Exploring the clinical relevance of vital signs statistical calculations from a new-generation clinical information system

New information on the intensive care applications of new generation ‘high-density data clinical information systems’ (HDDCIS) is increasingly being published in the academic literature. HDDCIS avoid data loss from bedside equipment and some provide vital signs statistical calculations to promote quick and easy evaluation of patient information. Our objective was to study whether manual records of continuously monitored vital signs in the Paediatric Intensive Care Unit could be replaced by these statistical calculations. Here we conducted a prospective observational clinical study in paediatric patients with severe diabetic ketoacidosis, using a Medlinecare® HDDCIS, which collects information from bedside equipment (1 data point per parameter, every 3–5 s) and automatically provides hourly statistical calculations of the central trend and sample dispersion. These calculations were compared with manual hourly nursing records for patient heart and respiratory rates and oxygen saturation. The central tendency calculations showed identical or remarkably similar values and strong correlations with manual nursing records. The sample dispersion calculations differed from the manual references and showed weaker correlations. We concluded that vital signs calculations of central tendency can replace manual records, thereby reducing the bureaucratic burden of staff. The significant sample dispersion calculations variability revealed that automatic random measurements must be supervised by healthcare personnel, making them inefficient.

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CLINICAL EXAMPLES IN CRITICALLY ILL PATIENTS A. REAL TIME CLINICAL MONITORING WITH THIS HDDCIS
The HDDCIS integrated real-time information from the monitoring and treatment equipment in use into one panel which showed the evolution of these data over the 5, 10, 20, 30, or 60 minutes prior.The attending doctor usually has to perform this type of integration in their mind while standing at the patient's bedside by observing the data that fleetingly appears on each piece of equipment connected them.Thus, there is no record of the doctor's estimations, nor can the data be reproduced later because this information is scattered among several devices and easily gets lost.
Figure S1 shows the clinical evolution (over the 10 minutes prior) of an infant on invasive mechanical ventilation due to severe bronchiolitis (pressure control ventilation).Note how the drop in their tidal volume (arrow on the yellow line) caused a drop in oxygen saturation (to 78%) 2 minutes later (arrow on the pink line) and an increase in end tidal CO2 (up to 64 mmHg) (arrow on the orange line).These parameters were normalised by increasing the ventilator pressure by 3 cmH2O (arrows on the dark blue line of the lower graph).Because the strict alarm programming of multiple independent parameters leads to an unacceptably high number of false positive alarms which affect patients, families, and caregivers (10), these episodes typically go undetected until they cause a significant vital sign disturbance (as in this case).A quick glance at these graphs allows early diagnosis of these events (in this case, 2 minutes earlier), thereby helping to avoid patient deterioration.
CLINICAL EXAMPLES IN CRITICALLY ILL PATIENTS A. REAL TIME CLINICAL MONITORING WITH THE HDDCIS Figure S1 Figure S2 B. DETECTION AND REPRODUCTION OF CLINICAL EPISODES USING HOURLY STATISTICAL INDICATORS Figure S3

Figure S2 .
Figure S2.shows the clinical evolution (over the 60 minutes prior) of an adolescent weighing

Figure S1 .
Figure S1.The real-time evolution of a ventilated infant with severe bronchiolitis.(1) Left: superimposed graphs (on the same time axis) of vital sign (top) and mechanical ventilation (bottom) data; a colour-code legend for each parameter represented in the graphs is shown in the tables.The vital signs graph has a common automatic adjustment scale for all the parameters (0-180) and, in this case, encompasses the 10 minutes prior for the following parameters: heart rate measured by electrocardiogram (HR (ECG), green line), heart rate measured by pulse oximetry (HR (pulse), red line), oxygen saturation (O2 sat, pink line), mean arterial pressure (MAP, magenta line), end-tidal carbon dioxide concentration (EtCO2, orange line), and respiratory rate (RR(t), dark blue line).The mechanical ventilation graph has a double automatic adjustment scale; in this case, the pressure scale shown on the left (0-30 in cmH2O) and volume scale on the right (0-60 mL) include the following parameters: peak inspiratory pressure programmed on the ventilator (PIP(p), dark blue line), peak inspiratory pressure measured by the ventilator (PIP, light blue line), ventilator-measured expiratory tidal volume (eVT, yellow line), and positive end-tidal pressure (PEEP, maroon line).(2) Right: tables with the real-time parameter values corresponding to the values on the right-hand limit of the graphs.

Figure S2 .
FigureS2.The real-time evolution of a ventilated patient with severe acute respiratory distress syndrome.These graphics can be interpreted following the same logic explained in Figure1for the vital signs and mechanical ventilation graphs.A colour-code legend for each parameter represented in the graphs is shown in the tables.Note how: (1) the patient was on volume-controlled mechanical ventilation (settings column: inspiratory tidal volume [iTV] LED activated), without any respiratory effort recorded during the entire period (the total respiratory rate [RR(t)] was equal to the programmed respiratory rate [RR(p)] and the spontaneous respiratory rate [RR (spon)] was 0).(2) Prior to mobilisation, the patient was stable on deep sedoanalgesia and muscle relaxation, requiring a peak inspiratory pressure (PIP) of 23-24 cmH2O to deliver the 400 mL of programmed gas (compliance was 30-31 mL/cmH2O).(3) Their manipulation in order to place an anti-decubitus mattress (shown in the highlighted area on the graphs) conditioned a significant and sustained increase in the heart rate and a progressive desaturation (up to 85%) with an increase in the PIP by up to 36 cmH2O (arrow over light blue line).This was the result of derecruitment following the mobilisation (a fall in compliance by 16 mL/cmH2O), despite not being disconnected from the mechanical ventilator as indicated by the evolution of the PIP, PEEP and EtCO2.(4) Monitoring of the electrical heart rate [HR (ECG)] was lost while the patient was being mobilised because of electrode disconnection (arrows on the upper graph on the red and green lines).(5) After mobilisation, the medical team increased PEEP from 8 to 9 cmH2O and decreased respiratory rate from 19 to 18 rpm (arrows on bottom graph maroon line and on the upper graph on the blue line, respectively).Note: the mechanical ventilation graph has a double automatic adjustment scale; in this case, the volume scale is shown on the left (0-600 mL) and the pressure scale is shown on the right (0-36 in cmH2O).

Figure S3 .
Figure S3.Desaturation episode in an infant with severe bronchiolitis after manipulation (a diaper change).Real-time evolution Graph (left) and Table with hourly statistical calculations (right).Note how (1) patient handling conditioned a significant drop in the expiratory tidal volume (lower yellow line), which caused a drop in oxygen saturation (pink line) and an increase in end-tidal CO2 (orange line) with the typical 'box' morphology of increased resistance in the patient's airway (6).(2)The haemodynamic repercussions of the episode were expressed over the baseline as a brief bradycardia (superimposed lines for the ECG-HR in green and pulse oximetry-HR in red) and a rise in mean blood pressure (magenta line) for more than 5 minutes.(3) The episode can be easily identified by estimating the hourly standard deviation (Std.deviation) of the oxygen saturation (row highlighted in blue in the table.Normal value ≤ 1).(4) The basal heart rate was fixed (graph and low basal Std.deviation-HR values), which was an expression of the serious condition of the patient.The fixed respiratory rate (RR(t)) in the graph (upper blue line) and in the table indicated that the patient was under controlled mechanical ventilation without respiratory rate modification during this period.