Engineering Better Health

19 November 2008

Patient monitoring
in and out of hospital

Prof. Lionel Tarassenko

Chair of Electrical Engineering
Director, Institute of Biomedical Engineering
 The changing landscape in healthcare

• The WHO predicts that chronic diseases (long-term

conditions) such as diabetes, asthma or hypertension
will be the leading cause of disability by 2020.
 Long-term conditions

¾ In the UK there are 17.5 million people with a long-term

condition (mainly diabetes, hypertension, asthma or Chronic
Obstructive Pulmonary Disease).

¾ Diabetes is the fastest growing disease in the Western world

as a result of poor diet and obesity.

¾ £5.8 billion is spent per year by the NHS on diabetes and its
related complications (2002 figures).

¾ Asthma affects 3.7 million adults and 1.5 million children in

the UK (70,000 hospital admissions for asthma in 2002).
 Long-term conditions

¾ 80% of primary care consultations relate to long-term

conditions and patients with such conditions or their
complications use over 60% of hospital days.

¾ The key to minimising long-term complications is to

empower patients to take more responsibility for the
management of their condition.

¾ The economic driver is reduction in unplanned hospital

admissions.
 The costs of long-term conditions

¾ Unplanned hospital admissions

¾ Repeated visits to primary care physician (GP)
60% of hospital bed days
80% of GP visits
125 million people in US
15 million people in UK

Typical Annual Care Plan for a Patient with a LTC

45 minutes
8,759 hours 15 minutes alone Managed Care

41.5% of UK diabetic population have an HbA1C greater than the 7.5% target*

*2007 National Review of Diabetes - DH

 Technology for self-management

¾ Wilson et al. (BMJ, 2005): “The evidence backing the use of

disease-specific self-management programmes like diabetes
is strong. The challenge is how to move to a programme that
can support the many millions of patients who might benefit.”

¾ Focus on mobile phone:

– Equality of care – 90% of UK population owns a mobile phone
– Real-time feedback, with two-way information flow
– Communication with remote carer based on shared data
– Economic model based on reduction in unplanned hospital
admissions makes mobile phone solution a financially viable
proposition
 Patient monitoring out of hospital
Telehealth using mobile phone technology

Readings automatically
Mobile phone transmitted by the phone
BG meter

Immediate
feedback
internet
Intelligent software
analyses incoming data

Prioritisation algorithms
for effective disease SERVER
management

Interactive tool to promote self-management

Regular support from remote nurse (based on real-time data)
 Delivering the telehealth vision

/ Healthcare
telehealth
Provider Patient
Patient Team
Any
network

Prioritisation of patients Server Mobile Health Tool

• Red Alert responses
• Compliance monitoring
• Education/coaching delivery
• Medicines optimization
• Admissions avoidance programmes
• Intelligent algorithms • Colour coded feedback
• Messaging • HbA1C prediction
• Weather forecasts
• Carer Alerts
Personalised feedback screens
Web-based tools (for the telehealth nurse)
 Summary of clinical studies and trials

¾ Asthma 3 published clinical studies, 1 recruiting for Asthma UK

¾ COPD 1 trial at Bristol Royal Infirmary published in Thorax
¾ Diabetes Type 1 1 RCT at OCDEM published in Diabetes Care
4 trials in progress in Dundee, Eire, Dubai and Oxford
2 studies pending with UK NHS and Singhealth in Singapore
¾ Diabetes Type 2 1 published clinical study for Lloyds Pharmacy
¾ Cystic Fibrosis 1 published clinical trial (data submitted to NICE)
¾ Cancer 1 study at Churchill Hospital published in Annals of Oncology
¾ Drug Titration 1 study at Corbeilles-Essone presented at Alfadiem
1 trial recruiting in Oxfordshire GP Practices
¾ Hypertension 1 trial recruiting in Oxfordshire GP Practices
¾ Health Economics 1 RCT in process with the UK Department of Health
1 RCT recruiting with Matria Inc
1 RCT recruiting with SHPS Inc
 Clinical evidence

¾ 20 clinical trials or studies with e-health disease management

system (type 1 & type 2 diabetes, asthma, COPD, cystic
fibrosis, chemotherapy)
¾ Diabetes:
• 0.62% reduction in HbA1c in people with Type 1 diabetes
(after 9 months)
• 0.7% reduction in HbA1c in people with Type 2 diabetes
(after 6 months) – Mean age of patients: 58 years
¾ Asthma:
• 31% reduction in uncontrolled use of reliever inhaler
¾ COPD:
• Reduction in hospitalisation rate from 1.64 per annum to
0.70 per annum
 Commissioning telehealth services
in the NHS

¾ The following have all signed up to the t+ Medical disease

management service:
• Walsall
• Oxfordshire
• Norfolk & Norwich
• Newham
• Southampton
• Leicester
• North-East Essex
• Calderdale
¾

¾ t+ Medical is also supplying telehealth services to the

Newham Whole-System Demonstrator (WSD) Project and
is involved in the Cornwall WSD Project.

13
Patient monitoring in hospital

¾ In August 2007, the National

Patient Safety Agency (NPSA)
reported that one of the two most
important actions which could be
taken to improve patient safety in
hospitals was “to identify patients
who are deteriorating and act
early”.
 The deteriorating patient
UK statistics

¾ 20,000 unscheduled ICU admissions per annum

¾ 23,000 avoidable in-hospital cardiac arrests per annum
¾ Between 5 and 24% of patients survive to discharge
¾ Vital sign abnormalities observed up to 8 hours beforehand
in >50% of cases
 The clinical need

• Early detection of patients at risk followed by

intervention and stabilisation can prevent
adverse events such as a cardiac arrest,
unscheduled admission to ICU or death.

• Why is patient deterioration so often missed?

 The clinical need:
identifying at-risk patients

• All acutely ill patients (Level 2 and upper end of Level 1 in

NHS) have their vital signs (heart rate, breathing rate, oxygen
levels, temperature, blood pressure) continuously monitored
but…

• Patient monitors generate very high numbers of false alerts

(e.g. 86% of alerts in 1997 MIT study).

• Nursing staff mostly ignore alarms from monitors (“alarm

noise”), apart from the apnoea alarm, and tend to focus on
checking the vital signs at the time of the 4-hourly
observations.
 Vital sign monitoring
of in-hospital patients

Heart
Heart rate
rate
Respiratory
Respiratory rate
rate
Oxygen
Oxygen saturation
saturation
Single
Single representation
representation
Fusion
Fusion
Blood
Blood Pressure
Pressure of
of patient status
patient status
Temperature
Temperature

Vital sign monitoring requires data fusion

technology to deal with problem of false alerts

Data fusion technology already developed within

Oxford University for monitoring of jet engines
 Vital sign monitoring
of in-hospital patients

Heart
Heart rate
rate
Respiratory
Respiratory rate
rate
Oxygen
Oxygen saturation
saturation
Single
Single representation
representation
Fusion
Fusion
Blood
Blood Pressure
Pressure of
of patient status
patient status
Temperature
Temperature

Data fusion system relies on having learnt a model of

normality for the vital signs using a comprehensive
training of thousands of hours of vital sign data

When the data fusion system is used to monitor a high-

risk patient, an alert is generated whenever the patient
state is about to go outside the boundaries of normality
 Data fusion model of normality

¾ The model of normality has been trained on a data set acquired

from a representative sample of patients

• The model of normality is an estimate of the

unconditional probability density function (pdf)
of the normal vital sign data (c.f. “5-D histogram”)

• The unconditional pdf of the data is estimated

using Parzen windows with a number of
prototype patterns:

P 2
|| x – x ||
p(x) = 1
———— ∑ exp {
_1
———— m
}
d/2 d
P (2π) σ
m=1 2 σ2
Data fusion model of normality

¾ These prototype patterns define the

¾ data fusion model of normality
 Detecting patient deterioration

¾ Data fusion software (Visensia) is connected to patient monitors via a

standard interface.
¾ When an alert is generated, the pie chart indicates the “most
abnormal vital sign(s)” or the trend mode shows changes prior to the
alert.
 Validation trials

1. John Radcliffe Hospital (Oxford)

• 440 high-risk elective/emergency surgery or medical patients
• September 2003 to July 2005

2. Clarian Methodist (Indianapolis)

• 220 patients from upper end of general floor or Progressive
Care Unit (PCU)
• January 2006 to June 2007

3. University of Pittsburgh Medical Center (UPMC):

• 1000 patients from 24-bed Step-Down Unit (SDU)
• November 2006 to August 2007
 False alert rate during UPMC trial

¾ There were 0.94 false alerts per 100 hours of monitoring.

¾ This corresponds to a false alert rate of 0.23 per patient per

day.

¾ The Visensia data fusion model automatically switches to a

lower-dimensional model when a parameter is artifactual or
missing.

¾ This makes the technology usable by the nursing team.

 Phase 3 trial of data fusion system
Hravnak et al, MET Conference (2008)

Three-fold reduction in the number of

patients becoming critically unstable
and needing an emergency call:
17.8% in Phase 1, 5.2% in Phase 3
(p < 0.0001).

Data fusion system was not withdrawn

from the SDU at the end of the 6-month
trial.

No cardiac arrests in last 18 months

(compared with 50 in previous 18
months, prior to introduction of data
fusion technology).
 “The hospital of the future” project
Wireless monitoring and data fusion

• Vital signs and data fusion alerts from

all patients on Central Station
• Vital signs/alerts from any patient
relayed to (m)any “nurse display”
• Hospital wired and WiFi network used
 The future:
Home monitoring of vital signs?

Technology will gradually move into home monitoring

context from the hospital setting

Level 2 ¾ Acute Care (Step-

Down Unit, High-
Dependency Unit)

Level 1 ¾ Upper end of general

ward

Level 0 ¾ Lower end of general

ward
• Combination of wireless sensors
Level -1 ¾ Home monitoring of and data fusion technology
vital signs • Early discharge from hospital