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Remote Monitoring of Physiologic Parameters is Feasible in Children

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Abstract

Background Remote monitoring of physiologic parameters has been established in adults; however there is a lack of paediatric data. Aims To prove feasibility and to assess accuracy of remote monitoring in children. Methods Patients on a cardiology ward were monitored with remote ECG (LifeTouch®, Isansys) and SpO2 (Wristox®, Nonin) monitoring devices. Periods of normal transmission were identified retrospectively by a PICU physician. Heart rate (HR), respiratory rate (RR) and SpO2 recorded by the remote sensors during periods of normal transmission were compared to routine intermittent measurements recorded by bedside nurses. Bias, precision (as per Bland-Altman), accuracy (root mean square, A(RMS) ) and percent error (PE) were calculated. A(RMS) <4% for SpO2, PE<10 for RR and HR was considered as acceptable agreement between measurements. Results for HR and RR were compared before and after a software update for LifeTouch. Results 1818 hours of monitoring in 41 patients (aged 5 months to 14 years) during 43 sessions (22 following software update) were recorded. 505 hours (28%) of data transmission was considered as normal. Agreement between standard and remote monitoring was good for HR (PE 6.9 vs 3.7 pre-, and post software update) and acceptable for SpO2 (A(RMS)=3.88). RR measurements improved following software update but remained inaccurate (PE 31 vs 22% pre-, and post software update). Conclusions Remote monitoring of physiology in children is feasible. Improvement in the duration of time when the sensors are connected to a child, and in the accuracy / quality of monitoring are needed. Development of specific paediatric sensors can help to achieve these aims.
Conclusions
Remote monitoring of physiology in
children is feasible.
Accuracy of SpO2 and heart rate
measurements were acceptable
Accuracy of respiratory rate measurements
improved after software update, however
did not yet reach target level. Further
improvements are needed.
Development of specific paediatric sensors
can help to improve patient comfort and
compliance.
Reference
1. Nangalia V, Critical Care 2010;14:233.
Acknowledgements
The sensors , gateways and the software
platform for data visualization and recording
was provided by Isansys Lifecare Ltd.
Data analysis and reporting was performed
by the authors independently.
No financial conflict of interest of the authors
declared.
Remote Monitoring of Physiologic Parameters is Feasible in Children
Background
Remote monitoring of physiologic
parameters has been established in adults;
however there is a lack of paediatric data.
We have conducted a pilot study to assess
feasibility of remote monitoring in children.
Aims
To prove feasibility of remote monitoring in
children.
To assess duration and accuracy of data
collection
To compare data before and after an
interim software (SW) update
Methods
Written consent was gained and the study
was registered with the Institutional Review
Board.
Patients on a cardiology ward were
monitored with remote ECG (LifeTouch®,
Isansys) and SpO2 (Wristox®, Nonin)
monitoring devices. (Figure 1.)
The recorded physiologic data was
transmitted via Bluetooth connection to a
gateway located near to the bedside. The
data was further transmitted from the
gateways to the hospital network on Wi-Fi.
Periods of normal transmission were
identified retrospectively by a PICU
physician. Heart rate (HR), respiratory rate
(RR) and SpO2 from the remote sensors was
compared to routine intermittent
measurements (Phillips SureSigns) recorded
by bedside nurses, during periods of normal
transmission (Figure 2).
Participant feedback was collected.
We have calculated
bias (routine monitoring - remote data)
precision (SD of bias),
accuracy (root mean square, ARMS) and
percent error (PE)
ARMS<4% for SpO2 , PE<10 for HR and RR
was considered as acceptable agreement
between measurements. Results for HR and
RR were compared before and after a
software update for LifeTouch.
Figure 1. Remote sensors used in the study: ECG
(LifeTouch®, Isansys) and SpO2 (Wristox®, Nonin)
Fule BK, McTiernan C, Cameron T, Laker S, Jarvis N, Tucker K, Matam BR, Duncan HP
Paediatric Intensive Care Unit, Birmingham Children’s Hospital, Birmingham UK
Figure 3. Bias , precision and percent error for heart rate
before and after SW update. Red line shows limit of
agreement (10% PE)
Figure 4. Bias , precision and percent error for respiratory
rate before and after SW update. Red line shows limit of
agreement (10% PE)
Figure 5. Bias , precision and percent error for respiratory
rate before and after SW update. Red line shows limit of
agreement (ARMS 4).
Results
1818 hours of monitoring in 41 patients (age
between 5 months and 14 years) during 43
sessions were recorded. 22 sessions were
recorded following software update. 505
hours (28%) of data transmission was
considered as normal.
Agreement between standard and remote
monitoring:
HR showed good agreement (PE 6.9 vs
3.7 pre-, and post SW update, Figure 3.)
SpO2 was acceptable (ARMS=3.88 overall;
3.49 pre-, 4.41 post SW update Figure 4.).
RR measurements improved following SW
update but remained inaccurate (PE 31 vs
22%. Figure 5.).
Participant feedback suggested discomfort
being the main reason for not wearing the
sensors. Remote ECG sensor was better
tolerated than pulse-oximetry.
Figure 2. A typical session of remote monitoring.
Continuous lines represent remote monitoring, markers
represent routine intermittent monitoring. Normal
transmission is indicated by a yellow line, patient not
wearing the ECG sensor by a purple line at the bottom of
HR chart.
... Unique features of the LifeTouch system are that it comes in three sizes, to facilitate monitoring children, and that the current version of the manufacturer-supplied software also allow inputs from third party devices, the Nonin WistOx2 3150 pulse oximeter and a third party wireless (but not wearable) blood pressure monitor. According to an abstract the LifeTouch has been used to monitor children 124 but full results of the trial are not yet available. Guardian dashboard software, which automatically calculates an EWS based on the monitor readings and data entered by staff. ...
... However, they are concordant with reports by Fule et al who reported a 9% data capture rate for the PPG when using the WristOx2 3150 to monitor children. 124 A notable exception to the poor system reliability observed in our testing was the RP2 which had a data capture rate of 95% and high user acceptance ratings. ...
Thesis
Full-text available
In spite of numerous quality improvement interventions, delayed recognition of inpatient deterioration is a significant cause of morbidity and mortality. Expert consensus suggests that continuous patient monitoring may have an important role in addressing the problem. The use of conventional bedside monitors for monitoring patients on general (Level 0 and Level 1) wards is poorly tolerated by patients and staff alike. Recent advances in technology have led to the development of a wide range of wearable monitors. This thesis examines the feasibility and efficacy of using wearable monitors to monitor the vital signs of patients in a general ward setting. The feasibility of monitoring was evaluated in two studies. The first was a comparative evaluation of five monitors used to monitor patients for 24 hours. The second study evaluated the feasibility of recording the electrocardiogram (ECG) and photoplethysmogram (PPG) of patients following cardiac surgery for their entire stay on the cardiac surgery ward. Data capture rates in both studies were low overall. ECG was more reliably recorded than PPG. System maturity, patient acceptance and intervention design were identified as key determinant of monitoring success. Based on our experiences we identified a need for better evaluation and implementation tools to assist future studies. We developed and validated an acceptance questionnaire. We also proposed a framework which provides a systematic approach to the implementation and evaluation of wearable monitoring systems. In selecting which vital signs to monitor, there is a trade-off between what is desirable and what is comfortable for the wearer. Respiratory rate, although a sensitive marker of deterioration, was difficult to measure comfortably. Therefore, we undertook an systematic evaluation of algorithms to estimate respiratory rate from the ECG and PPG in order to identify algorithms which might be clinically useful. We identified 4 algorithms which were more accurate than electrical impedance pneumography when operating in ideal circumstances. Further work is required to determine whether performance will be maintained in a real-world context. Finally, we examined whether continuous monitoring offered any advantage over intermittent observations according standard ward practice. We concluded that although individual patients might have benefitted from continuous monitoring, at the population level the benefit was minimal and outweighed the cost of the false alerts. The principle reason for lack of benefit was the low prevalence of abnormal vital signs. Future work should continue to address the technical and practical issues surrounding the design and implementation of wearable monitoring systems. In parallel research needs to be undertaken to gain a better understanding of which care processes are failing, what should be monitored and how the data can be used to improve the reliability of existing care.
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