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Table of Contents
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1. General Informations
1.1 Definition
- A clinical information system (CIS) is an information system designed specifically for use in the critical care environment, such as in an Intensive Care Unit (ICU). It can network with the many computer systems in a modern hospital, such as pathology and radiology. It draws information from all these systems into an electronic patient record, which clinicians can see at the patient’s bedside. This means all information systems used by Organization, currently or in the future, to collect, maintain, store, disseminate, or process any information related to patients, including but not limited to a practice management system or electronic medical record.
1.2 Benefits
A CIS can benefit both patients and clinicians by:
improving communication between the many health professionals caring for each patient providing all the information clinicians need to make good decisions making it easier for patients to have x-rays and scans when needed encouraging quality improvement allowing better clinical research.
2. Why have clinical information systems in Intensive Care?
Many medical devices are used to continually monitor extremely sick patients in ICUs. Vast amounts of information are produced.
This information allows clinicians to make the right decisions. It is estimated that ICU clinicians manage about 1700 clinical measurements per day per patient, compared to about 32 clinical measurements per day per patient in a general ward.
Without a CIS, clinicians must collect most of these measurements and record them on paper-based 24-hour ‘ICU flow charts.
All such measurements can be captured, recorded, and collated electronically with a CIS, which reduces the need for many different paper-based forms, saves time, and reduces the risk of error.
2.1 What is high-intensity care?
The Intensive Care Unit (ICU) is a hospital unit dedicated to the monitoring and intensive care of critical patients with a 24-hour continuous function. The activities are aimed at subjects suffering from one or more acute, potentially reversible organ failures, such as life-threatening and the risk of major complications, whose criticality does not allow them to be adequately managed in an ordinary hospital ward.
Patients eligible for ICU admission are divided into two broad categories, namely:
1. Patients require monitoring and treatment because one or more vital functions are threatened by an acute or chronic disease (e. g. sepsis, myocardial infarction, gastrointestinal haemorrhage) or by the sequelae of surgical or other intensive treatment (e. g. percutaneous procedures) leading to life-threatening conditions.
2. Patients who already have impairment of one of the vital functions such as cardiovascular, respiratory, renal, metabolic, or brain function but with a reasonable chance of significant functional recovery. In principle, patients with end-stage untreatable diseases are not admitted. Sometimes, however, the need for palliative care requiring intensive care measures may be considered. In addition, patients with brain death or expected brain death and organ donation may be admitted.
2.2 Levels of care
According to the classification proposed by the Intensive Care Society in the "Guidelines for the Provision of Intensive Care Services", three levels of intensive care are recognized based on the care needs of patients.
Level of Care I. Represents patients who exhibit signs of organ dysfunction and require continuous monitoring with less pharmacologic or electromedical-related support. These patients are at risk of developing one or more acute organ failures. Included are patients who are in the process of clinical improvement from one or more acute vital organ failures but whose condition is too unstable or the nursing workload is too high/complex to be managed in a regular inpatient unit.
Level of Care II. Represents patients who require pharmacological and/or electro-medical monitoring and support (e.g., hemodynamic support, respiratory assistance, renal replacement therapy) of a single vital organ system in severe, life-threatening failure.
Level of Care III. Represents patients with multiple acute organ failures with impaired vital functions (two or more) requiring immediate treatment. These patients are dependent on pharmacological and electromedical organ support such as hemodynamic support, respiratory assistance, or renal replacement therapy.
2.3 Allocation
The operating unit is preferably located in a hospital that is home to appropriate departments (e.g., presence of the trauma unit, general surgery, neurology, etc.) to ensure that the multidisciplinary needs of intensive care medicine are met. Surgical, medical diagnostic, and therapeutic facilities must be represented by medical consultants, anesthesiologists, surgeons, and radiologic technologists who must be available 24 hours a day. However, not all hospitals will develop their ICUs in the same way, with the same expertise, facilities, and equipment as each other. ICUs must be tailored to the region and hospital in which they operate in terms of size, staffing, and technology.
3. Organization in High-Intensity Care
In ICU there are special rules and needs since the sick need continuous assistance.
High-tech equipment is designed to control heartbeat, breathing and support vital functions when needed. ICU wards are generally large and open spaces; this structure derives from the need to supervise and care for several patients at the same time, both in routine and emergency conditions. Sliding glass doors or other similar solutions facilitate management and speed up access to the bed in emergencies. In general intensive care, healthcare professionals take care of patients suffering from a wide variety of conditions. However, intensive care units also deal with certain diseases: these are specialist intensive care units. The main types of Specialized Intensive Care are intensive cardiological, neurosurgical, and pediatric therapies.
- Intensive Cardiological Therapies: These care for patients who have undergone cardiac surgery and for patients whose main disease is related to the heart or circulatory system.
- Neurological ICUs: These deal with the treatment of patients with life-threatening neurological diseases, such as very extensive strokes, bleeding in the brain, brain tumours, and head and spinal cord injuries. An important role is played by assistance after major neurosurgical interventions. In general, most of the patients admitted to these wards are in a coma or deeply sedated, are subjected to specific monitoring systems, and are rarely present in general intensive care.
- Intensive neonatal therapies: deal with the care of children with very serious diseases, which must be treated with special technical support and cutting-edge technologies. The age of these patients makes it necessary to be admitted to a ward with specialized staff accustomed to caring for children and equipped with specific equipment.
3.1 Machines and equipment
Resuscitation is characterized by the presence of machines and equipment that surround the patient. On the page understanding the patient unit, you will find the explanation of all the machines around an ICU bed, which are essential to keep the patient's vital functions in balance. Some of these machines and instruments may emit sounds, indicating, for example, normal breathing activity. Therefore, it is important not to be impressed by the sounds and lights, or even by the many numbers displayed.
3.2 Assisted Ventilation
Mechanical ventilation is a form of instrumental therapy that, through a machine called "mechanical ventilator" (MV), supports the patient with severe respiratory failure, allowing him to ventilate adequately and maintaining normal gas exchange between the lungs and the environment.
It has the task of ensuring an adequate supply of O2 and CO2, administering an adequate and controlled amount of O2 to the patient, and eliminating the CO2 produced. It also aims to reduce the respiratory effort of a patient who has exhausted, or is exhausting, his energy reserves due to an excessive increase in lung work.
First of all, mechanical ventilation can be of two types:
- Invasive: necessarily requires the patient to have a tracheal gold tube, tracheal nose tube, or tracheostomy cannula in place;
- non-invasive ventilation (NIV): is performed using a face mask, mouthpiece, or helmet.
Mechanical ventilation can be performed either in the intensive care setting or at home with the aid of portable home ventilators. It can also be performed continuously or intermittently.
3.3 CPAP, BiPAP, and lung ventilators: what they are and how they work
Assisted mechanical ventilation devices such as CPAP, BiPAP, and lung ventilators are becoming increasingly necessary and important for the treatment of lung infections caused by a coronavirus. Let's take a look at what they are and what they are used for, how they work, the differences between the different devices, and what to do to use them properly. CPAP (Continuous Positive Airway Pressure) is a method of respiratory ventilation that is commonly used for patients who suffer from sleep apnea. In common jargon, CPAP refers to a device that delivers a flow of air that maintains a constant positive pressure within the airway, both in the inspiratory and expiratory phases. This non-invasive mechanical ventilation (NIV - non-invasive ventilation) is generally carried out using a face mask, mouthpiece, or helmet and can be performed both in the intensive care setting and at home, with the help of portable home devices. In the hospital, it is often used in intensive care in cases of acute cardiogenic pulmonary oedema and other forms of acute respiratory failure. At home, however, the device is almost always prescribed by pulmonologists for the treatment of sleep apnea.
During the health crisis generated by SARS-CoV-2, mechanical ventilation techniques were increasingly important and necessary for respiratory support to patients with Coronavirus interstitial pneumonia. The respiratory support used in patients with Coronavirus interstitial pneumonia has been the CPAP modality.
3.4 Operation and breathing support
Moderate and severe sleep apnea treatment guidelines call for the use of CPAP devices to help OSAS patients sleep better. Both hospital and home versions of positive airway pressure machines are very simple devices that use high pressure to push air into the airway, usually through a face mask. Continuous positive airway pressure machines, known as CPAPs, provide a continuous flow of air at constant pressure. BiPAPs, on the other hand, represent more advanced versions of CPAPs and can be used at home or in healthcare facilities. These devices push air into the lungs but then reduce the pressure to allow the air to be exhaled. BiPAP machines work similarly to CPAP but provide two types of air pressure throughout the breathing cycle, one for inhalation and one for exhalation. BiPAP therapy is used when CPAP therapy is not tolerated by some patients.
CPAP machines and lung ventilators are both considered mechanical ventilation devices; both help and support the patient's breathing. CPAP machines provide a constant flow of pressurized air to keep the airway open during sleep, thus preventing passage collapse and episodes of interrupted breathing. Lung ventilators, on the other hand, are machines that push air in and out of the lungs through tubes inserted into patients' airways when they have difficulty breathing on their own. The machines allow caregivers to fine-tune the volume of air supplied, rate of breathing, amount of oxygen, and pressure as needed. A ventilator is needed for more severe respiratory failure conditions. In this situation where the patient is unable to breathe on his own, the ventilator ensures an adequate and controlled amount of O2 and the elimination of CO2 produced.
3.5 Proper Use of CPAP and BiPAP Devices in the Time of the Coronavirus
The health crisis generated by the coronavirus has caused some agitation and anxiety among patients with pre-existing respiratory problems, such as sleep apnea, raising uncertainty about the continuation of therapy and device use. Many patients have questioned whether it is okay to continue using their CPAP machines during the outbreak. Although there is still much to learn about COVID-19, there are some basics that patients using CPAP machines should know to be aware of what they are up against during this time and avoid the risk of infection. Therefore, proper use and cleaning of CPAP and BiPAP devices should be adhered to.
4. Clinical care scoring systems
Different scoring systems have been developed to determine the severity of disease in critically ill patients. These systems are moderately accurate in predicting individual survival. However, these systems are a useful tool for monitoring the quality of care and for conducting research studies, because they allow the comparison of results between groups of critical patients with overlapping levels of disease severity.
One of the most widely used systems is the second version of the acute physiologic assessment and chronic health evaluation (APACHE II), introduced in 1985. It generates a score between 0 and 71 based on 12 physiological variables, age, and basic health conditions (see table apache ii score system). APACHE III (acute physiologic assessment and chronic health evaluation III) was developed in 1991, and APACHE IV (Acute physiologic assessment and chronic health evaluation IV) was developed in 2006. These systems are more complex with more physiological variables, but they are more complex and sometimes less used. Many other scoring systems include the second version of the simplified acute physiology score (SAPS II), the mortality prediction model (MPM), and the sequential organ failure assessment.
4.1 APACHE II
Criteria are a method for diagnosing the severity of a critical patient. A higher score corresponds to a higher criticality and a higher probability of mortality.
It is a final score that is given by the sum of a series of scores assigned to certain vital parameters, blood chemistry tests, and medical history.
The parameters evaluated are:
- Body temperature
- Blood pressure
- Heart rate
- Respiratory rate
- Oxygenation
- arterial pH
- Sodemia
- Kalemia
- Creatininaemia
- Haematocrit
- Leukocytes
- Glasgow Coma Scale
- Age
- A chronic state of health
- Bicarbonates
4.1.1 How do you build it?
- Body temperature
Lower than 29. 9°C - 4 points
between 30°C and 31. 9°C - 3 points
between 32°C and 33,9°C – 2 points
between 34°C and 35,9°C – 1 point
between 36°C and 38,4°C – 0 points
between 38,5°C and 38,9°C – 1 point
between 39°C and 40,9°C – 3 points
higher than 41°C – 4 points
- Blood pressure
The mean blood pressure values determine these scores:
Lower than 160 mmHg - 4 points
between 130 and 159 mmHg - 3 points
between 110 and 129 mmHg - 2 points
between 50 and 69 mmHg - 2 points
higher than 49 mmHg - 4 points
- Heart Rate
Heart rate values determine these scores:
Lower than 180 – 4 points
between 140 and 179 – 3 points
between 119 and 139 – 2 points
between 55 and 69 – 2 points
between 40 and 54 – 3 points
higher than 39 - 4 points
- Respiratory rate
Intended for both ventilated and non-ventilated patients
Lower than 5/min - 4 points
between 6 and 9 - 2 points
between 10 and 11 - 1 point0
between 25 and 34 - 1 point
between 35 and 49 - 3 points
over 50 - 4 points
- Oxygenation
If FiO2 < 0. 5 is used, then pO2 in mmHg should be used:
Lower than 55 - 4 points
between 55 and 60 - 3 points
between 61 and 70 - 1 point
between 200 and 349 – 2 points
between 350 and 499 – 3 points
higher than 499 – 4 points
- Arterial pH
Lower than 7. 15 - 4 points
between 7. 15 and 7. 24 - 3 points
between 7. 35 and 7. 32 - 2 points
between 7. 5 and 7. 59 - 1 point
between 7. 6 and 7. 69 - 3 points
higher than 7. 6 - 4 points
- Sodiemia
This is the amount of sodium in the plasma expressed in mmol/l:
Lower than 110 - 4 points
between 111 and 119 -3 points
between 120 and 129 – 2 points
between 150 and 154 – 1 point
between 155 and 159 – 2 points
between 160 and 179 – 3 points
higher than 179 – 4 points
- Kalemia
This is the amount of plasma potassium expressed in mmol/l:
Lower than 2. 5 - 4 points
between 2. 5 and 2. 9 -2 points
between 3 and 3. 4 - 1 point
between 5. 5 and 5. 9 - 1 point
between 6 and 6. 9 - 3 points
higher than 6. 9 -4 points
- Creatininemia
Blood creatinine in mg/dl is measured. NB if renal failure is ACUTE the score should be doubled
Lower than 0. 6 - 2 points
between 1. 5 and 1. 9 - 2 points
between 2 and 3. 4 - 3 points
higher than 3. 5 - 4 points
- Hematocrit
Lower than 20 -4 points
between 20 and 29. 9 - 2 points
between 46 and 49. 9 - 1 point
between 50 and 59. 9 - 2 points
higher than 60 - 4 points
- Leukocytes
The amount of white blood cells, over or under, determines the following scores (in thousands per microliter):
Lower than 1 -4 points
between 1 and 2. 9 - 2 points
between 15 and 19,9 – 1 point
20- 39. 9 - 2 points
higher than 40 – 4 points
Glasgow Coma Scale
The score to be awarded is 15 subtracted from the total score of the Glasgow Coma Real Scale (i.e. the score the patient would have if he were not sedated).
- Age
Additional points are awarded based on age:
Under 44 years – 0 points
between 45 and 54 years – 2 points
between 55 and 64 years – 3 points
between 65 and 74 years – 5 points
over 75 years – 6 points
- A chronic state of health
Additional chronic health scores are added:
- 2 points for a postoperative elective surgery patient with immunocompromised or
- 2 points for a positive history of severe organ failure; or
- 5 points for an inoperable patient or in the postoperative period of emergency surgery with immunocompromised or severe organ failure.
- Bicarbonates
Below are the bicarbonate values in mmol/l and the points awarded for each value:
Lower than 15 - 4 points
between 15 and 17. 9 - 3 points
between 18 and 21. 9 - 2 points
between 22 and 31. 9 - no point
between 32 and 40. 9 - 1 point
between 41 and 51. 9 – 2 points
higher than 52 – 4 points
4.2 Limits and use of assessment
As with all point scales, the system has obvious limitations for particular cases. For example, an amateur athlete will have a normally very low baseline heart rate and the system will give him a score as if it were pathological. However, the substance does not change, because the attribution of even a few points more or less does not change the substantial risk assessment.
For this reason, the APACHE system is universally used as a method for rough but effective estimation of the probability of a bad outcome in the individual critical patient.
Like all objective point scales, the APACHE score is important because it allows health care providers to use objective criteria to communicate with each other and with the patient's relatives. It is possible to give objective information to the relatives of the critically ill patient, which depends not on the doctor's subjective assessment, but precise and irrefutable figures. This allows the patient’s relatives to progressively enter the context of their condition's criticality and accept it more consciously.
