ICU Pad Project: application of modern computer technology in pediatric postoperative cardiac intensive care. Pilot study

After cardiac surgery procedures, all vital functions of the patient must be monitored carefully with particular focus on hemodynamic parameters. Optimizing the function of the circulatory system is the primary task of an intensive care physician as low cardiac output syndrome is one of the fundamental challenges of providing medical care to both children and adults after cardiac procedures. After a cardiac procedure, the cardiac output and, thereby, patient condition and prognosis, can be influenced by many factors, including arterial blood pressure, circulating fluid volume, arrhythmia as well as myocardial dysfunction resulting from open heart surgery using extracorporeal circulation [1, 2]. The evolution of hemodynamic parameters shortly after the procedure is usually difficult to predict. The situation may be additionally complicated by the presence of concomitant diseases or perioperative complications, specific properties of the procedure (palliative vs. total repair) and the heart defect, and the age of the patient (e.g., compensatory mechanisms are exhausted quicker in neonates and infants). The described clinical scenario requires making correct therapeutic decisions that consider all the variables characterizing the patient's condition before the procedure (including, among others, the diagnosis) and in the recent past (e.g., during the procedure and the following hours) as well as variables registered on a current basis by systems designed to monitor vital parameters (both physical and biochemical). Information obtained from clinical examinations, nurse activities and observations, life support systems (mechanical ventilators, renal replacement therapy, mechanical circulatory support) as well as information associated with pharmacotherapy (e.g., the amount of fluids administered to the patient, dosage of pressor agents) must also be considered [3]. Making therapeutic decisions in the situation presented above involves analyzing significant amounts of data from various sources (Fig. 1). This makes tracking the changes of individual parameters on an ongoing basis particularly difficult. Moreover, the variety of information sources makes data analysis less effective due to potential time loss and errors associated with the necessity of alternately gaining access to different systems. Additionally, the variety of information sources precludes uniform data presentation and introduction of mechanisms for detecting variables that fall outside of the norms set for a given patient [4]. Fig. 1 Sources of information for physicians Using a clinical system to integrate access to various data sources describing the patient's condition and enable clear analysis (on a current and retrospective basis) of all registered variables would surely facilitate the work of intensivists treating hemodynamically unstable patients after cardiac procedures. Such a system should be simple and intuitive to use, mobile, and easy to disinfect. An additional advantage comes with the ability to couple a visualization system with an expert system or a clinical decision support system (CDSS), which are able to analyze the incoming stream of medical data on a current basis, pinpointing pathological trends and associations between all variables from the whole period of hospitalization, thus aiding the intensive care physician [5, 6]. This paper describes a prototype of a system for integrating medical data, created on the basis of the foregoing rationale as part of the pilot program ICU Pad Project (IPP). The main component enabling communication between the user and the system is a mobile touch screen tablet. The system owes its development to intercollegiate cooperation with the Department of Information Technology of the Poznan University of Technology. The ICU Pad Project was approved by the Bioethical Committee of the Poznan University of Medical Sciences (approval no. 837/12, date: September 13, 2012). Testing the system involved gathering sensitive information; for this reason, the system was isolated from the “external world” and the hospital medical network. Each time when the gathered data had to be exported outside of the hospital, sensitive data were anonymized. Work on the project involved the participation of physicians, nurses, as well as individuals who did not take part in the therapeutic process. Non-medical employees working on the project were required to sign confidentiality agreements and were prohibited from disclosing the medical data they accessed. Encrypted wireless transmission between authorized devices only was used during system testing. The system consists of a server based on the Windows Vista operating system with the following software installed: Postgress SQL database (v. 9.2, http://www.postgresql.org) for data storage, Apache Tomcat http server (v. 7.0.37, http://httpd.apache.org) for handling data transmission to the mobile component, and a “stationary” software component enabling the management of the system (admitting and discharging the patients, adding users, printing observation cards). The element serving the function of joining the server and mobile components was a WiFi router ensuring encrypted transmission and access control on the level of trusted MAC addresses (Media Access Control addresses). The mobile component consisted in tablet devices (ASUS EeePAD Transformer, 32GB RAM, Android 4.1, https://www.android.com). In order to test the system, it was used to gather the data of 28 patients in stable clinical condition; during the same time, conventional medical documentation, standard for postoperative wards, was maintained.