similarly, free text information regarding functioning of thesystem9050 is permitted and also associated with notes regarding the particular patient andprocedure9042.
• Specific notes regarding, for example, surgical procedures are also kept. Surgery notes9054 are associated with a particular note ID and have such information as anesthesia, surgical diagnosis, elective information, and other related surgical information.Surgical fluids9052 administered during the course of surgery are associated with thesurgery information9054. Additionally, anysurgical complications9056 are noted and also associated with the surgery which in turn has an associated note ID.
• Referring now toFIG. 4B, the logical data structure for notes and its description is continued. Anassessment plan9058 is created and associated with the same note ID for the particular patient. The plan has a free text field that allows a physician to create the appropriate assessment plan and associate it with anote ID9042.
• Various daily notes are also kept and associated with theindividual note ID9042. For example, the dailymental state9060 is recorded to document the mental state of the patient. Thedaily treatment9062 administered to the patient is associated with the unique note ID. Thedaily diagnosis9068 is also created and associated withunique note ID9042.
• Any unstable conditions are also noted9070 and records kept of those conditions. Similarly mortality performance measures (MPM)information9072 is kept and associated with the unique note ID. To the extent that anyphysical exam9074 is administered, that physical exam and any free text created by the physician is associated with the unique ID and records kept.Allergy information9076 for the particular patient is also created and stored along with the allergy type, and allergy name. This information is uniquely associated with the note ID. Referring now toFIG. 4C, the Logical Data Structure for the Notes Creation and Storage description is continued. A specificnote item record9078 is also kept and associated with unique note ID. This note item comprises the principal diagnosis, the chief complaint, the past history of the patient, the reason for the note, and various other identifications and flags of information which help in documenting the patient's condition.
• Any drugs that are administered to the patient, including dosage, type, andnumber9086 is kept and associated with theunique note ID9042.
• Procedural note items are also documented9082. Procedural notes involve the procedural type, the principal diagnosis, the procedural location, procedural indications, and other information of a procedural nature.Procedural description information9088 is kept as input to the procedural note item. This information is also associated with aprocedural evaluation9084 which comprises text describing the procedural evaluation that occurred, These three items, theprocedural description9088,procedural evaluation9084, andprocedural note items9082, are all uniquely associated with thenote ID9042.
• Referring now toFIG. 5, the Logical Data Structure of the Medical Order Functionality of the Present Invention is illustrated. Eachmedical order9092 has a unique order ID associated with it. This information derives its uniqueness from the visit ID, the representative ID, and various information about the date in which the order was created and other such relevant information. Anynon-drug orders9090 are associated with a unique non-drug order ID. The order is classified, identified, and free text can be created by the physician to describe the order. This information in thenon-drug order9090 is associated with the unique medical order for thatparticular patient9092.
• Again physician and physicianextender identification information9002 is also uniquely associated with the medical order to identify the physician involved in creating the particular order in question.
• Drug orders9094 are created each with its own unique drug order ID. Various information is collected as part of the drug order including the type of drug, the dosage, start date, frequency, stop date, to name but a few elements typical of a drug order. Thedrug order information9094 is associated with the uniquemedical order ID9092 assigned to that particular patient. All of the medical order information is associated withpatient visit information9017 which allows that information to be uniquely identified with a particular patient for a particular visit.
• Referring again toFIG. 4C, the system is also capable of annotating and storingvarious log items9080. For example, an event log item is given a number, a patient profile item has its own number, as do neurological, cardiographic, pulmonary, renal, and other events can have log items associated with them and may be used as input to any of the note taking of the present invention.
• Referring toFIGS. 6A and 6B, the logical data structure of the patient care functionality of the present invention is illustrated. Each patient visit with itsunique ID9017 has a number of other pieced of information associated with it. For example, physician-patient tasks are tracked9098 and have a unique task ID associated with them. Thepatient code status9096 is documented and associated with the physician-patient task9098 task ID. This information is uniquely associated with the patient visit via thepatient visit ID9017.
• Laboratory information9100 has a unique lab ID associated with it. That information is keyed to the visit ID and records the specimen taken, the date it was taken, and various other information germaine to the laboratory procedure involved.Other lab procedures9102 are also documented with another unique ID. “Other” lab ID is associated with thelaboratory ID9100 which again is uniquely associated with the particular patient.
• Microbiological studies9104 are documented together with the date and the date taken and the type of study involved. Any study ofmicroorganisms9106 is documented with a unique microorganism ID.Micro sensitivities9108 which record the sensitivity to microorganisms and certain antibiotics is recorded and associated with themicroorganism ID9106. This information in turn is associated with amicrobiological study9104, all of which is associated with the unique patient visit ID9107.
• Respiratory studies9101 are also recorded with unique identification numbers and a description. This information is again associated with thepatient visit ID9017.
• Referring now toFIG. 6B, the logical data structure of the patient care functionality of the Present Invention is further illustrated.Other organism studies9118 are also conducted to determine any other conditions associated with microorganisms that might exist with the particular patient. Thisother organism information9118 is associated with themicroorganism studies9106 which in turn is associated with the microbiology category of information of thepresent invention9104.
• Various diagnostic imaging also takes place and is recorded. Thisimage information9114 has unique image ID associated with each image and comprises associated information such as the image type, the date performed, and other information relevant to the diagnostic imagery. The result of the image taken9116 is also uniquely identified with the image ID and a unique image result ID. This information is associated with theimage information9114 which again is uniquely associated with the patient visit ID.
• Various intake and output for the patient's biological functioning is recorded9110. Intake andoutput total9112 is recorded and uniquely associated with the intake/output identification note9110. Intake/output totals9112 also comprised the weight the total taken in, the total out, and five-day cumulative totals for biological functioning of the particular patient.
• Referring toFIG. 7, The Logical Data Structure Concern with Reference Information for the present invention is illustrated. This data structure allows only certain ranges of data to be input by care givers into the system. This is accomplished by having categories ofinformation9120 each category capable of having only certain values. Similarly, each type ofdata9126 associated with each category is only permitted to have certain values. This combination of Category and Type results in aCombined ID9122 which can be used in combination withcertain values9128 to create a value andcombination9124 that can be presented to a care giver viewing and entering data. This effectively limits errors in data entry by only allowing certain values to be entered for given types of data. For example, if only milligrams of a medication are supposed to be administered, this data structure prevents a care giver from administering kilograms of material since it is not a permitted range of data entry. The “nextkey”function9027 is the function that keeps track of the ID's that are given during the administration of the present invention. This function insures that only unique ID's are given and that no identical ID's are given to two different patients for example.
• Referring toFIG. 8A, the Logical Data Structure of the Vital Signs Functionality of the Present Invention is illustrated. Vitalsign header information9120 is created and uniquely associated with the visit ID for the particular patient. This header information comprises a date-time stamp combined with hospital information, medical reference numbers, and identification of the patient.Vital sign details9122 are also created and uniquely date-time stamped and associated with the particular visit ID for the patient. This information comprises all manner of vital sign information relating to blood pressure, respiration, and other factors. Vital sign information is associated with thepatient visit9017 and the demographic information concerning thepatient9016. Such associations of information can be the basis for later studies.
• Referring toFIG. 8B, Additional Vital Sign Logical Data Structures are illustrated. For example, a vitalsign log header9120 is created using the unique hospital ID and medical record numbers. Other information such a patient name, and date-time stamp are also stored. Vitalsign log details9124 are created and associated with the vitalsign log header9120. For example, blood pressure measurements, respiration, and other factors are all detailed for a particular hospital ID. It should be noted that all vital sign data is logged in and kept by the systems of the present invention. Where vital sign information is received but cannot be associated with a particular patient, such communications are noted as errors.
• Vitalsign error details9126 are also recorded and associated with a particular hospital. Information and the vital sign error detail also comprises heart rate, blood pressure, and other information. This information is associated with a vitalsign error header9130 which is associated with the hospital identifier and the patient first and last name and other information. Various vitalsign error codes9128 exist with the present invention and are used in association with the vitalsign error detail9126. This information however relates to communications of vital sign data that are deemed “errors” as noted above.
• CareNet patient location9132 is recorded and associated with a particular hospital ID and location ID for the particular patient. Carenet is a proprietary product designation of Hewlett-Packard and is kept by the system of the present invention since it identifies the equipment from which measurements come. TheICU bed information9038 is associated with the CareNet patient location9132.
• Referring toFIG. 9, the distributed architecture of the present invention is shown. In concept, the distributed architecture comprises aheadquarters component200, a command center/remote location202, and ahospital ICU204, which, while represented as a single hospital in this illustration, in the preferred embodiment comprises several hospital ICUs at different locations. Theheadquarters unit200 comprises a database server and data warehouse functionality, together with a patient information front end. The patient informationfront end206 provides patient specific information to the command center/remote location. The database server/warehouse function208 comprises the amassed information of a wide variety of patients, in their various conditions, treatments, outcomes, and other information of a statistical nature that will assist clinicians and intensivists in treating patients in the ICU. The headquarters' function also serves to allow centralized creation of decision support algorithms and a wide variety of other treatment information that can be centrally managed and thereby standardized across a variety of command center/remote locations. Further, the database server/data warehousing functionality208 serves to store information coming from command center/remote locations replicating that data so that, in the event of a catastrophic loss of information at the command center/remote location, the information can be duplicated at the command center/remote location once all systems are up and running.
• At thehospital ICU204, eachpatient room232,234 has a series of bedside monitors and both video and audio monitoring of each patient in the patient room. Each ICU further has a nurse's station with a video camera and monitor230 so that videoconferencing can go on between the nurses and doctors at the nursing station and those intensivists at the command center/remote location. The monitoring equipment at the ICU is served by amonitor server236, which receives and coordinates the transmission of all bedside monitoring and nurses station communication with the command center/remote location. Finally, each ICU has a patient informationfront end228, which receives and transmits to the command center/remote location information concerning the identity and other characteristics of the patient.
• Command center/remote location202 comprises its own video capture andmonitoring capability212 in order to allow the intensivists to view the patients and information from the bedside monitoring as well as to have videoconferencing with the nursing station and with patients as the need arises. Information from themonitor server236 at the hospital ICU is served to an HL7 (the language for transmitting hospital/patient/diagnostic data)gateway214 to adatabase server222. In this fashion, information from the bedside monitors can be stored for current and historical analysis. Monitor front ends216 and218 allow technicians and command center/remote location personnel to monitor the incoming data from the patient rooms in the ICU. Information from the patient informationfront end228 is provided to anapplication server224, having its own patient informationfront end226 for aggregating and assembling information in thedatabase222 that is associated with individual patients in the ICU.
• It is expected that there will be a great deal of concurrent hospital data that is necessary to the implementation of the present invention. It is therefore expected that there will be alegacy database system210 having afront end220 from which intensivists and command center/remote location personnel can retrieve legacy database information.
• Referring toFIG. 10, a system architecture of one embodiment of the present invention is illustrated.Headquarters200 comprises anapplication server238, anNT file server240, and Sun SPARC Enterprise250242 and Enterprisenetwork management system244, aCisco 3600router246, aCisco 2924switch248, and ahot phone250. Theapplication server238 is designed to monitor and update those applications used at the command center/remote location. The NT file server serves to monitor, store, and replicate information coming from the command center/remote locations. TheSPARC Enterprise250server242 is a disc storage server, for storing and serving information, such as practice guidelines, algorithms, patient information, and all matter of other information records that must be stored in order to support the present invention. As explained below, theSPARC Enterprise250 server and other components are such as routers and switches are commonly used in the ICU, the command center/remote location, and the headquarters. For example:
• • TheCisco 3600 router is a multi-function device that combines dial access, routing, and local area network (LAN) to LAN services, as well as the multi-service integration of voice, video, and data in the same device. This is necessary, since the various command center/remote locations, headquarters, and intensive care units all must integrate and transmit video, audio, and data among the various entities.
  • TheCisco 7204 is a router which provides high speed LAN interconnect, virtual private networks, and Internet access, all of which is required for providing the communication in the network of the present invention; and
  • TheCisco 2924 switch is an autosensing fast ethernet switch, allowing networked multimedia and virtual LAN support. Multi-level security is also offered in the switch to prevent unauthorized users from gaining access and altering switch configuration. These components are also identified in the figures (below).
• The particular commercial systems named here are given as but some examples of equipment available today. The function of these equipment is the important factor. Other similar or improved equipment can also be utilized.
• Thenetwork management system244 allows the entire traffic and condition of the network to be monitored and to allow maintenance to take place. Therouter246 and switch248 is used for communication with the various command center/remote locations that are served by the Headquarters component. The Headquarters component interacts via frame relay with the command center/remote location202.
• Command center/remote location202 comprises anapplications server262 for the purpose of running various applications for the intensivists and command center/remote location staff. TheNT file server264 at the command center/remote location allows patient files, historical files, algorithms, practice standards, and guidelines, to be served to the clinicians and intensivists to assist in monitoring the patients. The Sun SPARC Enterprise250266 is used to for storage purposes as noted above. The Enterprisenetwork management system268 monitors the overall health of the network of command center/remote locations and intensive care units as well as the functionality of the individual pieces of equipment within the command center/remote location. ACisco 2924switch256 andCisco 7204router258, combined with theCisco 3600router260 allows for point to point communication over a T1 line, with a plurality of intensive care units located remotely from the command center/remote location.Hot phones252 and254 allow communication with the headquarters and the intensive care unit.
• Intensive care unit204 comprises aCisco 2924switch272 for the purpose of interfacing with the various audio-video feeds274,276 from the various patient rooms and the nursing station. Alocal work station280 is connected to ascanner282 which allows data to be input, scanned, and communicated via the point to point T1 communications to the command center/remote location. Further, theworkstation280 provides for textual advice and patient orders to be delivered to the intensive care unit for execution. The intensive care unit also comprises alaser printer284 for the printing of patient orders and other information relevant to the care of intensive care patients. Referring toFIG. 11, the videoconferencing/surveillance/imaging components of the present invention are illustrated. Thehospital ICU204 comprises a series ofvideo cameras290, which are located in patient rooms and at the nurse's station. Control for the cameras is provided through an RS424 toRS232 converter288, with instructions for imaging emanating from the workstation at the command center/remote location252 through theICU workstation280 through a multi-portserial controller286. Video feed from thevideo cameras290 is provided to an audio-video switcher292, which in turn provides its output to the multi-portserial controller286 for subsequent viewing at the nurse's station and at the command center/remote location. Of equal importance is a microphone feed from the patient and from the nurses. Thatmicrophone296 provides its signal to anaudio line amplifier294, which in turn provides an audio feed to the audio-video switcher292. In this way, a patient can provide information, as can nurses who are visiting the patient during the course of patient care. It is also important that information of an audio nature be fed to the intensive care unit, both to the patient rooms and to the nurse's station. To do this, the multi-portserial controller286 provides an audio signal to areverse audio switcher298, which in turn provides information tospeakers300 that are located at the nurse's station as well as at the bedside of the patients. Information to the reverse audio switcher is provided anaudio amplifier302 from information from avideo code304, which in turn is connected to the workstation at the ICU. As noted earlier, ascanner282 is provided, so that information can be scanned and provided to the command center/remote location202 and ahot telephone278 communicates with atelephone252 at the command center/remote location.
• Referring toFIG. 12 the vital signs data flow is illustrated. The monitoring system at each ICU bedside comprises a monitoring system for monitoring the vital signs for the patient. The vitalsign monitoring system450 capturesvital sign data452 and transmits thatvital sign data454 using the HL7 language (the standard processing language for hospital data and information). The processor at the ICU processes the vital sign data for transmission and storage purposes and transmits that information to the remote location. Vital sign data is then loaded into thedata base458. The data base for each individual patient is then reviewed and process rules are applied460 to the vital sign data. These process rules relate to certain alarming conditions which, if a certain threshold is reached, provides an alarm to the intensivist on duty. Thevital sign alarm462 is then displaced to the intensivist who can then take appropriate action. A typical type of rule processing of the vital sign data might be if blood pressure remains at a certain low level for an extended period of time, or if heart rate remains high for an extended period of time. In addition a wide range of other rules are provided which will provide an audible alarm to the intensivist before a critical situation is reached.
• In addition to the information being provided to the alarming system for the intensivist, thevital sign data464 is also transmitted466 into adatabase warehouse468 comprisingvital sign data470 from not only the individual patient but from all of the patients being cared for in the ICU. This database warehouse provides the ability to do data mining for trends that can give rise to additional process rules and vital sign thresholding. In addition to the transmission ofvital sign data454 to the remote site, the vital sign data is displayed in real time at theICU472.
• Referring toFIG. 13A the diagnostic imaging interaction is illustrated. X-rays for example, are created and transmitted to thecommand center472. Additionally, the information could be ACT scan, MRI, or any other method of medical diagnostic imaging. The x-ray image is captured at thecommand center474 where it is stored and in addition displayed on the image monitor476 for the intensivist to review.
• Referring toFIG. 13B the interactive video session is illustrated. A video conferencing session is established478 regarding a particular patient in an ICU bed. Using the video cameras in each room and/or at the nurses station at the ICU, the patient and/or the nurse can be viewed480. On the other end of the video conferencing session is the intensivist who can then both visually and orally communicate with the patient and/ornurse482.
• Referring toFIG. 14 the physician resources and order writing data interface is illustrated. Theuser interface484 allows the physicians to accessphysician resources486. These resources provide guidelines for the treatment of the critically ill. In this example the intensivist is requested to enter the antibiotic associated withcolitis488. The system then generates a request for afecal leukocyte test490. This request is translated into anorder writing module496 which results in the actual order for thetest502. Since the order needs to be transmitted to the appropriate organization for execution, an appropriate order is generated to themicrobiology laboratory500 in this instance. The order results are then achieved506 and the completion of the order is reported to the orderwriting assignment manager496. In addition, theorder writing module502 also results in atask list504 of orders for various other individuals in laboratories. In addition,user interface484 allows the physician to re-enter the physician resources module at any particular location with results of the tests. These tests are then fed into the system to continue with the diagnostic algorithm processing of the patient test results494. The user interface also allows interaction with theresident database498.
• Referring toFIG. 15 the physician resources database data interface is illustrated.User interface508 allows the intensivist to interact with the physicianresources data base510. In this example,resident data base524 which comprises the identification and background of the resident admitting the patient causes anadmission diagnosis526 to be created. In this example a diagnosis of pancreatitis is illustrated. This diagnosis ofpancreatitis522 alerts thephysician resources module510 which causes an entry for thetopic pancreatitis512. The diagnosis algorithm forpancreatitis514 is then retrieved and a request for anApache II score516 is requested. The system also requests information foroperative data528 describing what if any operations have taken place with respect to this patient,vital sign data530, request forlaboratory information532, past medical history for thepatient534 andpatient demographics536. All this information is provided to the Apache IIscore assignment manager538 which assigns an Apache II score based upon weighted composite up to twenty five different variables. This Apache II score is provided to the Apache IIscore request module516. If the severity based Apache II score is greater than or equal to eight the diagnostic of the system continue520. If the Apache II score is less than eight, the patient is triaged to anone ICU bed518 since the patient will not necessarily require intensive care thereby saving relatively scarce resources of the ICU for those who are truly critically ill.
• Referring toFIG. 16 the automated coding/billing work flow and data flow is illustrated. Clearly ICUs must be paid for the care that they give. At the outset of thevisit540 theuser interface542 allows for the input of International Classification of Diseases, Ninth Revision (ICD 9) diagnosis code information concerning complexity of the case, whether the patient is stable, whether the physician involved is the attending physician or consulting physician and all other manner of information required for billing purposes. In addition,resident data544 is input such as patient demographics, insurance information, physician, guarantor, the date that the service is provided. All this information is provided to thedata manager546 which assembles the required data element for subsequent processing. The data manager sends the demographic, physician, guarantor, insurance and related information to abill generator548 which begins to assemble of the information to subsequently generate a bill. Clinical information is provided to the current procedural terminology (CPT) code assignment manager which assigns codes based upon the scores and user input for bill generation purposes. A history of present illness (HPI) score560 is generated along with a review of systems (ROS)score562. A past, family, and/or social history (PFSH) score564 is generated along with a score relating to thephysical exam566. A mortality prediction model (MPM) score568 which is a score relating to the severity of the illness is also generated. All of these various scores are provided to theCPT assignment manager558. Periodically information is downloaded for management reports556. Once all of the information for the CPT code assignment is generated that information is provided to thebill generator548 which assembles all the data elements needed to generate a Health Care Financing Administration (HCFA) 1500 claim form. The input for the bill generator is then verified550 where the physician can disagree with code assignments return progress notes and generally review the bill. This smart processing of theHCFA 1500 claim form allows for fewer mistakes to be made. If there is any error or additional information that is required, the verification process fails the proposed claim form and information regarding that failure is provided back to the resident data for completion of any missing items. Once an invoice has been verified as having the appropriate information to be submitted theHCFA 1500 claim form is generated554. Additional information is written to a billing data file552 for importation to the patient accounting system of the present invention.
• Referring toFIG. 17 the order writing data flow is illustrated. Orderentry user interface600 allows the intensivist to order procedures and medication to assist the patients in the ICU. For example, the intensivist can order anECG604. Thereafter the order is reviewed and a digital signature relating to the intensivist is supplied606. Once reviewed and signed off, the order is approved607 and sent to thedata output system610. Thereafter the data output system prints the order to the printer in theICU616. For record keeping purposes the order is exported in the HL7 language to thehospital data system618. In addition the data output system adds an item to the data base that will subsequently cause an intensivist to check the ECG results. This notification to the task list is provided to thedatabase614. In addition, as part of the database an orders file relating to the specific patient is also kept. The fact that and ECG has been ordered is entered in the orders file for that patient.
• In a similar fashion using the orderentry user interface600 the intensivist can ordermedications602 for a patient. The medication order then is provided to anorder checking system608. The order checking system retrieves information from thedatabase614 relating to allergies of the patient and medication list which includes medications which are already being administered to the patient. This allows for the order checking system to check for drug interactions. Further laboratory data is extracted from thedatabase614 and the order checking system checks to insure that there will be no adverse impact of the recommended dosage upon the renal function of the patient. Once theorder checking system608 is completed, the order is okayed and provided to the order review andsignature module606. In this module the digital signature of the intensivist is affixed to the order electronically and the order is approved607. Thereafter it is provided to thedata output system610 where again the orders are printed for ICU and616 and for the hospital data system. In this case, any medications that are ordered are then provided to the medications list file in thedatabase614 so that the complete list of all medications that are being administered to the ICU patient is current.
• Referring toFIG. 18 the event log is illustrated. Thedatabase620 contains all manner of notes and data relating to the particular patient that is admitted to the ICU. For example, admission notes622 are taken upon admission of the patient and stored in the file that is specific to that patient. Progress notes624 are created during the patients stay within the ICU to note the progress the patient is making giving the various treatments.Procedural notes626 are also created by the intensivist to note what procedures have taken place and what if any events have occurred associated with those procedures. Laboratory data such as positive blood cultures are also stored in thefile628 in thedatabase620.Further x-ray data630 and abnormal CT Scan results are stored in the database.
• The result of these individual files are then provided to anevent log manager632. For example, admission notes might contain operations performed. Progress notes624 might relate to the operations preformed. This information is provided to theevent log manager632. Admission information is also input to the event log manager as are a listing of the procedures administered to the patient. To the extent there are positive blood cultures in thelaboratory data628 those are provided to theevent log manager632 as are abnormal CT scan results. All of this information is made available through theuser interface634. Thus the event log presents in a single location key clinical information from throughout a patients stay in the ICU. The event log user interface provides caregivers with a snapshot view of all salient events since admission. All relevant data on procedures and laboratory tests, etc. are presented chronologically.
• Referring toFIG. 19 the smart alarms of the present invention are illustrated. The smart alarm system constantly monitors physiologic data (collected once per minute from the bedside monitors) and all other clinical information stored in the database (labs, medications, etc). The periodicity of the collection of data is stated for illustrative purposes only. It is well within the scope of the present invention to collect physiological data at more frequent time intervals. Thus, monitor636 provides information in HL7 form to theinterface engine638. The physiological data is then formatted by the interface engine for storage in thedatabase640 where all patient information is maintained. Therules engine642 searches for patterns of data indicative of clinical deterioration.
• One family of alarms looks for changes in vital signs over time, using pre-configured thresholds. These thresholds are patient-specific and setting/disease-specific. For example, patients with coronary artery disease can develop myocardial ischemia with relatively minor increases in heart rate. Heart rate thresholds for patients with active ischemia (e.g. those with unstable angina in a coronary care unit) are set to detect an absolute heart rate of 75 beats per minute. In contrast, patients with known coronary artery disease in a surgical ICU have alarms set to detect either an absolute heart rate of 95 beats per minute or a 20% increase in heart rate over the baseline. For this alarm, current heart rate, calculated each minute based on the median value over the preceding 5 minutes, is compared each minute to the baseline value (the median value over the preceding 4 hours). Physiologic alarms can be based on multiple variables. For example, one alarm looks for a simultaneous increase in heart rate of 25% and a decrease in blood pressure of 20%, occurring over a time interval of 2 hours. For this alarm, thresholds were initially selected based on the known association between changes in these two variables and adverse clinical events. Actual patient data were then evaluated to determine the magnitude of change in each variable that yielded the best balance between sensitivity and specificity. This process was used to set the final thresholds for the rules engine.
• Alarms also track additional clinical data in the patient database. One alarm tracks central venous pressure and urine output, because simultaneous decreases in these two variables can indicate that a patient is developing hypovolemia. Other rules follow laboratory data (e.g. looking for need to exclude active bleeding and possibly to administer blood).
• The purpose of the rules engine is to facilitate detection of impending problems and to automate problem detection thereby allowing for intervention before a condition reaches a crisis state.
• Referring toFIG. 20 the procedural note-line log is illustrated. This log allows clinicians to evaluate the likelihood that a given procedure might result in further complications. In this example presented in thisFIG. 20 a catheter removal is illustrated. When a new catheter is inserted in a patient648 a procedural note is created on the procedure notecreation user interface646. The note is reviewed and a digital signature is attached to the note to associate the note with aparticular intensivist654. The procedure is then approved and is provided to thedata output system656. The procedural note is then printed on the printer in theICU658 and is exported in HL7 language to thehospital data system660. In addition, this also triggers a billing event and the data output system provides appropriate output to thebilling module662 to generate an invoice line item. In addition, the note is stored in the emergency medical record associated with the patient in thedatabase664. In addition, the line log is updated in thedatabase664 to show what procedure was administrated to a patient at what time. If there is an existing catheter, that is displayed to the intensivist at the procedure notecreation user interface646. This would show an existing catheter changed over awire650. That information is provided to theline id module652 which extracts information from the line log in thedatabase664. This information results in a note being created and provided to the note review andsignature module664. Thus the line log contains, for each patient, relevant information about all in-dwelling catheters, including type and location of the catheter, insertion date, the most recent date that the catheter was changed over a wire, and the date the catheter was removed. This information helps clinicians evaluate the likelihood that a given catheter is infected and guides its subsequent management of that procedure.
Evidence-Based Guidelines, Algorithms, and Practice Standards Decision Support Algorithms
• In order to standardize treatment across ICUs at the highest possible level, decision support algorithms are used in the present invention. These include textural material describing the topic, scientific treatments and possible complications. This information is available in real time to assist in all types of clinical decisions from diagnosis to treatment to triage.
• All connections among components of the present invention are presently with a high bandwidth T-1 line although this is not meant as a limitation. It is anticipated that other existing and future high bandwidth communication capabilities, both wired and wireless, as well as satellite communications will be suitable for the communications anticipated for the present invention.
• As noted earlier, a key objective of the present invention is to standardize care and treatment across ICUs. This is effective in the present invention by providing decision support to intensivists as well as information concerning the latest care and practice standards for any given condition. As noted in Table I below, a wide variety of conditions is noted. Each of the conditions has an associated guideline of practice standard that can be presented to the intensivist who might be faced with that particular condition in a patient. These guidelines of practice standards can be accessed at the command center/remote location or at the ICU to assist in the treatment of the patient. Thus, the general categories of cardiovascular, endocrinology, general, gastrointestinal, hematology, infectious diseases, neurology, pharmacology, pulmonary, renal, surgery, toxicology, trauma all have guidelines and practice standards associated with them.

• TABLE 1
  EVIDENCE-BASED GUIDELINES
  ALGORITHMS & PRACTICE STANDARDS
  DECISION SUPPORT

  CARDIOVASCULAR

  BRADYARRHYTHMIAS

  CARDIOGENIC SHOCK

  CARDIO-PULMONARY RESUSCITATION GUIDELINES

  CONGESTIVE HEART FAILURE

  EMERGENCY CARDIAC PACING

  FLUID RESUSCITATION

  HYPERTENSIVE CRISIS

  IMPLANTABLE CARDIO-DEFIBRILLATORS

  INTRA-AORTIC BALLOON DEVICES

  MAGNESIUM ADMINISTRATION IN PATIENTS

  MANAGEMENT OF HYPOTENSION, INOTROPES

  MYOCARDIAL INFARCTION

  MI WITH LEFT BUNDLE BRANCH BLOCK

  PA CATHETER GUIDELINES & TROUBLE-SHOOTING

  PERMANENT PACEMAKERS & INDICATIONS

  PULMONARY EMBOLISM DIAGNOSIS

  PULMONARY EMBOLISM TREATMENT

  SUPRA-VENTRICULAR TACHYARRHYTHMIAS

  UNSTABLE ANGINA

  VENOUS THROMBOEMBOLISM PROPHYLAXIS

  VENOUS THROMBOSIS: DIAGNOSIS & TREATMENT

  VENTRICULAR ARRHYTHMIAS

  ENDOCRINOLOGY

  ADRENAL INSUFFICIENCY

  DIABETIC KETOACIDOSIS

  HYPERCALCEMIA: DIAGNOSIS & TREATMENT

  HYPERGLYCEMIA: INSULIN TREATMENT

  STEROID REPLACEMENT STRATEGIES

  THYROID DISEASE

  GENERAL

  DEALING WITH DIFFICULT PATIENTS AND FAMILIES

  END OF LIFE DECISIONS

  ETHICAL GUIDELINES

  PRESSURE ULCERS

  ORGAN PROCUREMENT GUIDELINES

  GASTROINTESTINAL

  ANTIBIOTIC ASSOCIATED COLITIS

  HEPATIC ENCEPHALOPATHY

  HEPATIC FAILURE

  MANAGEMENT OF PATIENTS WITH ASCITES

  NUTRITIONAL MANAGEMENT

  ACUTE PANCREATITIS

  UPPER GI BLEEDING: STRESS PROPHYLAXIS

  UPPER GI BLEEDING: NON-VARICEAL

  UPPER GI BLEEDING: VARICEAL

  HEMATOLOGY

  HEPARIN

  HEPARIN-INDUCED THROMBOCYTOPENIA

  THE BLEEDING PATIENT

  THROMBOCYTOPENIA

  THROMBOLYTIC THERAPY

  TRANSFUSION GUIDELINES

  USE OF HEMATOPOETIC GROWTH FACTORS

  WARFARIN

  INFECTIOUS DISEASES

  ACALCULUS CHOLECYSTITIS

  ANTIBIOGRAMS

  BLOODSTREAM INFECTIONS

  CANDIDURIA

  CATHETER RELATED SEPTICEMIA

  CATHETER REPLACEMENT STRATEGIES

  ENDOCARDITIS PROPHYLAXIS

  ENDOCARDITIS DIAGNOSIS AND TREATMENT

  FEBRILE NEUTROPENIA

  FUO

  HIV+ PATIENT INFECTIONS

  MENINGITIS

  NECROTIZING SOFT TISSUE INFECTIONS

  NON-INFECTIOUS CAUSES OF FEVER

  OPHTHALMIC INFECTIONS

  PNEUMONIA, COMMUNITY ACQUIRED

  PNEUMONIA, HOSPITAL ACQUIRED

  SEPTIC SHOCK

  SINUSITIS

  SIRS

  TRANSPLANT INFECTION PROPHYLAXIS

  TRANSPLANT-RELATED INFECTIONS

  NEUROLOGY

  AGITATION, ANXIETY, DEPRESSION & WITHDRAWAL

  BRAIN DEATH

  GUILLAIN-BARRE SYNDROME

  INTRACEREBRAL HEMORRHAGE

  MYASTHENIA GRAVIS

  NEUROMUSCULAR COMPLICATIONS OF CRITICAL ILLNESS

  NON-TRAUMATIC COMA

  SEDATION

  STATUS EPILEPTICUS

  STROKE

  SUB-ARACHNOID HEMORRHAGE

  PHARMACOLOGY

  AMINOGLYCOSIDE DOSING AND THERAPEUTIC MONITORING

  AMPHOTERICIN-B TREATMENT GUIDELINES

  ANALGESIA

  ANTIBIOTIC CLASSIFICATION & COSTS

  DRUG CHANGES WITH RENAL DYSFUNCTION

  PENICILLIN ALLERGY

  NEUROMUSCULAR BLOCKERS

  VANCOMYCIN

  THERAPEUTIC DRUG MONITORING

  PULMONARY

  ARDS: HEMODYNAMIC MANAGEMENT

  ARDS: STEROID USE

  ARDS: VENTILATOR STRATEGIES

  ASTHMA

  BRONCHODILATOR USE IN VENTILATOR PATIENTS

  BRONCHOSCOPY & THORACENTESIS GUIDELINES

  COPD EXACERBATION & TREATMENT

  CXR (INDICATIONS)

  NONINVASIVE MODES OF VENTILATION

  ENDOTRACHEAL TUBES & TRACHEOTOMY

  TREATMENT OF AIRWAY OBSTRUCTION

  VENTILATOR WEANING PROTOCOL

  RENAL

  ACUTE RENAL FAILURE: DIAGNOSIS

  ACUTE RENAL FAILURE: MANAGEMENT & TREATMENT

  DIALYSIS

  DIURETIC USE

  HYPERKALEMIA: ETIOLOGY & TREATMENT

  HYPERNATREMIA: ETIOLOGY & TREATMENT

  HYPOKALEMIA: ETIOLOGY & TREATMENT

  HYPONATREMIA: ETIOLOGY & TREATMENT

  OLIGURIA

  SURGERY

  OBSTETRICAL COMPLICATIQNS

  DISSECTING AORTIC ANEURYSM

  POST-OPERATIVE HYPERTENSION

  POST-OPERATIVE MYOCARDIAL ISCHEMIA (NON-CARDIAC

  ARRHYTHMIAS AFTER CARDIAC SURGERY

  POST-OPERATIVE BLEEDING

  POST-OPERATIVE MANAGEMENT OF ABDOMINAL

  POST-OPERATIVE MANAGEMENT OF OPEN HEART

  POST-OPERATIVE MANAGEMENT OF THORACOTOMY

  POST-OPERATIVE POWER WEANING

  POST-OPERATIVE MANAGEMENT OF CAROTID

  WOUND HEALING STRATEGIES

  TOXICOLOGY

  ACETAMINOPHEN OVERDOSE

  ANAPHYLAXIS

  COCAINE TOXICITY

  ALCOHOL WITHDRAWAL

  HYPERTHERMIA

  LATEX ALLERGY

  UNKNOWN POISONING

  TRAUMA

  ABDOMINAL COMPARTMENT SYNDROME

  BLUNT ABDOMINAL INJURY

  BLUNT AORTIC INJURY

  BLUNT CARDIAC INJURY

  DVT PROPHYLAXIS

  EXTREMITY COMPARTMENT SYNDROME

  HEAD INJURY

  HYPOTHERMIA

  IDENTIFICATION OF CERVICAL CORD INJURY

  SPINAL CORD INJURY

  OPEN FRACTURES

  PENETRATING ABDOMINAL INJURY

  PENETRATING CHEST INJURY

• Referring toFIGS. 21A-B, the acalculous cholecystitis decision support algorithm of the present invention is illustrated. If an intensivist suspects that acalculous cholecystitis may be present, the intensivist may not be certain of all of the aspects that would be indicative of this particular condition. Therefore, the intensivist is lead through a decision support algorithm, which first causes the intensivist to determine if the patient is clinically infected, either febrile orleukocystosis800. If this criterion is not met, the intensivist is prompted that it is unlikely that the patient hasacalculous cholecystitis802.
• If the patient is clinically infected800, the intensivist is prompted to determine whether the patient has had aprevious cholesystectomy804. If patient has had a previous cholesystectomy, the intensivist is prompted that it is very unlikely that the patient hasacalculous cholecystitis806. Alternatively, if a patient has not had a previous cholesystectomy, the intensivist is prompted to determine whether the patient has any of seven (7) risk factors, specifically: 1) Prolonged intensive care unit (ICU) stay (defined as greater than six (6) days); 2) recent surgery (particularly aortic cross clamp procedures); 3) hypotension; 4) positive end-expiratory pressure (PEEP) greater than ten (10) centimeters (cm); 5) transfusion greater than six (6) units of blood; 6) inability to use the gastrointestinal (GI) tract for nutrition; or 7) immunosuppresssion (AIDS, transplantation, or leukemia)808. If the patient has none of these seven risk factors, the intensivist is prompted that the patient probably does not haveacalculous cholecystitis810.
• If the patient has any of the sevenrisk factors808, the intensivist is prompted to determine whether the patient has any of the following symptoms: right upper quadrant (RUQ) tenderness; elevated alkalinephosphatase; elevated bilirubin; orelevated livert transaminases812. If the patient has none of these four (4)symptoms812, the intensivist is prompted to consider other more likely sources of infection (see fever of unknown origin or FUO)814. If the infection remains undiagnosed following an alternative work-up, the intensivist is prompted to re-enter thealgorithm814.
• If the patient has any of these four (4)symptoms812, the intensivist is prompted to determine whether alternative intra-abdominal infectious sources are more likely816. If alternative intra-abdominal infectious sources are not more likely, the intensivist is prompted to determine whether the patient is sufficiently stable to go for atest826. If the patient is sufficiently stable to go for a test, the intensivist is prompted to perform anmso4 Cholescintigraphy836. The normal AC is excluded838. If the test indicates an abnormality, the intensivist is prompted to consider a cholecystectomy orprecutaneous drainage840. If the patient is not sufficiently stable to go for a test, the intensivist is prompted to perform abedside ultrasound828. If no other infectious etiologies are identified and no abnormalities of the gall-bladder are noted but: a) the patient remains ill830, the intensivist is prompted to considerempiric cholecystostomy832. If no other infectious etiologies are identified and no abnormalities of the gall bladder are noted but: b) the patient is improving830, the intensivist is prompted to continue to observe thepatient834.
• If alternative intra-abdominal infectious sources are more likely816, the intensivist is prompted to determine whether the patient is sufficiently stable to go for atest818. If the patient is sufficiently stable to go for atest818, the intensivist is prompted to perform anabdominal CT scan820. If no other infectious etiologies are apparent and the test: a) demonstrates abnormalities of the gall-bladder but not diagnostic; or b) no gall-bladder abnormalities are noted822, the intensivist is prompted to maintain continued observation of thepatient824. Alternatively, if neither of these criteria is met822, the intensivist is prompted to perform anmso4 cholescintigraphy836. Normal AC is excluded838. If the test is abnormal, the intensivist is prompted to consider cholecystectomy orprecutaneous drainage840. If the patient is not sufficiently stable to go for a test, the intensivist is prompted to perform abedside ultrasound828. If no other infectious etiologies are identified and no abnormalities of the gall-bladder are noted but: a) the patient remains ill830, the intensivist is prompted to considerempiric cholecystostomy832. If no other infectious etiologies are identified and no abnormalities of the gall bladder are noted but: b) the patient is improving830, the intensivist is prompted to continue to observe thepatient834.
• Referring toFIG. 22, the adrenal insufficiency decision support algorithm of the present invention is illustrated. When an intensivist suspects an adrenal problem may be presented in a patient, the intensivist may initiate the adrenal insufficiency decision support algorithm which prompts questions concerning all aspects of the condition. First the intensivist is prompted to determine whether the patient is either hypotensive and/or has been administered pressors for forty-eight hours or longer900. If neither condition is met, the system advises the intensivist that it is unlikely that an adrenal problem is present902.
• If one or both conditions are met, the intensivist is asked whether an obvious cause for hypotensive blood pressure or treatment with pressors are manifested, such as hypovolemia or low blood volume, myocardial dysfunction, orspinal injury904. If at least one of these obvious causes is present, the intensivist is alerted by the system that the underlying cause must first be treated906. If treatment of a suspected underlying cause is reversed, yet the hypotension or pressor need persists, the intensivist is further directed to determine whether other adrenal problems have occurred in the patient'shistory908,910,912.
• In order to examine prior treatment issues, the intensivist is first prompted by the system to determine if the patient has been treated with steroids in the previous six months for at least a twoweek period908. Next, the intensivist is prompted to determine whether the patient has hyponatremia orhyperkalemia910. The intensivist is also prompted to determine whether the patient has experienced anticoagulation or become coagulopathic prior to the hypotension orpressor treatment912. According to the responses provided by the intensivist to the system queries or blocks908,910, and912, the system calculates atreatment action914 as follows: The array of possible responses todiagnosis questions908,910, and912 are given a Decision Code as shown in Table 1A: Adrenal Insufficiency Considerations, below.

• TABLE 1A
  AdrenalInsufficiency Considerations

  Question

  1	Question 2	Question 3
  	908	910	912	Decision Code
  	N	N	N	A
  	N	N	Y	A
  	N	Y	N	B
  	N	Y	Y	C
  	Y	Y	Y	C
  	Y	N	N	D
  	Y	Y	N	B
  	Y	N	Y	D
  	Y	Y	Y	C

• The possible decision codes of Table 1A are as follows:

• 	Decision
  	Code	Treatment Action
  	A	Do cosyntropin stim test
  	B	Consider possible Adrenal Insufficiency. Give
  		decadron 5 mg IV, so cosyntropin stim test and
  		empirically treat with hydrocortione 50 mg IV
  		every 8 hours until stim test results return.
  	C	Consider possible Adrenal Insufficiency,
  		secondary to adrenal hemorrhage.
  		Givedecadron 5 mg IV, so cosyntropin stim test
  		and empirically treat with hydrocortione 50 mg
  		IV every 8 hours until stim test results return.
  	D	Do cosyntropin stim test, may empirically treat
  		with hydrocortisone 25-50 mg IV every 8 hours
  		until stim test results return

• Besides specialized treatment actions listed in the decision codes above, the intensivist is directed to administer acosyntropin stimulation test914 in order to see how much cortisone the adrenal gland is producing.
• After performing the cosyntropin stimulation test, the intensivist is prompted to enter the patient's level of cortisol before administering cosyntropin and thirty minutes afterwards916. The software analyzes the test results as follows: The results in Table 2, shown below, are shown as having certain decision codes A through F.

• TABLE 2
  Cosyntropin Stimulation Test Results

  	basal (A)	basal (B)	basal (C)
  	<15	15-20	>25
  	stim (D)	stim (E)	stim (F)
  	<5	5-10	>10

• Depending upon the outcome of the analysis of Table 2, one of the treatment actions, shown below in Table 3, will be displayed918.

• TABLE 3
  Cosyntropin Test Result Treatment Actions

  	Decision Code	Treatment Action
  	A + D	Adrenal insufficiency diagnosed - treat
  		withhydrocortisone 50 mg IV every 8
  		hours and consider endocrine consult
  	A + E	Probable Adrenal insufficiency- treat with
  	B + D	hydrocortisone 25-50 mg IV every 8 hours
  		and taper as intercurrent illness improves
  	A + F	Possible Adrenal insufficiency- consider
  	B + E	treatment withhydrocortisone 25 mg IV
  		every 8 hours and taper as intercurrent
  		illness improves
  	A + F	Adrenal insufficiency unlikely-
  	B + F	would not treat
  	C + E
  	C + F

• Referring toFIG. 23, the blunt cardiac injury decision support algorithm of the present invention is illustrated. If an intensivist suspects that blunt cardiac injury may be present, the intensivist may not be certain of all aspects that would be critical to or indicative of this particular condition. Therefore, the intensivist is lead through a decision support algorithm, which first causes the intensivist to determine whether any of seven (7) risk factors are present: 1) was thoracic impact greater than fifteen (15) mph; 2) was the steering wheel deformed; 3) was there precordial ecchymosis, contusions, or abrasions; 4) was marked precordial tenderness present; 5) was there a fractured sternum; 6) were bilateral rib/costal cartilage fractures present; 7) were thoracic spine fractures present1000. If none of the 7 risk factors are present, the intensivist is prompted that no further evaluation is necessary1002. If any of the 7 risk factors are present, the intensivist is prompted to obtain an electrocardiogram (ECG) and chest X-ray (CXR)1004.
• Once the results of the ECG and CXR are obtained, the intensivist is prompted to determine: whether the ECG results are abnormal, with abnormal being defined as anything other than sinus rhythm, including ectopy and unexplained sinus tachycardia (greater than 100 beats/minute); and whether the CXR results are abnormal, with abnormal being defined as any skeletal or pulmonary injury, especiallycardiac enlargement1006. If either the ECG or CXR is not abnormal, the intensivist is prompted that a monitored bed is unnecessary for thepatient1008. If either the ECG or CXR is abnormal, the intensivist is prompted to determine whether there is any hemodynamic instability (hemodynamic instability being defined as the absence of hypovolemia, spinal cord injury, or sepsis) that cannot be explained by hypovolemia, spinal cord injury, orsepsis1010.
• If this criterion is not met, the intensivist is prompted: that the patient should be in a monitored bed; that the ECG should be repeated at 24 hours; that, at any time, if unexplained hemodynamic instability is present, the intensivist should request a stat echo; and that, if blunt thoracic aortic injury is also suspected, a transesophogeal echocardiogram (TEE) is favored over a transthoracic echocardiogram (TTE)1012. Once the results of these tests are obtained, the intensivist is prompted further to determine whether ectopy, arrhythmia, or abnormality is present on theECG1014. If none of these criteria are met, the intensivist is prompted that cardiac injury is excluded1016. If any of these criteria are met, the intensivist is prompted that he should consider monitoring the patient for an additional 24hours1018.
• If the internist determines that there is any hemodynamic instability that cannot be explained by hypovolemia, spinal cord injury, orsepsis1010, he is prompted: to perform a stat echo; and, if blunt thoracic aortic injury is also suspected, that a transesophogeal echocardiogram (TEE) is favored over a transthoracic echocardiogram (TTE)1020. Once the results of the stat echo are obtained, the intensivist is prompted to determine whether the echo is abnormal with possible causes for the abnormality being: pericardial effusion (tamponade; hypokineses or akinesis (wall motion); dilatation or reduced systolic function; acute valvular dysfunction; and/orchamber rupture1022. If the stat echo is abnormal, the intensivist is prompted to treat as indicated for the particular cause of theabnormality1026. If the stat echo is not abnormal, the intensivist is prompted to continue to monitor the patient and repeat the ECG at 24hours1024.
• Once the results of the ECG are obtained, the intensivist is prompted to determine whether ectopy, arrhythmia, or abnormality are present on theECG1014. If any of these criteria are not met, the intensivist is prompted that cardiac injury is excluded1016. If any of these criteria are met, the intensivist is prompted that he should consider monitoring the patient for an additional 24hours1018.
• Referring toFIGS. 24A-B, the candiduria decision support algorithm, which is yet another decision support algorithm of the present invention is illustrated. In the candiduria decision support algorithm, the intensivist is presented with the criteria for diagnosing candiduria, or severe fungal infection. First, the intensivist determines whether the patient has any medical conditions that render the patient prone to fungal infections, such as diabetes, GU anatomic abnormality, renal transplant, orpyuria1100. If there are no such conditions, the intensivist is next prompted by the system to look for dissemination or spreading of thefungal infection1102. If the infection does not seem to have spread, the intensivist is prompted to change the patient's catheter and test for pyuria after twenty four hours have passed1104.
• The intensivist is prompted by the system to determine whether the patient can have P.O.1106. If the patient can take P.O., the system next prompts the intensivist to determine whether azoles, an organic compound for inhibiting fungal growth, have been administered in the past three days to fight theinfection1108. If azoles have been previously administered, the systemic infection diagnosis is confirmed and the intensivist is referred to the systemicamphotericin dosing algorithm1110. If azoles have not been previously administered, directions for the proper treatment dosage of fluconazole (a type of azole) is provided to the intensivist along with adjustments for the species of fungus found1112. Where the patient cannot take P.O., the intensivist is again referred to the systemicamphotericin dosing algorithm1114.
• When the patient does have some condition prone to fungal infection, the intensivist is prompted to determine what other signs of dissemination are exhibited in thepatient1116. The intensivist is prompted to see if the patient can take P.O. If the patient cannot take P.O., the intensivist is referred to the systemicamphotericin dosing algorithm1120. If the patient can take P.O., the intensivist is prompted to check whether azoles have been administered in the previous threedays1122. If azoles have been administered, the systemic infection is confirmed and the intensivist is referred to the systemicamphotericin dosing algorithm1124. If no azoles have been administered previously, the intensivist is given instructions for administering fluconazole to treat theftmgal infection1126.
• If there is no evidence of dissemination, the intensivist is still prompted to determine whether the patient can take P.O.1128. Where the patient cannot take P.O., directions are provided to administer amphotericinbladder washing procedures1130. If the patient cannot take P.O., the intensivist is prompted to determine whether azoles have been administered in the previous threedays1132. If azoles have been administered, the systemic infection is confirmed and the intensivist is referred to the systemicamphotericin dosing algorithm1134. If no azoles have been administered previously, the intensivist is given instructions for administering fluconazole to treat thefungal infection1136.
• Referring toFIGS. 25A-B, the Cervical Spine Injury decision support algorithm of the present invention is illustrated. If an intensivist suspects that a cervical spine injury may be present, the intensivist may not be certain of all of the factors that would be indicative of this particular condition. Therefore, the intensivist is lead through a decision support algorithm, which first prompts the intensivist to determine if the patient is awake, alert, not intoxicated, and has no mental status changes1200. If these criteria are met, the intensivist is prompted to determine whether the patient has anyneck pain1202. If the patient does not have any neck pain, the intensivist is prompted to determine whether the patient has any other pain which would distract from his or herneck pain1204. If this criterion is not met, the intensivist is prompted to determine whether the patient has anyneurologic deficits1206. If this criterion is not met, the intensivist is prompted that a stable C-spine is present if the patient can flex, extend, move neck left/right without pain and without neck tenderness topalpitation1208. The intensivist is prompted further that he can remove thecollar1208.
• Alternatively, if the patient does haveneck pain1202, the intensivist is prompted toorder 3 xrays1210 consisting of: 1) lateral view revealing the base of the occiput to the upper border of the first thoracic vertebra; 2) anteroposterior view revealing spinous processes of the second cervical through the first thoracic vertebra; and 3) an open mouth odontoid view revealing the lateral masses of the first cervical vertebra andentire odontoid process1210. If the x rays are normal the intensivist is prompted to consider extension then flexion lateral x rays; if normal he is prompted that he can remove the collar; if abnormal, he is prompted to obtain asurgical consult1212. If the x rays are abnormal, the intensivist is prompted to obtain a surgical consult and order aCT scan1214. If the x rays are indeterminate, the intensivist is prompted to order aCT scan1216.
• Alternatively, if the patient has no other pain which would distract from theirneck pain1204, the intensivistis prompted toorder 3 x rays (the same types of x rays described in1210 above with the same prompting based on normal, abnormal, or indeterminate x rays)1218.
• If the patient does haveneurologic deficits1206, the intensivist is prompted to determine whether the neurologic deficit is referable to the cervical spine1226. If this criterion is not met, the intensivist is prompted toorder 3 x rays (the same types of x rays described in1210 above with the same prompting based on normal, abnormal, or indeterminate x rays)1218. If the neurologic deficit is referable to the cervical spine1226, the intensivist is prompted that the patient should obtain immediate spine trauma surgery consult and CT or MRI (if available)1228.
• Alternatively, if the intensivist determines that the patient does not pass the criteria of being awake, alert, not intoxicated and having no mental status changes1200, the intensivist is prompted to determine whether the patient hassevere head trauma1232. If this criterion is met, the intensivist is prompted to order CT of the neck withhead CT1236. If this criterion is not met, the intensivist is prompted to determine whether the patient has any neurologic deficit referable to thecervical spine1234. If the intensivist determines that the patient does have a neurologic deficit referable to the cervical spine, the intensivist is prompted that the patient should obtain immediate spine trauma surgery consult and CT or MRI (if available)1228. If the intensivist determines that the patient does not have a neurologic deficit referable to thecervical spine1234, he is prompted toorder 3 x rays (the same types of x rays described in1210 above with the same prompting based on normal, abnormal, or indeterminate x rays)1218.
• Referring toFIG. 26A-B, the Oliguria decision support algorithm of the present invention is illustrated. If an intensivist suspects that Oliguria may be present, the intensivist may not be certain of all of the aspects that would be indicative of this particular condition. Therefore, the intensivist is lead through a decision support algorithm, which first causes the intensivist to determine if the patient is oliguric, with the criterion being passage of less than 25 cc of urine in a period of 2hours1300. If this criterion is met the intensivist is prompted to determine whether the patient is anuric (the criterion for which is passage of less than 10 cc of urine in a 2 hour period) in spite offluid administration1302.
• If this criterion is met, the intensivist is prompted to determine whether the urinary catheter is working by flushing thecatheter1304. The intensivist is then prompted to determine whether the catheter is functioning1306. If the catheter is not functioning, the intensivist is prompted to replace or reposition thecatheter1308. If the catheter is functioning, the intensivist is prompted to determine whether the patient has a history of: 1) renal stone disease; 2) abdominal, pelvic, or retroperitoneal cancer; or 3) recent pelvic orretroperitoneal surgery1310. If any of these criteria are met, the intensivist is prompted to perform the following actions: 1) do renal ultrasound emergently to rule out obstruction; 2) while waiting for ultrasound, administer fluid at the rate of 7-15 ml/kg of bodyweight; and 3) send urine forspecific gravity determination1312. Based on the renal ultrasound test results, the intensivist is prompted to determine whether an obstruction is present1314. If an obstruction is determined to be present, the intensivist is prompted to consult a urologist immediately1316.
• Alternatively, if the intensivist determines that the patient does not have a history of: 1) renal stone disease; 2) abdominal, pelvic, or retroperitoneal cancer; or 3) recent pelvic orretroperitoneal surgery1310, the intensivist is prompted to determine whether: 1) the patient has a history of heart failure or known ejection fraction of less than 30 percent; or 2) there are rales on thephysical exam1318.
• Alternatively, if following the renal ultrasound test, the intensivist determines that there is no obstruction the intensivist is prompted to determine whether: 1) the patient has a history of heart failure or known ejection fraction of less than 30 percent; or 2) there are rales on thephysical exam1318.
• If the intensivist determines that the patient is not anuric1302, then the intensivist is prompted to determine whether: 1) the patient has a history of heart failure or known ejection fraction of less than 30 percent; or 2) whether there are rales on thephysical examination1318. If neither of these criteria is met, the intensivist is prompted to administer fluids to the patient at the rate of 10-20 ml/kg ofbodyweight1320 and send the patient's urine sample for aspecific gravity test1322 as more fully described inFIGS. 26B-C.
• Alternatively, if the patient does: 1) have a history of heart failure or known ejection fraction less than 30 percent; or 2) there are rales on thephysical exam1318, the intensivist is prompted to determine whether there has been a chest x-ray (CXR) in the last 6hours1324. If this criterion is not met, the intensivist is prompted to determine whether there has been a change inrespiratory status1326. If there has been no change in the respiratory status, the intensivist is prompted to administer 7-15 ml of fluids per kg ofbodyweight1328 and to send the patient's urine sample for a specific gravity test.
• Alternatively, if the intensivist determines that there has been a change inrespiratory status1326, the intensivist is prompted to: 1) do a chest x-ray; and 2) determine whether there is evidence of edema orcongestion1334. If there is evidence of edema orcongestion1334, the intensivist is prompted to: 1) insert a PA catheter to measure wedge pressure and liver function to direct fluid replacement; and 2) send urine creatinine andsodium1332.
• If the intensivist determines that there has been a CXR in the last 6hours1324, the intensivist is prompted to determine whether there is evidence of edema orcongestion1330. If there is no evidence of edema or congestion, the intensivist is prompted to administer 7-15 ml of fluids per kg ofbodyweight1328 and send the patient's urine for aspecific gravity test1322.
• Alternatively, if the intensivist determines there is evidence of edema orcongestion1330, the intensivist is prompted to: 1) insert a PA catheter to measure wedge pressure and liver function to direct fluid replacement; and 2) send urine creatinine andsodium1332.
• Referring now toFIG. 26C-D, the oliguria algorithm description continues. Following the specific gravity test of the patient's urine, the intensivist is prompted to determine whether the results indicate the specific gravity is less than 1.018. If this criterion is met, the intensivist is prompted to: 1) send blood and urine immediately to test for blood urea nitrogen (BUN), creatinine, electrolytes, and Hgb, and spot urine for creatinine, sodium, and sediment; and 2) administer 5-10 ml of fluid per kg ofbodyweight1356. Once the results of these tests are obtained, the intensivist is prompted to determine what is theHgb1338.
• If the Hgb has increased by more than 1.5 gm/dl compared to theprevious Hgb1340, the intensivist is prompted to: 1) administer fluids 5-10 ml/kg of bodyweight and follow the urine output closely 1342. Following this, the intensivist is prompted to determine whether the labs confirm renal failure by use of the formula FE.sub.Na=Urine Na.times.Serum Creatinine/Urine Creatinine .times.Serum Na.times.1001344.
• If the Hgb is within 1.5 gm/dl from the previous Hgb or nocomparison1352, the intensivist is prompted to determine what is themean blood pressure1354. If the mean blood pressure is determined to be within 20 percent or higher than thebaseline blood pressure1356, the intensivist is prompted to determine whether the labs confirmrenal failure1344. If the mean blood pressure is determined to be greater than 20 percent below thebaseline pressure1358, the intensivist is prompted to give additional fluids and consider invasivehemodynamic monitoring1360. Following this, the intensivist is prompted to determine whether the labs confirm renal failure by use of the formula FE.sub.Na=Urine Na.times.Serum Creatinine/Urine Creatinine.times.Serum Na.times.1001344.
• Alternatively if the Hgb has decreased by 1.5 gm/dl compared to theprevious Hgb1362, the intensivist is prompted to: 1) transfuse PRBCs as needed; 2) look for source of bleeding and check PT, aPTT, &platelet count1364. Following this, the intensivist is prompted to determine what is themean blood pressure1354. If the mean blood pressure is determined to be greater than 20 percent below thebaseline pressure1358, the intensivist is prompted to give additional fluids and consider invasivehemodynamic monitoring1360. Following this, the intensivist is prompted to determine whether the labs confirm renal failure by use of the formula FE.sub.Na=Urine Na.times.Serum Creatinine/Urine Creatinine.times.Serum Na.times.1001344.
• If the labs do not confirm renal failure, as indicated by FE.sub.Na.ltoreq.1percent1346, the intensivist is prompted to: 1) continue to administer fluids and follow urine output; and 2) recheck creatinine in 6-12hours1348.
• Alternatively, if the labs do confirm renal failure, as indicated by FE.sub.Na>1percent1350, the intensivist is prompted to: 1) place central venous pressure (CVP); 2) Assure adequate intravascular volume; 3) give trial of diuretics: 40 mg lasix IV, if no response in 1 hour, give hydrodiuril 500 mg IV, wait 20-30 minutes then give 100 mg lasix, if persistent oliguria, restrict: 1) fluids; 2) potassium & phosphate; if diuresis ensues, restrict only potassium & phosphate; in both situations, adjust all renally excreted medications; and 4) see acuterenal failure1350.
• Referring now toFIG. 26E, the oliguria algorithm description continues. Alternatively, following the specific gravity test of the patient's urine, the intensivist is prompted to determine whether the results indicate the specific gravity is greater than or equal to 1.0181336. If this criterion is not met1364, the intensivist is prompted to determine whether the urine is dark or tea colored1366. If this criterion is met, the intensivist is prompted to: 1) check creatinine phospho/kinase; and 2) force fluids to inducediuresis1368.
• If the intensivist determines that the urine is not dark or tea colored, the intensivist is prompted to: 1) administer 10-20 ml of fluids per kg of bodyweight; and 2) checkHgb1370. The intensivist is then prompted to determine what is theHgb1372.
• If the Hgb is determined to be greater than 1.5 gm/dl higher than theprevious Hgb1374, the intensivist is directed to: 1) force fluids; and 2) continue to follow theurine output1376.
• Alternatively, if the Hgb is determined to be within 1.5 gm/dl of the last Hgb or there is no Hgb forcomparison1378, the intensivist is prompted to determine what is the mean blood pressure1380. If the mean blood pressure is determined to be 20 percent or higher than thebaseline pressure1382, the intensivist is prompted to: 1) continue to administer fluids; 2) follow urine output; and 3) check creatinine in 6-12 hours1384. If the mean blood pressure is determined to be greater than 20 percent below thebaseline pressure1386, the intensivist is prompted to: 1) continue to push fluids; 2) consider invasive hemodynamic monitoring; and 3) if post-op abdominal trauma, considerabdominal compartment syndrome1388.
• If the Hgb is determined to be greater than 1.5 gm/dl below theprevious Hgb1390, the intensivist is prompted to: 1) transfuse blood as needed; 2) look for bleeding source; 3) check PT, aPPT & platelet count; 4) continue to push fluids; and 5) recheck Hgb in 1-2hours1392.
• Referring toFIG. 27A-B, the open fractures decision support algorithm of the present invention is illustrated. Open fractures are where bone, cartilage, or a tooth break and push through the skin surface. The intensivist is first prompted by the system to determine whether the patient has anopen fracture1500. If one has occurred, the intensivist must then determine whether the wound is contaminated with soil, or was inflicted in a barnyard1502 in order to address higher risk of infection. If the wound is contaminated with soil, or was inflicted in a barnyard, the intensivist is prompted to administer a high dose of penicillin to the antibiotics prescribed1504. The intensivist is also prompted to takeseveral treatment steps1506. These treatment steps include administering tetanus prophylaxis, such an antitoxin injection, monitoring staphylococcus aureus until twenty-four hours after surgery, caring for the wound within six hours, and where the injury is found to be more severe during surgery, the intensivist is prompted to administer aminoglycosides for seventy two hours.
• If the wound is not contaminated with soil, or was inflicted in a barnyard, the intensivist is next prompted to determine the severity of thewound1508. To do so, the intensivist must determine the length of the wound and corresponding soft tissue damage. If the wound is either less than one centimeter and clean or greater than a centimeter long without extensive soft tissue damage, the intensivist is prompted to takeseveral treatment steps1506 as previously described. Where the soft tissue damage is extensive or amputation has occurred, the intensivist is prompted by the system to makefurther determinations1510,1512,1514 about the wound caused by the fracture. The intensivist is prompted to determine if enough soft tissue coverage is remaining for the wound to close and heal1510, if any arterial repair is needed1512, and if extensive soft tissue damage with periostitial injury, andbone exposure1514. If there is adequate soft tissue coverage, the intensivist is advised that risk of infection is low and directed to taketreatment actions1516. If arterial damage requiring repair is present, the intensivist is advised by the system that risk of infection is moderate to high and giventreatment instructions1518. Where there is soft tissue injury with periostitial stripping and bone exposure, the intensivist is alerted by the system that risk of infection is high and giventreatment instructions1520. The treatment instructions in eachcase1516,1518,1520 include administering tetanus prophylaxis, such an antitoxin injection, caring for the wound within six hours, and performing: monitoring for staphylococcus aureus, and administering aminoglycosides and high doses of penicillin, all for seventy two hours before and after any operative procedures.
• If the intensivist has determined that no exposed fracture has occurred, the system next prompts the intensivist to determine whether there is any evidence of neuro-vascular damage1522. If there is evidence of neuro-vascular damage, the intensivist is prompted to consult with a nerosurgeon or vascular surgeon immediately1524. If the intensivist determines there is no evidence of neuro-vascular damage to the patient, the system next prompts the intensivist to determine whether the patient hascompartment syndrome1526. If there is evidence of compartment syndrome seen in the patient, the intensivist is prompted to consult orthopedics right away1528. If there is no evidence of compartment syndrome seen in the patient, the intensivist is still prompted to consult orthopedics, but without any prompt fortime sensitivity1530.
• Referring toFIGS. 28A-B, the Pancreatitis diagnostic algorithm of the present invention is illustrated. To evaluate whether a patient has pancreatitis, the intensivist is first prompted to examine whether severe epigastric abdominal pains and amylase levels three times greater than normal are present in thepatient1600. If neither or one of the conditions is present, the intensivist is prompted to consider other causes of the abdominal pain, such as mesenteric ischemia, a perforated ulcer, intestinal obstruction, biliary colic, or anectopic pregnancy1602.
• If severe epigastric abdominal pains and amylase levels three times greater than normal are present, the intensivist is next prompted to provide the Ranson Criteria which is a criteria associated with the severity of pancreatitis and the potential outcome or prognosis at that particular level of severity, or Apache II score which is also a score associated with the severity of the disease and the potential prognosis at a particular level of thepatient1604. If the patient has a Ranson Criteria less than three or an Apache II score of less than eight, the intensivist is prompted by the system to consider removing the patient from theIntensive Care Unit1606. However, if the patient has a Ranson Criteria greater than three or an Apache II score of greater than eight, the intensivist is instructed to perform an abdominal ultrasound test within twenty-fourhours1607. If the results of the ultrasound test show a biliary obstruction, the intensivist is instructed to consider performing an ERCP to find and remove anygallstones1608.
• If the abdominal ultrasound results do not show any biliary obstruction, intensivist is next prompted to perform morediagnostic tests1610. The intensivist is directed to perform a Dynamic IV contrast and an abdominal Tomography (CT) scan. If the intensivist does not suspect a surgical condition exists, such as a perforated ulcer, mesenteric infarction or pancreatic infection, the tests may be performed after three days have passed. If the intensivist does suspect a surgical condition exists, the tests should be performed within three days. In either case, if the patient has creatinine levels greater than or equal to 2 miligrams per dl, the intensivist should not perform the Dynamic IV contrast test.
• Once the CT scan is performed, the intensivist is prompted to determine whether necrotizing pancreatitis is present1612. The intensivist is next required to determine whether the patient has improved sinceadmission1614. If no improvement has been seen, the intensivist is directed to perform percutaneous fluid aspiration and do a gram stain culture the collectedfluid1616. If the culture showsinfection1618, the intensivist is directed to perform surgical debridement of thepancreas1620. If the results of the culture are sterile1622, the intensivist is directed to closely follow up on the patient'scondition1624 and watch forclinical deterioration1626. If the patient does further deteriorate, the intensivist is then instructed to perform a surgical debridement of thepancreas1628. If the patient does not deteriorate, the intensivist is still prompted to closely follow the patient'scondition1630.
• Where the CT scan does not show signs of necrotizingpancreatitis1612, the intensivist is prompted by the system to closely observe thepatient1632. The intensivist is also prompted to check whether clinical deterioration is occurring1634. If no deterioration is observed, the intensivist continues to observe the patient'scondition1636. If clinical deterioration is occurring1634, the intensivist is directed to perform percutaneous fluid aspiration and do a gram stain culture the collectedfluid1616. If the culture showsinfection1618, the intensivist is directed to order surgical debridement of thepancreas1620. If the results of the culture are sterile1622, the intensivist is directed to closely follow up on the patient'scondition1624 and watch forclinical deterioration1626. If the patient does further deteriorate, the intensivist is then prompted to order a surgical debridement of thepancreas1628. If the patient does not deteriorate, the intensivist is still directed by the system to closely follow the patient'scondition1630.
• Referring toFIGS. 29A-B, the penicillin allergy diagnosis algorithm of the present invention is illustrated. In order to diagnose a penicillin allergy, the intensivist is first prompted to determine whether the patient has a history suggestive of previous penicillin orcephalosporin anaphylaxis1700. Various known reactions, including angioedema, flushing, pruritis, airway obstruction, syncope, and hypertension, are displayed for the intensivist's review. If the patient has previously had any of these reactions, the intensivist is prompted to determine whether the patient has ever taken synthetic or partially synthetic antibiotics, such as ampicillin, amoxicillin, duricef or kefzol, without anyanaphylaxis symptoms1702. If the patient has taken synthetics without reaction, the intensivist is advised by the system that penicillin or cephalosporin may be administered1716. If the patient has reacted to synthetic or partially synthetic antibiotics, the intensivist is next prompted to determine whether the patient needs penicillin or cephalosporin specifically1704.
• If the patient is not required to have penicillin or cephalosporin, the intensivist is prompted to administer thesynthetic antibiotics1706. If the patient does need penicillin or cephalosporin, the intensivist is directed by the system to consider consulting with an allergist or immunologist and perform skin tests forreactions1708. Next, the intensivist is prompted to enter whether the skin test was positive1710. If the results are negative, the intensivist is further directed by the system to administer penicillin or cephalosporin with caution, to consider pretreatment with benadryl or prednisone to counter any reaction, and to closely monitor thepatient1712. If the results of the skin test are positive, the intensivist is prompted by the system to performdesensitization procedures1714.
• If the patient does not have a history suggestive of previous penicillin orcephalosporin anaphylaxis1700, the intensivist is prompted to determine whether the patient has previously experienced skin-level reactions, such as exfoliative dermatitis, Stevens Johnson Syndrome, or Toxic Epidernial Necrolysis, when given penicillin orcephalosporin1718. If the patient has previously experienced one of these reactions, the intensivist is directed by the system to administer analternative antibiotic1720. If the patient has not experienced one of these reactions, the intensivist is prompted to determine whether there is a history of any rash when given penicillin orcephalosporin1722. If the patient has not previously had a rash when given penicillin or cephalosporin, the intensivist is advised that the patient will most likely be able to take penicillin orcephalosporin1724.
• If the patient has previously experienced a rash when given penicillin or cephalosporin, the intensivist is prompted to determine whether the rash presented when the patient was given ampicillin oramoxycillin1726. If the rash resulted from ampicillin or amoxycillin, the intensivist is next prompted to determine whether the rash was urticarial1728. If the rash was not urticarial, the intensivist is advised by the system that the patient probably can take penicillin or cephalosporin, but should be closely monitored1730. If the rash was urticarial, the intensivist is prompted to determine whether or not the patient needs penicillin orcephalosporin1704.
• If the patient is not required to have penicillin or cephalosporin, the intensivist is directed by the system to administer thesynthetic antibiotics1706. If the patient does need penicillin or cephalosporin, the intensivist is directed to consider consulting with an allergist or immunologist and perform skin tests forreactions1708. Next, the intensivist is prompted to enter whether the skin test was positive1710. If the results are negative, the intensivist is further directed to administer penicillin or cephalosporin with caution, to consider pretreatment with benadryl or prednisone to counter any reaction, and to closely monitor thepatient1712. If the results of the skin test are positive, the intensivist is directed to performdesensitization procedures1714.
• Referring toFIG. 30A-B, the Post-Op Hypertension decision support algorithm of the present invention is illustrated. If an intensivist determines that there may be a possibility of post-op hypertension, the intensivist may not be certain of all aspects that would be involved in this particular condition. Therefore, the intensivist is lead through a decision support algorithm which prompts the intensivist to determine the appropriate care to be given.
• Initially, the intensivist is prompted to determine whether the patient is hypertensive (BP greater than 20 percent above mean baseline)1800. If this criterion is met, the intensivist is prompted to determine whether the patient has any of the causes of reversible hypertension: 1) hypercapnia; 2) bladder distension; 3) pain; 4) increased ICP; 5) drugs (pressors, cocaine, ketamine and chronic MAO use with indirect acting vasopressors); 6) automatic hyperreflexia; or 7)volume overload1802. If any of these criteria are met, the intensivist is prompted to first treat those specific etiologies and, if pressure remains high, re-enteralgorithm1804.
• Alternatively, if none of these criteria are met1802, the intensivist is prompted to determine whether the patient is at risk of injury from post-op hypertension (i.e., vascular surgery, coronary artery disease, neurosurgery, ocular surgery, etc.)1806. If this criterion is not met1806, the intensivist is prompted to determine whether the BP is greater than 40 percent abovemean baseline1808. If this criterion is not met, the intensivist is prompted that the patient may not needBP treatment1810.
• If the BP is greater than 40 percent above themean baseline1808, the intensivist is prompted to determine whether the patient is inpain1812. If this criterion is met1812, the intensivist is prompted to treat pain and continue1814. Following this prompt1814, the intensivist is prompted next to determine whether the patient is actively bleeding or at significant risk for post-op bleeding (i.e., “moist closure” or high drain output)1816. If either of these criteria is met1816, the intensivist is prompted to use only short acting agents including emolol and nitroprusside as needed until bleeding has abated1818.
• Alternatively, if neither of these criteria is met1816, the intensivist is prompted to determine whether the patient is tachycardic (absolute greater than 90 bpm or ((relative greater than 15 percent over baseline))1820. If either of these criteria is met1820, the intensivist is prompted to go to Decision Table C, which is programmed for the condition of a high heart rate. If neither of these criteria is met1820, the intensivist is prompted to eliminate (NOT C) Table C and proceed to thenext decision point1820.

• TABLE C
  HR↑

  		CAD	Y	Y	Y	N	N	N
  		RAD	N	Y	Y	N	Y	N
  		↓EF	N	N	Y	N	Y	Y
  	Treatment	1ST	L	E	L	L	A	E
  		2ND	E	L	A	N	N	A

• The intensivist is prompted next to determine whether the patient is bradycardic (absolute less than 60 bpm)1822. If this criterion is met, the intensivist is prompted to go to Decision Table B, which is programmed for the condition of a low heart rate.

• TABLE B
  HR ↓

  		CAD	Y	Y	Y	N	N	N
  		RAD	N	Y	Y	N	Y	N
  		↓EF	N	N	Y	N	Y	Y
  	Treatment	1ST	N	N	A	N	A	A
  		2ND	S	S	S	H	H	H

• If this criterion is not met, the intensivist is prompted to eliminate (NOT B) Table B and proceed to thenext decision point1822. [Note: If NOT C and NOT B, the intensivist is prompted to go to Table A by default, i.e., If NOT C and NOT B Then A].

• TABLE A
  HR (nl)

  		CAD	Y	Y	Y	N	N	N
  		RAD	N	Y	Y	N	Y	N
  		↓EF	N	N	Y	N	Y	Y
  	Treatment	1ST	L	E	A	N	A	A
  		2ND	N	N	E	A	N	N

• The intensivist is prompted next to determine, sequentially, table input values for CAD, RAD, and EF.
• In these decision tables, the letter references have the following meanings: L=labetalol, E=esmolol, A=enalapril, N=nicardipine, H=hyrdalazine, S=nitroprusside. The reference to 1.sup.st and 2.sup.nd means that treatment should begin with the 1.sup.st drug and add or substitute the 2.sup.nd drug as needed.
• Using the above decision tables, the intensivist is prompted to determine whether the patient has known coronary artery disease (CAD) or 3 or more risk factors forCAD1824. If either of these criteria is met1824, the intensivist is prompted to enter a “Y” or “YES” for CAD into the table selected above in1820 and1822. If neither of these criteria is met, the intensivist is prompted to enter a “N” or “NO” for CAD into the table selected above in1820 and1822.
• Next, the intensivist is prompted to determine whether the patient has known reactive airway disease (RAD)1826. If this criterion is met1826, the intensivist is prompted to enter a “Y” or “YES” for RAD into the table selected above in1820 and1822. If this criterion is not met, the intensivist is prompted to enter a “N” or “NO” for RAD into the table selected above in1820 and1822.
• Next, the intensivist is prompted to determine whether the patient has known EF less than 30 percent or a history ofsystolic heart failure1828. If either of these criteria is met1828, the intensivist is prompted to enter a “Y” or “YES” for EF into the table selected above in1820 and1822. If neither of these criteria is met1828, the intensivist is prompted to enter a “N” or “NO” for EF into the table selected above in1820 and1822.
• Based on the table selected in1820 and1822 above, and the table inputs determined from1824,1826, and1828, the intensivist is prompted with the proper medication to administer for the 1.sup.st and 2.nd treatment.
• If the patient is not inpain1812, the intensivist is prompted to employ the procedures described above in1816.
• If the patient is at risk of injury frompost-op hypertension1806, the intensivist is prompted to determine whether the blood pressure is greater than 40 percent abovebaseline1830. If this criterion is met1830, the intensivist is prompted to employ the procedures described above in1812.
• Alternatively, if this criterion is not met1830, the intensivist is prompted to determine whether the patient is inpain1836. If this criterion is met1836, the intensivist is prompted to treat pain and reevaluate following analgesia and, if still hypertensive, to continuealgorithm1838. Following thisaction1838, the intensivist is prompted to employ the procedures described above in1816. If the patient is not inpain1836, the intensivist is prompted to employ the procedures described above in1816.
• If the patient is determined not to be hypertensive1800, the intensivist is prompted to determine whether the patient requires their BP controlled near baseline (i.e., neurosurgery, carotid surgery, thoracic aorta surgery)1832. If this criterion is not met1832, the intensivist is prompted that the patient probably does not needtreatment1834.
• Alternatively, if this criterion is met1832, the intensivist is prompted to employ the procedures described above in1836.
• Referring toFIG. 31A, the pulmonary embolism diagnosis algorithm is illustrated. If a pulmonary embolism is suspected, the intensivist is first prompted to determine whether the patient is hemodynamically unstable2900. If the patient is hemodynamically unstable, the intensivist is directed by the system to consider performing an immediate transthoracic echocardiogram, pulmonary angiogram and treatment consistent with massivepulmonary embolism2902. If the patient is not hemodynamically unstable, the intensivist is prompted to perform a VQ scan and perform further assessment of thepatient2904.
• In order to further assess the patient, the intensivist is prompted to respond to a series ofquestions2906,2908,2910,2912. The intensivist is prompted to determine whether any of the following patient conditions are present: Dyspnea, Worsening chronic dyspnea, Pleuritic chest pain, Chest pain that is non-retro sternal & non-pleuritic, O.sub.2 saturation<92% on room air that corrects with 40% O.sub.2 supplementation, Hemoptysis, orPleural rub2906. The intensivist is also prompted to determine whether any risk factors are in the patient's history, such as: Surgery within 12 weeks, Immobilization (complete bed rest) for >3 days within 4 weeks, Previous DVT or objectively diagnosed PE, Lower extremity fracture & immobilization within 12 weeks, Strong family history of DVT or PE(.gtoreq.2 family members with objective proven events or 1.sup.st degree relative with hereditary thrombophilia), Cancer (treatment within the last 6 months or palliative stages), Postpartum, orLower extremity paralysis2908. Further, the intensivist must determine whether the patient has any of the following symptoms: Heart rate>90 beats/min, Temp.gtoreq.38.0, CXR free of abnormalities (edema, pneumonia, pneumothorax), or Leg symptoms c/w DVT, syncope, blood pressure less than 90 mm Hg with heart rate greater than 100 beats/min, receiving mechanical ventilation and/or oxygen supplementation greater than 40%, and new onset or right heart failure (-JVP, new S1, Q3, T3, or RBBB)2910. The intensivist is also queried by the system to consider alternative diagnosis that may be more likely than pulmonary embolism. To do so, the intensivist is prompted to consider conditions that simulate major pulmonary embolism, such as myocardial infarction, acute infection with COPD, septic Shock, dissecting aortic aneurysm, or occult hemorrhage. The intensivist is additionally prompted to consider conditions that simulate minor pulmonary embolism, such as acute bronchitis, pericarditis, viral pleurisy, pneumonia, andesophageal spasm2912.
• Referring toFIG. 31B, the pulmonary embolism algorithm description continues. The intensivist enters the answers to the assessment queries posed2906,2908,2910,2912 into the system. If two or more responses to thepatient condition query2906 were answered yes and one or more questions were answered yes from: Heart rate>90 beats/min, Temp.gtoreq.38.0, CXR free of abnormalities, or Leg symptoms c/w DVT of the symptoms query2910, the intensivist is informed that a typical pulmonary embolism is present2914. Next, the system compares this response to the answer to thealternative diagnosis query2912. If an alternative diagnosis is at least as likely aspulmonary embolism2916, the intensivist is also given alow probability2918 tomoderate probability2920 risk factor. If an alternative diagnosis is less likely thanpulmonary embolism2922, the intensivist is given a moderate2924 to high 2926 probability risk factor.
• If less than two yes answers resulted from thepatient conditions2906, the intensivist is advised by the system that an atypical pulmonary embolism may be present2928. Next, the system compares this response to the answer to thealternative diagnosis query2912. If an alternative diagnosis is at least as likely aspulmonary embolism2930, the intensivist is told there is no risk andlow probability2932 or some risk with alow probability2934 risk factor. If an alternative diagnosis is less likely thanpulmonary embolism2934, the intensivist is given a no risk andlow probability2938 to risk butmoderate probability2940.
• If at least one answer to the symptoms of syncope, blood pressure less than 90 mm Hg with heart rate greater than 100 beats/min, receiving mechanical ventilation and/or oxygen supplementation greater than 40%, and new onset orright heart failure2910 is yes, the intensivist is prompted with a message that severe pulmonary embolism is occurring2942. Next, the system compares this response to the answer to thealternative diagnosis query2912. If an alternative diagnosis is at least as likely aspulmonary embolism2944, the intensivist is told there is a moderate probability ofpulmonary embolism2946. If an alternative diagnosis is less likely thanpulmonary embolism2948, the intensivist is notified that a high probability of pulmonary embolism is present2950.
• Once the risk factors and probabilities are determined the system compares this information to the VQ scan results. This comparison is performed according to the following Table 4 below.

• TABLE 4
  Probability table

  Input

  Clinical Probability

  	V/Q Scan	High	Moderate	Low
  	High	A	A	B
  	Intermediate	B	C	C
  	Low	B	C	E
  	Normal	E	E	E

• Where the VQ scan column and the risk column intersect, a letter code is assigned to various treatment instructions. The treatment instructions are as follows.
• A=Pulmonary embolus diagnosed. Begin treatment
  E=Pulmonary embolus excluded
  B=Proceed with the following work-up:
• • 1) Perform spira CT (If patient has real insufficiency [creatinine>2.0],consider going directly to pulmonary angiogram to reduce the potential dye load). If positive begin treatment,
  • 2) If negative, assess for DVT using compression ultrasound or venography. If positive begin treatment,
  • 3) If negative, perform pulmonary angiogram. If positive begin treatment, if negative diagnosis excluded.
    C=Proceed with the following work-up:
  • 1) Perform spiral CT. If positive begin treatment,
  • 2) If negative, assess for DVT using compression ultrasound or venography. If positive begin treatment,
  • 3) If negative perform D-dimer assay (elisa only). If negative diagnosis excluded, If positive, perform serial ultrasound of the lower extremities.
• Once the correlation is made, the instructions associated with the letter code are displayed by the system to prompt the intensivist with diagnosis and treatment instructions.
• Referring toFIG. 32, the seizure decision support algorithm of the present invention is illustrated. If an intensivist encounters seizure in a patient, he may not be certain of all of the aspects and the timelines that are critical to treating this particular condition. Therefore, the intensivist is lead through a decision support algorithm, which divides the treatment sequence into three segments: 0-30 minutes; 30-60 minutes; and beyond 60 minutes.
• At the onset of a seizure, in the 0-30 minute segment of the algorithm, the intensivist is prompted to give the patient lorazepam (0.1 mg/kg of bodyweight) in 2 mg boluses up to 8mg 2000. Subsequently, the intensivist is prompted to give the patient phenytoin (18-20 mg/kg of bodyweight) at 50 mg/min of fosphenytoin (18-20 mg/kg of bodyweight) at 150 mg/min followed by 5 mg/kg of bodyweight/day throughseparate IV line2002.
• During the 30-60 minute segment of the algorithm, the intensivist is prompted to: reload additional phenytoin or fosphenytoin (10 mg/kg of bodyweight) maintaining previous infusion; and give additional lorazepam (0.05 mg/kg of bodyweight)2004. Subsequently, the intensivist is prompted to begincontinuous EEG monitoring2006.
• The intensivist is then prompted to determine whether the patient is hemodynamically stable2008. If hemodynamically stable, the intensivist is prompted to administer propofol 1-2 mg/kg of bodyweight bolus followed by 2-10 mg/kg/hr2010.
• At the 60 minute segment of the algorithm, the intensivist is prompted that if seizure activity stops, he should taper either midazolam or propofol over the next 12-24 hours while maintaining phenytoin but if seizures persist, he is prompted to move to thepentobarbital coma block2012.
• Under pentobarbital coma, the intensivist is prompted to administer 10-15 mg/kg/hr and to maintain until seizure control is achieved onEEG2014. The intensivist is prompted further that the patient usually requires PA catheter and pressors to maintainhemodynamic control2014.
• Alternatively, if the patient is determined to be hemodynamically unstable2016, the intensivist is prompted to utilize fluids and pressors as needed (phynylephrine or dopamine) midazolam 0.2 mg/kg bolus followed by 0.1-2.0 mg/kg/hr2018.
• At the 60 minute segment of the algorithm, the intensivist is prompted that if seizure activity stops, he should taper either midazolam or propofol over the next 12-24 hours while maintain phenytoin but if seizures persist, he is prompted to move to thepentobarbital coma block2012.
• Under pentobarbital coma, the intensivist is prompted to administer 10-15 mg/kg/hr and to maintain until seizure control is achieved onEEG2014. The intensivist is prompted further that the patient usually requires PA catheter and pressors to maintainhemodynamic control2014.
• Referring toFIGS. 33A-B, the supra ventricular tachycardia (SVT) decision support algorithm of the present invention is illustrated. If an intensivist determines that SVT is present, the intensivist may not be certain of all aspects that would be involved in treating this particular condition. Therefore, the intensivist is lead through a decision support algorithm which prompts the intensivist to determine the appropriate care to be given.
• Initially, the intensivist is prompted to determine whether SVT is stable or unstable2100. If SVT is stable2102, the intensivist is prompted to determine whether the patient has a regular orirregular rhythm2102. If the patient has aregular rhythm2104, the intensivist is prompted to determine whether there is a wide complex or a narrow complex2104. If the intensivist determines that there is a wide complex2106, the intensivist is prompted to administeradenosine 6 mg/12 mg (if needed)2108. Following the administering ofadenosine2108, the intensivist is prompted to consider that if the patient converts to sinus rhythm (SR) to—consider re-entrant junctional or WPW re-entrant. If the wide complex recurs, treat the patient with esmolol or Ca+2 blockers.
• Alternatively; if no effect, the intensivist is prompted to consider V-tach2112. Next, the intensivist is prompted to: 1) load procainamide 150 mg over 10 min, then 1 mg/min infusion; and 2)synchronized cardiovert2114.
• Alternatively, if the wide complex slows, the intensivist is prompted to consider SVT w/aberrancy and continue to slow with esmolol or Ca+2blockers2116.
• The intensivist is prompted next to administer esmolol/calcium blockers and link toventricular rate control2118. The intensivist is prompted next to determine whether there has been a conversion toSR2120. If there is no conversion to SR in 24 hours, the intensivist is prompted to add antiarrhythmic agent and consideranticoagulation2122. The intensivist is prompted next to determine whether there has been conversion to SR. If conversion to SR, the intensivist is prompted to continue maintenance antiarrhythmic agent duringhospitalization2124. If no conversion to SR, the intensivist is prompted to cardiovert while on antiarrhythmic & followingheparinization2126.
• If the patient has aregular rhythm2104, the intensivist is prompted to determine whether there is a wide complex or a narrow complex2104. If the intensivist determines that there is a narrow complex2128, the intensivist is prompted to to administeradenosine 6 mg/12 mg (if needed)2130. If administering theadenosine2130 slows the ventricular rate only and the atrial rate persists, the intensivist is prompted to consider atrial flutter and continue to slow with esmolol or Ca+2blockers2132. The intensivist is prompted next to employ the procedures described above in2118.
• If administering theadenosine2130 converts the patient to SR, the intensivist is prompted to consider re-entrant sinus or junctional and if recurs, treat with esmolol or Ca+2blockers2134.
• If administering theadenosine2130 slows both atrial and ventricular rates the intensivist is prompted that there is aprobable sinus tachycardia2136. The intensivist is prompted next to continue to slow withesmolol2138. The intensivist is prompted next to employ the procedures described above in2118.
• If SVT is stable2102, the intensivist is also prompted to determine whether the patient has a regular orirregular rhythm2102. If the patient has anirregular rhythm2140, the intensivist is prompted that if no p waves, there is probableAtrial fibrillation2142. The intensivist is prompted next to slow ventricular response with esmolol or Ca+2blockers2144. The intensivist is prompted next to employ the procedures described above in2118.
• If the patient has anirregular rhythm2140, the intensivist is prompted to determine whether there are more than 3 p wave types MAT—and to treat underlying lung dz. and avoidtheophylline compounds2146. The intensivist is prompted next to slow rate with Ca+2 blockers only2148. The intensivist is prompted next to employ the procedures described above in2118.
• Referring now toFIG. 33C, the description of the SVT decision algorithm continues. If SVT is unstable2101, the intensivist is prompted to determine whether the patient has SBP less than 80, ischemia, mental status changes2150. The intensivist is prompted next to perform synchronous cardioversion (100 J, 200 J, 300 J)2152. The intensivist is prompted next that if sinus rhythm: 1) correct reversible etiologies; 2) consider starting IV antiarrhythmic for maintenance ofsinus rhythm2154. Alternatively, following2152, the intensivist is prompted next that if continued SVT: 1) correct reversible etiologies; 2) load IV antiarrhythmic (see dosing guidelines) and repeatDC cardioversion2156.
• For example, and without limitations, wide complex QRS Tachycardia is also addressed in the decision support algorithm of the present invention. Referring toFIGS. 34A-B, the wide complex QRS tachycardia decision support algorithm is illustrated. If an intensivist determines that there may be a possibility of wide complex QRS tachycardia, the intensivist may not be certain of all aspects that would be involved in this particular condition. Therefore, the intensivist is lead through a decision support algorithm which prompts the intensivist to determine the appropriate care to be given.
• Initially, the intensivist is prompted to determine whether the patient is hemodynamically stable (no angina, heart failure, or hypotension (systolic less than 80 mm))2200. If this criterion is not met, the intensivist is prompted to go to the cardio-pulmonary guidelines algorithm which is generally known to those skilled in the art.
• Alternatively, if this criterion is met, the intensivist is prompted to determine whether the patient is within 7 days of a myocardial infarction or at risk formyocardial ischemia2202. If the patient is not within 7 days of a myocardial infarction or at risk formyocardial ischemia2202, the intensivist is prompted to determine whether the wide complex QRS rhythm is sustained (greater than 30 seconds)2234. If this criterion is not met, the intensivist is prompted to determined whether the QRS is monomorphic2236. If the QRS is monomorphic2236, the to intensivist is prompted to determine whether the patient hasstructural heart disease2242. If the patient hasstructural heart disease2242, the intensivist is prompted to: 1) monitor closely; 2) look for reversible etiologies; and 3) considerantiarrhythmic therapy2244. If the patient does not havestructural heart disease2242, the intensivist is prompted to: 1) monitor closely; 2) look for reversible etiologies; and 3) if recurs and symptomatic may require further testing (prolonged holter or EP study)2246.
• If the QRS is not monomorphic2236, the intensivist is prompted to determine whether the QT is prolonged2238. If this criterion is met, the intensivist is prompted to: 1) check K; 2) give Mg; and 3) consider overdrive pacing2240. If the intensivist determines that the QT is not prolonged,2238, the intensivist is prompted to employ the procedures described above in2242.
• If the wide complex QRS rhythm is sustained2234, the intensivist is prompted to determine whether the rhythm is polymorphic or irregular2208. If the rhythm is polymorphic or irregular, the intensivist is prompted to consider atrial fibrillation with accessory pathway conduction and load with procainamide and get acardiology consultation2210. If the rhythm is not polymorphic or irregular, the intensivist is prompted with the question of whether he wishes to: 1) perform ECG diagnosis; or 2) administeradenosine diagnostically2220. If the intensivist makes the determination to perform anECG diagnosis2220, he is prompted to go to theECG diagnosis algorithm2300.
• If the intensivist makes the determination to administer adenosine diagnostically2220, he is prompted to go to the administer adenosine branch of thealgorithm2222. If there is no effect, the intensivist is prompted that there is probable VT and to determine whether the VT is monomorphic2224. If the VT is monomorphic2224, the intensivist is prompted to load with procainamide and performsynchronous cardioversion2226.
• Alternatively, if the VT is not monomorphic2224, the intensivist is prompted to load with lidocaine and performimmediate cardioversion2228.
• If the ventricular response is slowed after administeringadenosine2222, the intensivist is prompted to consider SVT with aberrancy and treat with esmolol orCa blockers2230.
• If the ventricular response converts to sinus rhythm after administeringadenosine2222, the intensivist is prompted: to consider re-entrant mechanism with BBB or WPW; and, 1) if WPW consult cardiology forpossible ablation2232.
• If the patient is within 7 days of a myocardial infarction or at risk formyocardial ischemia2202, the intensivist is prompted to determine whether the wide complex is sustained (30 seconds)2204. If the wide complex is not sustained2204, the intensivist is prompted to determine whether the patient: 1) symptomatic; 2) tachycardia runs are frequent; or 3) the tachycardia rates are rapid (greater than 180)2212. If none of these criteria is met, the intensivist is prompted to observe2216. Alternatively, if any of these criteria is met2212, the intensivist is prompted to: 1) administer lidocaine 100-200 mg & 1-4 mg/min infusion; and 2)amiodarone2214.
• If the wide complex is sustained2204, the intensivist is prompted to determine whether the rate is greater than 140/min2206. If this criterion is not met2206, the intensivist is prompted: to consider accelerated idioventricular, and that in some patients this can lead to hemodynamic compromise; and that 1) he can perform overdrive pacing if needed2218.
• Alternatively, if this criterion is met, the intensivist is prompted to follow the procedures in2208.
• If the intensivist makes the determination to performECG Diagnosis2220, he is prompted to go to the ECG Diagnosis branch of thealgorithm2220. Referring now toFIG. 34C, in the ECG Diagnosis branch, the intensivist is prompted to determine whether the patient has knownpre-excitation syndrome2300. If this criterion is met, the intensivist is prompted to determine whether the QRS complexes are predominantly negative in leads V4-V62302. If the QRS complexes are predominantly negative in leads V4-V6, the intensivist is prompted that there isprobable VT2304.
• If the QRS complexes are not predominantly negative in leads V4-V62302, the intensivist is prompted to determine whether there is a QR complex in one or more of leads V2-V62306. If this criterion is met, the intensivist is prompted that there isprobable VT2308.
• Alternatively, if this criterion is not met2306, the intensivist is prompted to determine whether there are more QRS complexes than P waves2310. If there are more QRS complexes thanP waves2310, the intensivist is prompted that there isprobable VT2312. If there are not more QRS complexes thanP waves2310, the intensivist is prompted: to consider pre-excited SVT; and that he may wish to performEP study2314.
• If the intensivist determines that the patient does not have knownpre-excitation syndrome2300, the intensivist is prompted to determine whether there is an RS complex present in anyprecordial lead2316. If this criterion is not met2316, the intensivist is prompted that there isprobable VT2318.
• Alternatively, if this criterion is met2316, the intensivist is prompted to determine whether the R to S interval is greater than 100 MS in any oneprecordial lead2320. If this criterion is met, the intensivist is prompted that there isprobable VT2322.
• If the R to S interval is not greater than 100 MS in any oneprecordial lead2320, the intensivist is prompted to determine whether there is evidence ofatrioventricular dissociation2324. If this criterion is met, the intensivist is prompted that there isprobable VT2326.
• Alternatively, if there is no evidence ofatrioventricular dissociation2324, the intensivist is prompted to determine whether V-1 is negative and V-6 positive and QRS greater than 0.14mSEC2328. If these criteria are met, the intensivist is prompted that there isprobable VT2330.
• If none of these criteria is met2328, the intensivist is prompted that the situation may represent SVT with aberrancy or underlyingbundle branch block2332.
• Referring toFIG. 35A, the assessment of sedation algorithm of the present invention is illustrated. If an intensivist encounters a need for sedation, he may not be certain of all of the aspects and the timelines that are critical to this particular process. Therefore, the intensivist is lead through a decision support algorithm, which prompts the intensivist to address a number of factors in theprocess3100.
• The intensivist is prompted initially to go to the Scoring section of thealgorithm3100. The intensivist is prompted to proceed through a number ofscorings3102 and to first score the patient's alertness with points being allocated in the following manner: asleep/unresponsive=0; responsive to voice=1; and hyperresponsive=23104.
• The intensivist is prompted next to score the patient's movement with points being allocated in the following manner: no spontaneous movement=0; spontaneous movement=1; and pulls at lines, tubes, dressings=23106.
• The intensivist is prompted next to score the patient's respiration based on whether the patient is mechanically ventilated or spontaneously breathing with points being allocated as subsequently discussed. If the patient is mechanically ventilated, the intensivist is prompted to allocate points in the following manner: no spontaneous ventilation=0; spontaneous ventilations and synchronous with ventilator=1; or spontaneous ventilations with cough or dysynchrony>10 percent of breaths=23108. Alternatively, if the patient is spontaneously breathing, the intensivist is prompted to allocate points in the following manner: respiration rate (RR)<10=0; RR=10-30=1; or RR>30=2 3108.
• The intensivist is prompted next to score the patient's heart rate with points being allocated in the following manner: >20 percent below mean for last 4 hr=0; within 20 percent mean for last 4 hr=1; or >20 percent above mean for last 4 hr=23110.
• The intensivist is prompted next to score the patient's blood pressure with points being allocated in the following manner: MAP>20 percent for last 4 hr=0; MAP within 20 percent mean for last 4 hr=1; or MAP>20 percent above mean for last 4 hr=23112.
• The intensivist is prompted next to determine the sedation score by the following formula: SEDATION SCORE=alertness+movement+respirations+heart rate+blood pressure3114. In one embodiment, respiratory rate, heart rate, and BP can be computer linked to monitor data thereby simplifying the sedation scoring assessment. The nursing observations are deemed intuitive and the nursing burden in sedation scoring can be minimal by using this point scoring.
• Referring now toFIG. 35B, the sedation assessment algorithm description continues. The intensivist is prompted then to continue the sedation assessment by moving to the Pain Assessment section of thealgorithm3116.
• In the Pain Assessment section, the intensivist is prompted to determine whether the patient is conscious, communicative, and acknowledgingpain3118. If any of these criteria is not met, the intensivist is prompted to determine: whether the sedation score is greater than 2 and the patient: is known to be in pain before becoming uncommunicative; or S/p recent surgery; or having tissue ischemia or infarct; or has wounds; or has large tumor possibly impinging on nerves. If the answer to either of these two questions is YES, the intensivist is prompted to treat forpain3118. The intensivist is prompted then to continue the assessment by moving to the Delirium Assessment section of thealgorithm3118.
• In the Delirium Assessment section, the intensivist is prompted to determine whether the sedation score is greater than 2 AND the patient has: day/night reversal with increased agitation at night OR eyes open and “awake” but disoriented; or eyes open and “awake” but pulling at lines, tubes, or dressings OR difficult to sedate prior to ventilator weaning OR paradoxical response to benzodiazepines. If these criteria is met, the intensivist is prompted to considerbutyrophenone3120.
• Referring toFIG. 36, the Bolus sliding scale algorithm is illustrated. If an intensivist encounters a need for sedation, the algorithm for which may contain a reference to the bolus sliding scale for midazolam, he nay not be certain of all of the aspects which are critical to this scale. Therefore, the intensivist is lead through a decision support algorithm, which prompts the intensivist through the use of thescale3200.
• If lorazepam is less than 0-2mg IV q 6 hr, then the intensivist is prompted to give midazolam 1-2mg q 5 min until adequately sedated3202.
• Alternatively, if lorazepam equals 2-4mg IV q 4 hr, then the intensivist is prompted to givemidazolam 2mg q 5 min until adequately sedated3202.
• Alternatively, if lorazapam is greater than 10mg IV q 4 hr, then the intensivist is prompted to givemidazolam 5mg q 5 min until adequately AND consider fentanyl and/or droperidol or Haldol for synergy despite delirium andpain assessment3202.
• Yet another decision support routine is the sedation algorithm. Referng toFIG. 37, the sedation process decision support algorithm is illustrated. If an intensivist determines that a patient will require sedation, the intensivist may not be certain of all aspects that would be involved in this particular process. Therefore, the intensivist is lead through a decision support algorithm, which prompts the intensivist to conduct a sedation assessment based on: 1) scoring; 2) pain; and 3) delirium (see Assessment of Sedation algorithm)3300.
• Following completion of thesedation assessment process3300, the intensivist is prompted to determine whether the patient is inpain3302. If this criterion is met, the intensivist is prompted to administer bolus morphine, fentanyl, other narcotic, start patient controlled analgesic (PCA) or epidural analgesia as indicated3324. If the patient is not inpain3302 or after administering bolus morphine, fentanyl, other narcotic, start patient controlled analgesic (PCA) or epidural analgesia as indicated3324, the intensivist is prompted to determine whether the patient is delirious3304.
• If the intensivist determines that the patient is delirious3304, he is prompted to administer droperidol 2.5-5mg q 30 min pm and that he may consider IV Haldol not to exceed 30 mg/24hr3326. If the patient is not delirious or after following the procedures in3326, the intensivist is prompted to determine whether the patient will need sedation for more than the next 24hours3306. If the patient will not need sedation for more than the next 24hours3306, the process continues as described inFIG. 38.
• Alternatively, if the patient will need sedation for more than the next 24hours3306, the intensivist is prompted to determine whether the sedation score is 8-103308. If this criterion is met, the intensivist is prompted to employ the Bolus sliding scale midazolam and increase lorazepam by 20 percent3328 (see Bolus sliding scale midazolam algorithm—FIG. 36). Subsequently, the intensivist is prompted to reassess sedation in 4hr3330.
• Alternatively, if the patient will need sedation for more than the next 24hours3306, the intensivist is prompted to determine whether the sedation score is 8-103308. If this criterion is met, the intensivist is prompted to employ the Bolus sliding scale midazolam and increase lorazepam by 20 percent3328 (see Bolus sliding scale midazolam algorithm—FIG. 42). Subsequently, the intensivist is prompted to reassess sedation in 4hr3330.
• If the sedation score is not 8-10, the intensivist is prompted to determine whether the sedation score is greater than or equal to the last Sed Scr after sedative bolus or increase3310. If this criterion is met, the intensivist is prompted to employ the procedures described above in3328 and3330.
• If the sedation score is not greater than or equal to the last Sed Scr after sedative bolus or increase3310, the intensivist is prompted to determine whether four (4) or more midaz boluses have been given sincelast q 4hr assessment3312. If this criterion is met, the intensivist is prompted to employ the procedures described above in3328 and3330.
• Alternatively, if less than four (4) midaz boluses have been given sincelast q 4hr assessment3312, the intensivist is prompted to determine whether the patient is adequately sedated3314. If this criterion is not met, the intensivist is prompted to employ the procedure described in3328 and3330.
• If the intensivist determines that the patient is adequately sedated3314, the intensivist is prompted to determine whether the sedation score is 0-23316. If this criterion is met, the intensivist is prompted to decrease lorazepam by 20percent3332 and reassess sedation in 4hr3334.
• Alternatively, if the sedation score is not 0-23316, the intensivist is prompted to determine whether the sedation score is less than or equal to the last Sed Scr after sedative decrease3318. If this criterion is met, the intensivist is prompted to employ the procedure described in3332 and3334.
• If the sedation score is not less than or equal to the last Sec Scr after sedative increase3318, the intensivist is prompted to determine whether the patient is clinically oversedated3320. If the patient is clinically oversedated3320, the intensivist is prompted to employ the procedure described in3332 and3334. If the patient is not clinically oversedated3320, the intensivist is prompted to reassess sedation in 4hr3322.
• Referring toFIG. 38, the short term sedation process decision support algorithm of the present invention is illustrated. If an intensivist determines that a patient will not require sedation past the next 24 hour period, the intensivist may not be certain of all aspects that would be involved in this particular process. Therefore, the intensivist is lead through a decision support algorithm, which prompts the intensivist to conduct a sedation assessment based on: 1) scoring; 2) pain; and 3) delirium (see Assessment of Sedation algorithm)3100.
• Following completion of thesedation assessment process3100, the intensivist is prompted to decrease lorazepam by 20 percent from baseline perday3102. The intensivist is prompted next to determine whether the patient is inpain3104. If this criterion is met, the intensivist is prompted to administer bolus morphine orfentanyl3122. If the patient is not in pain or after administering bolus morphine orfentanyl3122, the intensivist is prompted to determine whether the patient is delirious3106.
• If the intensivist determines that the patient is delirious, he is prompted to administer droperidol 2.5-5 mg q30min pm3124. If the patient is not delirious or after administeringdroperidol3124, the intensivist is prompted to determine whether the sedation score is 8-103108.
• If this criterion is met, the intensivist is prompted to employ the Bolus sliding scale midazolam (see Bolus sliding scale midazolam algorithm) and begin midazolam infusion or begin propofol 1-2 mg/kg bolus and 5-50 mcg/kg/min infusion3126. Subsequently, the intensivist is prompted to reassess sedation in 1hr3128.
• If the sedation score is not 8-10, the intensivist is prompted to determine whether the sedation score is greater than or equal to the last Sed Scr after sedative bolus orincrease3110. If this criterion is met, the intensivist is prompted to employ the procedures described above in3126 and3128.
• If the intensivist determines that the sedation score is not greater than the last sedation score after sedative bolus or increase3110, the intensivist is prompted to determine whether the patient is adequately sedated3112. If this criterion is not met, the intensivist is prompted to employ the procedures described above in3126 and3128.
• If the intensivist determines that the patient is adequately sedated3112, he is prompted to determine whether the sedation score is 0-23114. If this criterion is met, the intensivist is prompted to determine if the patient has been sedated for more than 72hours3130. If the patient has not been sedated for more than 72hours3130, the intensivist is prompted to hold midazolam or propofol and hold or decrease lorazepam by 50percent3132. The intensivist is prompted subsequently to reassess sedation in 1hour3134.
• Alternatively, if the intensivist determines that the patient has been sedated for more than 72hours3130, the intensivist is prompted to hold midazolam or propofol and decrease lorazepam by 20 percent perday3136. The intensivist is prompted subsequently to reassess sedation in 1hour3134.
• Alternatively, if the intensivist determines that the sedation score is not 0-23114, the intensivist is prompted to determine whether the sedation score is less than or equal to the last sedation screening aftersedative decrease3116. If this criterion is met, the intensivist is prompted to determine whether the patient has been sedated for more than 72 hours and to follow the procedures described above in3130.
• If the intensivist determines that the sedation score is not less than or equal to the last Sed Scr aftersedative decrease3116, the intensivist is prompted to determine whether the patient is clinically oversedated3118. If this criterion is met, the intensivist is prompted to determine whether the patient has been sedated for more than 72 hours and to follow the procedures described above in3130. If this criterion is not met, the intensivist is prompted to reassess sedation in 1hr3120.
• Referring toFIG. 39, the respiratory isolation decision support algorithm is illustrated. If an intensivist determines that there may be a need for respiratory isolation, the intensivist may not be certain of all aspects that would be involved in this process. Therefore, the intensivist is lead through a decision support algorithm which prompts the intensiviat to determine the need for respiratory isolation based upon: a) clinical assessment; and/or b) smear/culture findings3500.
• Pursuing the clinical assessment branch of the decision support algorithm, the intensivist is prompted to determine whether the patient has known mTB (mycobacterium tuberculosis)3502. If this criterion is met, the intensivist is prompted to determine whether the patient has been compliant with their medications for over 2 weeks and is clinically responding3512. If the patient has not been compliant with their medications for over 2 weeks and is not clinically responding3512, the intensivist is prompted that isolation is required3514. If the patient has been compliant with their medications and is clinically responding3512, the intensivist is prompted that no isolation is required3516.
• Alternatively, if the patient does not have knownmTB3502, the intensivist is prompted to determine whether the patient has known mycobacterial disease other thanTB3504. If this criterion is met, the intensivist is prompted to determine whether the patient has new CXR (chest x ray) findings and symptoms (cough 2 weeks, fever, weight loss)3518. If the patient does not have new CXR findings andsymptoms3518, the intensivist is prompted that no isolation is required3520. If the patient does have new CXR findings andsymptoms3518, the intensivist is prompted that isolation is required3522.
• If the patient does not have known mycobacterial disease other thanTB3504, the intensivist is prompted to determine whether there is a new cavitary lesion onCXR3506. If this criterion is met, the intensivist is prompted that isolation is required3524.
• Alternatively, if there is no new cavitary lesion onCXR3506, the intensivist is prompted to determine whether there are pulmonary infiltrates or whether the patient is HIV (human immunodeficiency virus) positive3508. If neither of these criteria is met, the intensivist is prompted that no isolation is required3510. If either of these criteria is met, the intensivist is prompted to determine whether the patient has new CXR findings and symptoms (cough 2 weeks, fever, weight loss) and at high risk: 1) known mTB exposure; 2) homeless; 3) prisoner; 4) travel to area with multi-drugresistant TB3526. If these criteria are met, the intensivist is prompted that isolation is required3528. Alternatively, if these criteria are not met, the intensivist is prompted that no isolation is required3530.
• Pursuing the smear/culture branch of thedecision support algorithm3500, the intensivist is prompted to determine whether the AFB (acid-fast bacilli) smear is positive3532. If the AFB smear is not positive, the intensivist is prompted that: no isolation is required; await culture results; if culture negative, no isolation required; if culture positive and patient has mycobacterial disease other than TB (MOTT no isolation is required; if the culture is positive and the patient does not have MOTT consultID3534.
• Alternatively, if the AFB smear is positive, the intensivist is prompted to determine whether the patient has known mycobacterial disease other thanTB3536. If this criterion is not met, the intensivist is prompted that isolation is required3538. If this criterion is met, the intensivist is prompted: to isolate until results of NAP test are in; if mTB positive isolate the patient; if no mTB, no isolation is required3540.
• Referring toFIG. 40, the empiric meningitis tratment decision support algorithm of the present invention is illustrated. If the intensivist is treating a patient for meningitis, the intensivist is prompted to answer a series of queries by the system to properly address medication and dosage. First, the intensivist is prompted to determine whether the patient has suffered a head trauma or undergoneneurosurgery3700. The answer to this question isinput1 to table x below. The intensivist is next prompted to determine whether the patient is allergic to penicillin or is from an area where penicillin resistant staphylococcus pneumoniae is prevalent3702. The answer to this question becomesinput2 to table x below. The intensivist must also determine whether the patient is immunocompromised3704, and the answer becomesinput3 to table x below. The intensivist determines if the patient is over fifty years ofage3706, with theanswer being input4 in table x below. Lastly, the intensivist is prompted to determine whether the patient has alteredmental status3708, and the answer becomesinput5 in table x below. The inputs to each of theseprompts3702,3704,3706,3708 is compared to a dosage database according to the Table 5 below.

• TABLE 5
  Meningitis Input-Output Table

  Input	Combinations	Output
  1	1 = yes	A)vancomycin
  	2 = no	1.5-2 gm IV q 12 h +
  		ceftazedine 2gm IV q 8 hr
  		orcefapime 2gm IV q 8hr
  2	1 = yes	B)vancomycin
  	2 = no	1.5-2 gm IV q 12 h +
  		aztreonam
  		0.5-2 gm IV q 6-8hr
  3	1 = no	ampicillin 2 gm IV q 4 h +
  	2 = no	ceftriaxone 2gm IV q12
  	3 = no	cefotaxime 2 gm IV q 6h
  	4 = yes
  4	1 = no	ceftriaxone 2gm IV q 12 hr or
  	2 = no	cefotaxime 2gm IV q 6hr
  	3 = no
  	4 = no
  5	1 = no	ampicillin 2gm IV q 4 hr +
  	2 = no	ceftazidime 2gm IV q 8hr
  	3 = yes	orcefipime 2gm IV q 8hr
  6	1 = no	vancomycin 1.5-2gm IV q 12 hr +
  	2 = yes	chloramphenicol 1gm IV q 6hr
  	3 = no
  	4 = yes
  7	1 = no
  	2 = yes
  	3 = no
  	4 = no
  8	1 = no
  	2 = yes
  	3 = yes
  9	5 = yes to	add to output
  	inputs 3-8	consideracyclovir
  		10 mg/kg IV q 8 h

• In the Meningitis Input-Output Table, possible combinations of the five inputs are listed. For the conditions manifested in the patient, different drugs and dosages will be required. The proper treatment for each combination is listed in the output column of Table 5. After the algorithm runs the comparison, the output is displayed on the computer screen, prompting the intensivist with theproper treatment3712.
• Referring toFIG. 41A, the ventilator weaning decision support algorithm of the present invention is illustrate The ventilator weaning decision support algorithm is used to determine whether an intensive care unit patient can return to breathing unassisted, and discontinue use of a ventilator. Such a determination weuires evaluation of the patient by the intensivist over the course of several days.
• To begin the decision process of whether to wean a patient from ventilator use, the intensivist is prompted to conduct daily screening, preferably during the hours of 06:00 a.m. to 10:00 a.m.3800. The daily screen prompts the intensivist to determine whether: the patients P/F ratio is greater than 200, the patient's positive end-expiratory pressure (PEEP) is less than or equal to 5, whether cough suctioning has been adequate and/or spontaneous, infusions with vasopressors have been necessary, and continuous infusions of sedatives or neuromuscular blocking agents have been necessary3800. If allconditions3802 are answered no, the intensivist is directed by the system to repeat thedaily screen3805 the following morning. If all the conditions of the daily screen are met3802, the intensivist is prompted to perform additional tests.
• If the patient has satisfied the daily screen, the intensivist is next directed to conduct a rapidshallow breathing test3804. To perform the test, the intensivist is directed to change the ventilator setting to continuous positive airway pressure (CPAP) less than or equal to 5. In other words, there is no intermittent mandatory ventilation or pressure support provided for the patient. The patient is given one minute to reach a steady state of breathing. Then the intensivist measures the ratio of breaths per minute to tidal volume (f/V.sub.T). The intensivist next is prompted to determine whether the patient's f/V.sub.T is less than or equal to 105 breathes perminute3806. If the patient's f/V.sub.T is greater than 105 breathes per minute, the intensivist is prompted to return to performing daily screening the followingmorning3808.
• If the patient's f/V.sub.T is less than or equal to 105 breathes per minute, the intensivist is next directed to perform a trial of spontaneous breathing. Here, the intensivist can either insert a T-Piece in the patient's airway or reduce the patient's CPAP to less than or equal to 5 over the course of two hours. The intensivist is prompted to observe the patient periodically in order to evaluate if the patient is breathing withoutassistance3810. The intensivist is prompted to perform a periodic assessment by determining whether: the patient's breathing characteristics are greater than 35 breaths per minute for 5 minutes, or SpO.sub.2 is less than 90%, or the patient's Heart Rate (HR) is grater than 140, or HR deviates from the baseline breathing rate by more than 20%, or the patient's SBP is outside the range of 90 to 180. If any of the conditions are met, the intensivist is directed by the system to terminate ventilator weaning3812. If the conditions are not met, the patient is further assessed.
• In further assessment, the intensivist is prompted to determine whether the patient has been able to breathe spontaneously for two hours, keep a clear airway, and does not have any procedures scheduled within twenty-four hours that would require the patient to be intubated3814. If the patient meets all of thesecriteria3814, the intensivist is notified by the system that the patient may be extubated3816. If the patient does not meet one or more of thecriteria3814, the intensivist is prompted to perform steps forprogressive weaning3818.
• Referring toFIG. 41B, the ventilator weaning decision support algorithm of the present invention is further illustrated. The intensivist, at his or her discretion may choose either T-piece progressive weaning or pressure support progressive weaning. In order to perform T-piece progressive weaning, the intensivist is directed to repeat the trial of spontaneous breathing (as previously described3810). The intensivist can either insert a T-piece in the patient's airway or reduce the patient's CPAP to less than or equal to5 over the course of two hours. The intensivist is prompted to perform periodic assessment of the patient by either a two hour or 30minute trial3820.
• In order to perform pressure support progressive weaning, the intensivist is first prompted to observe whether the patient's pressure support (PS) rating is equal to eighteen plus or minus the positive end-expiratory pressure (PEEP). Next, the intensivist is directed by the system to regulate the pressure values in order to keep the patient's respiratory rate (RR) between twenty and thirty. Next, the intensivist is directed by the system to decrease the patient's pressure support by 2-4 centimeters of water two times per day. Once the patient maintains pressure support for at least two hours, the intensivist is prompted to further pursue extubating thepatient3822.
• After either T-Piece progressive weaning3820 or pressure supportprogressive weaning3822, the intensivist is next prompted to perform a periodic assessment of the patient. Here, the intensivist must determine whether whether: the patient's breathing characteristics are greater than 35 breaths per minute for 5 minutes, or SpO.sub.2 is less than 90%, or the patient's HR is grater than 140, or HR deviates from the baseline breathing rate by more than 20%; or the patient's SBP is outside the range of 90 to 180. Where the patient meets any of these criteria, the intensivist is prompted to terminate weaning. If the patient meets none of these criteria; the intensivist is prompted to further assess the patient's ability to breath spontaneously3824.
• In further assessment, the intensivist is prompted to determine whether the patient has been able to breathe spontaneously for two hours, keep a clear airway, and does not have any procedures scheduled within twenty-four hours that would require the patient to be intubated3826. If the patient meets all of thesecriteria3814, the intensivist is notified by the system that the patient may be extubated3828. If the patient does not meet one or more of thecriteria3826, the intensivist is directed by the system to allow the patient to rest for at least twelve hours at A/C, the last level of pressure support the patient achieved3830. The intensivist is prompted to resume progressive weaning the followingday3832.
• Referring toFIG. 42, the Warfarin Dosing Algorithm of the present invention is illustrated. The intensivist is first prompted to give the initial dose and determine subsequent dosage eachday3900. When the intensivist determines subsequent dosage, he is first prompted to determine the patient'starget INR3902. If the patient's target INR ranges from 2.0 to 3.0, the intensivist is prompted by the system to make further determinations relevant to dosage. The intensivist is directed by the system to determine whether the patient is taking drugs that effectprothrombin time3904, thebaseline INR value3906, and whether rapid anticoagulation is required3908. Each answer is assigned a point value, and the total points are tabulated. If the point value is greater than one, the system refers to the 10 milligram load target database for dosing. If the point value is less than one, the system refers to the 5 milligram load target database fordosing3910.
• At theinitial INR determination3902, if the patient's INR was initially between 1.5 and 2.0, the system refers to the 5 milligram load target database for dosing. If the patient's INR was initially between 3.0 and 4.0, the system refers to the 10 milligram load target database fordosing3910. Next the intensivist is prompted to enter the day oftreatment3912 and the patient'sINR3914. Depending on whether the system has been directed to the 5 milligram load target or the 10 milligram load target, a comparison is run3916 according to the following tables.

• TABLE 6
  5 mg Load Target INR 1.5-2.0

  Day	<1.5	1.5-2	2-2.5	>2.5
  2	5	1.25-2.5	0	0
  3	5-7.5	1.25-2.5	0-1.25	0
  4	10- (Check to see	1.25-2.5	0-1.25	0
  	whether pt has
  	received vit K)
  5	10	2.5-5	0-2.5	0-1.25
  	(Check to see
  	whether pt
  	Has received vit K)
  6	15	2.5-5	1.25-2.5	0-1.25
  	Obtain hematology
  	consultation.

• TABLE 7
  10 mg Load Target INR 3.0-4.0

  Day	<1.5	1.5-2	2-2.5	2.5-3	>3
  2	10	7.5-10	5-7.5	2.5-5.0	0-2.5
  3	10-15	7.5-10	5-7.5	2.5-5	2.5-5
  4	10-15	7.5-12.5	5-10	5-7.5	2.5-5
  	(Check to see
  	whether pt
  	has received
  	vit K)
  5	15	10-12.5	7.5-10	5-7.5	2.5-5
  	(Check to see
  	whether pt
  	has received
  	vit K)
  6	15-20 obtain	10-15	7.5-12.5	5-10	5-7.5
  	hematology
  	consultation.

• The appropriate dosage and instructions is displayed on the computer screen to theintensivist3918.
• Referring toFIG. 43, the heparin-induced thrombocytopenia (HIT) decision support algorithm of the present invention is illustrated. The intensivist is prompted to observe whether the patient's platelet count has dropped 50% or more over seventy-two hours while being treated with heparin, and whether any other obvious causes of platelet reduction might be present4100. If such a drop has not occurred, the intensivist is notified by the system that the patient most likely does not have HIT, but monitoring of the platelet count should continue4102. If the patient's platelet count has drastically dropped, the intensivist is prompted to determine whether the patient has been treated with heparin for more than threedays4104. Regardless of the answer, the intensivist is next prompted to determine if the patient has been treated with heparin in the preceeding threemonths4106. If the patient has not received heparin in the proceeding three months, the intensivist is notified by the system that HIT is not likely to be the cause of the platelet drop. The intensivist is also prompted to monitor platelet count for infection or other thronbocytopenia-causing drugs, and to consider stopping heparin therapy if the platelet count drops below 50,000 percubic millimeter4108.
• If the patient has received heparin in the last threedays4104, the intensivist is further prompted to look for signs of thrombosis, orblood clotting4110. If the patient shows signs of thrombosis, the intensivist is notified by the system that the patient is likely to have HIT. Accordingly, the intensivist is prompted to stop administering heparin and flush any drug administration equipment that would contain heparin traces. The intensivist is also provided instructions by the system to treat a patient still requiring anticoagulation treatment with alternate drugs andmethods4112.
• Where the patient does not show signs ofthrombosis4110, the intensivist is prompted to check forheparin resistance4114. Signs of heparin resistance include inability to hold aPTT though heparin doses have been increase. If the patient shows signs of heparin resistance, the intensivist is prompted to consider stopping heparin treatment and to consider treating a patient still requiring anticoagulation treatment with alternate drugs andmethods4116. If the patient does not show signs of heparin resistance, the intensivist is notified by the system that the patient possibly has HIT. The intensivist is accordingly prompted to continue monitoring for thrombosis, consider infection or other drugs that cause throbocytopenia, and to consider stopping heparin therapy if the platelet count drops below 50,000 percubic millimeter4118
Results
• The structure of the present invention and its efficacy have yielded striking results in practice. In a research setting, deployment of certain rudimentary aspects of the present the invention designed to experimentally test the approach described and developed in detail above, yielded unprecedented improvements in clinical and economic outcomes: 50% improvement in severity adjusted mortality, 40% improvement in clinical complication rates, 30% improvement in ICU length of stay, and 30% improvement in overall ICU cost of care.
• A remote command center for providing services to geographically dispersed hospitalized patients has been shown. It will be apparent to those skilled in the art that other variations of the present invention are possible without departing from the scope of the invention as disclosed. For example, one can envision different ratios of command center/remote location to ICU's, other decision support algorithms that would be used by intensivists, other types of remote monitoring of not only geographically dispersed hospitalized patients but other types of hospital functions as well as industrial functions where critical expertise is in limited supply but where that expertise must be applied to ongoing processes. In such cases a system such as that described can be employed to monitor processes and to provide standardized interventions across a number of geographically dispersed locations and operations. Further, any reference to claim elements in the singular, for example, using the articles “a,” “an,” or the is not to be construed as limiting the element to the singular.

Claims (1)

1. A system for providing to a remote command center alerts concerning patients in geographically separate health care locations (HCLs) comprising:

a network;

the remote command center;

wherein the network is connected to the remote command center and wherein the network is configured to provide the remote command center access to:

a database;

monitoring stations located in the geographically separate health care locations comprising instructions for obtaining monitored patient data elements, wherein the monitored patient data elements are communicated to the database via the network, and wherein the database comprises stored patient data elements comprising the monitored patient data elements and other patient data elements associated with medical conditions of the patients;

a computerized patient care management system, wherein the computerized patient care management system comprises a processor and a memory comprising computer readable instructions, and wherein the instructions when executed by the processor cause the processor to perform operations comprising:

accessing patient data elements from the stored patient data elements;

utilizing a rules engine to apply rules repeatedly and automatically to at least two patient data elements, wherein the rules applied by the rules engine identify existing or potential patient conditions;

using information generated by the rules engine to determine if an alert should be provided to the remote command center; and

providing alerts to be concurrently displayed at the remote command center for all patients for whom the computerized patient care management system determines that an alert should be displayed at that time.

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