Computer Applications in Respiratory Care



Computer Applications in Respiratory Care


Michael E. Anders



Chapter Objectives


After reading this chapter you will be able to:


image Describe computer applications in clinical care, management, education, and research


image Retrieve evidence-based information


image Outline steps to maintain security and confidentiality



Key Terms












Computer applications are universal in respiratory care, and their impact continues to advance exponentially. Respiratory therapists (RTs) and other members of the health care team rely on computer applications in clinical care, diagnostics, management, education, and research. Emerging computer technology, or eHealth, applications aim to improve the processes of care and the performance of health care providers, engage patients, facilitate care from a distance, and manage information, improving health outcomes. Abundant, accessible, and up-to-date information from the government, universities, publishers, professional organizations, and industry is available to health care providers and patients on the World Wide Web. As established by a task force of the American Association for Respiratory Care (AARC) to chart a vision for the future, RTs will benefit from knowing how to retrieve information efficiently from the best available evidence-based resources.1 RTs have compelling reasons to learn about computer applications.



Applications in Clinical Care


Mechanical Ventilators


Conventional mechanical ventilators use microprocessors to control flow and pressure for triggering, limiting, and cycling breaths. Some modes of ventilation are closed-loop or adaptive, with predetermined algorithms that take actions automatically within preset limits. Breath-by-breath, microprocessors equilibrate measured values with target values. Based on the lung compliance measured during the previous breath, some modes adjust inspiratory pressure to attain a target tidal volume set by the clinician. New advanced adaptive systems, such as proportional assist ventilation and neurally adjusted ventilatory assist, aim to enhance the patient-ventilator synchrony via automation that is highly responsive to the patient.2


Microprocessors perform additional functions. They control ventilator alarms and archive the history of set and measured values, which can be uploaded to a computer. Current conventional ventilators allow for updating and adding new modes of ventilation via uploading new software, rather than purchasing new ventilators.


Protocols for ventilator weaning and management of acute respiratory distress syndrome can improve patients’ outcomes; complete, accurate, and consistent documentation of ventilator settings is key. However, manual ventilator charting is frequently incomplete, inaccurate, and inconsistent.3 Computerized ventilator charting applications have the potential to improve the quality and consistency of ventilator charting. Automated ventilator charting, verified by RTs, takes ventilator charting a step further, with the potential to improve completeness, accuracy, consistency, and efficiency.4 Figure 7-1 is an example of a computer screen for automated charting.


image
FIGURE 7-1 Automated ventilator charting.


Patient-Driven Protocols


Evidence-based, patient-driven protocols can improve health outcomes.5,6 Under medical direction and based on patient assessment, RTs use protocols to allocate and titrate respiratory care. Consistency and timeliness of implementation are keys to the effectiveness of protocols. Automation of protocols at the point of care can help RTs address these concerns. An automated protocol for discontinuation of the mechanical ventilation program on hand-held computers can decrease the time to the first spontaneous breathing trial and the length of stay in the intensive care unit (ICU) compared with a protocol without automation.7 At least once a shift, RTs enter information about each mechanically ventilated patient via a hand-held computer. When patients meet preset criteria, the computer program prompts the RTs to conduct a spontaneous breathing trial to help determine the patients’ readiness for ventilator discontinuation.



Clinical Decision Support


Information technology has the potential to assist clinicians actively with preventive measures, diagnosis, drug dosing, response to critical laboratory values, evidence-based care clinical practice guidelines, and chronic disease management. Clinical decision support systems match the characteristics of individual patients and their clinical interventions, drugs, and diagnostic tests to databases of scientific evidence and drug calculations and generate tailored recommendations, reminders, or even standing orders. These systems can optimally communicate these recommendations to clinicians via hospital information systems (HIS), e-mails, pagers, mobile phones, or printouts without the clinicians having to activate the system.


Clinical decision support systems are associated with improved clinician performance, decreased unnecessary care, and adherence to evidence-based clinical practice guidelines.8,9 These systems are particularly useful in preventive care. Computerized reminders increased the proportion of indicated influenza vaccinations, rates of screening, counseling, and adherence to medications. They have also resulted in decreased unnecessary hospital admissions for inappropriately diagnosed cardiac ischemia, appropriately decreased tidal volume and more consistent monitoring of plateau pressure in patients with acute respiratory distress syndrome, and decreased exacerbations in asthma patients.8 Clinical decision support is instrumental in improving clinical outcomes of patients by determining optimal drug dosages. Beneficial outcomes include the following:




Telemedicine


Telemedicine is the use of telecommunication and computer technology to promote access to diagnosis, monitoring, clinical decision support, and treatment for patients at medically underserved sites that are distant from health care providers. Telemedicine has been effectively implemented in various clinical settings, including home care, emergency departments, and ICUs, and is well accepted by patients.11 Clinical outcomes have generally been similar to traditional health care delivery models; however, in the ICU setting, supplemental telemedicine has been associated with improved clinical outcomes, particularly among the most critically ill patients.12,13 From a distance, on computers either within the hospital or at home, intensive care physicians can see the vital signs, ventilator data, medical record, and diagnostic images of the remote patients. Supplemental telemedicine helps to provide additional support that can potentially result in more rapid recognition of problems and timely, appropriate interventions.14



Treatment of Tobacco Use and Dependence


In the United States, tobacco use and dependence is the leading preventable cause of death and chronic diseases.15 Health care costs attributable to tobacco use are unsustainable. Effective evidence-based treatments are available, but their implementation by health care providers is lagging.16 RTs can play a vital role in the treatment of tobacco-related diseases and should aid in the pursuit of cost-effective ways to help tobacco users.


Emerging applications of computer technology, or eHealth applications, are exciting new components of treatment for tobacco use and dependence. With the extensive reach of the Internet and the demonstrated efficacy of some applications, the potential impact on health outcomes is immense. More than 10 million Internet users have searched for online information about how to quit smoking.17


Internet-based treatment programs can recruit tobacco users via search engines, or they can be an adjunct to telephone quitline counseling. Figure 7-2 is a screen shot from the smokefree.gov tobacco treatment website. When eHealth applications are tailored to individual tobacco users, with frequent automated contacts via e-mail or text messages, rates of long-term abstinence from tobacco use are similar to other evidenced-based interventions.18–22


image
FIGURE 7-2 Example of an internet-based program: (http://women.smokefree.gov).

Consistent with the U.S. Public Health Service clinical practice guideline recommendation for a high-intensity, multicomponent approach, an Internet-based application has the capacity to provide both counseling that promotes tailored quit strategies and tobacco cessation medications that have been approved by the U.S. Food and Drug Administration (FDA).16 Internet-based applications can provide unlimited, sustained access to virtually limitless numbers of participants. These applications can be highly cost-effective. Table 7-1 lists some websites related to the treatment of tobacco use and dependence.




Management of Chronic Respiratory Diseases


Management of chronic diseases presents a grave challenge to the U.S. health care system. In the United States, 7 out of 10 deaths are due to chronic disease.23 Chronic disease is present in 8 out of 10 Americans on Medicare, and chronic diseases account for three out of every four dollars of health care expenditures in the United States.24,25 As baby boomers age in the coming decades, the proportion of the U.S. population 65 years old and older is expected to double. There is much interest in addressing the historically disjointed, misallocated processes of chronic disease management through advances in eHealth technologies, to improve health outcomes in a cost-effective manner. In the United States, 60% of households have access to computers, and the availability of broadband access to the Internet is expanding.17 In the United States, which has a population of 311 million people, there are more than 307 million wireless mobile phone connections.26,27



Asthma


eHealth applications for asthma include interactive Internet applications, such as games for children, Internet applications linked to cell phones for personalized or automated voice or text messaging, and other telemonitoring devices. Many of these applications use monitored patient data to tailor the adjustment of the plan of care. Some provide for personalized goals, calendars, and reminders. Educational tools include audiovisuals and quizzes. In patients with persistent asthma, evidence from research studies shows that these eHealth applications can result in an improvement in asthma knowledge, self-management skills, peak flow rates, and adherence to inhaled corticosteroid controller medications and fewer symptoms, missed school days, nighttime awakenings, activity limitations, emergency department visits, and hospitalizations.28–33 These applications are well received by patients.30


A cornerstone of asthma disease management is assessing patients’ level of control of the disease over time. One validated measure of impairment, recommended by the National Asthma Education and Prevention Program, is the Asthma Control Test.34 This free questionnaire is available in an online format (see www.asthmacontrol.com), which patients can complete and take to a health care provider.



Chronic Obstructive Pulmonary Disease


Increasingly, chronic obstructive pulmonary disease (COPD) is being managed in the home. Internet-based telemonitoring systems, smartphones, and mobile phones with computer applications extend the reach of health care providers into the home. eHealth applications for patients with COPD facilitates education, self-management, and timely feedback from health care providers (Figure 7-3). Patients generally have a positive attitude about the role of this technology, and the quality of the transmitted data is good.35 Improved outcomes include earlier identification of deteriorating symptoms, better response to exacerbations, increased rate of sustained exercise after pulmonary rehabilitation, and decreased emergency department visits and hospitalizations.35–37 Additionally, eHealth applications can help detect comorbidities, such as sleep apnea.35


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FIGURE 7-3 Telehealth Homepod. (Courtesy Tele Health Ltd. Dublin, Ireland.)


Applications in Diagnostics


Hemodynamic Monitoring


In hemodynamic monitoring via pulmonary artery catheters, computers calculate cardiac output, using the thermodilution technique. The thermistor port of the pulmonary artery catheter is linked to a computer. After the health care provider injects room air or iced solution into the catheter, the computer reads the subsequent change in the temperature of the solution and deduces the amount of blood flow or cardiac output.



Blood Gas Laboratories


The accuracy and precision of blood gas data influence clinical decisions and patient safety. Computerized blood gas analyzers and computer-assisted quality assurance measures in a blood gas laboratory are crucial functions in a respiratory care department. Quality assurance data are necessary for accreditation of blood gas laboratories by the College of American Pathologists, the Clinical Laboratory Improvement Amendments, or The Joint Commission. Manual backup procedures must be in place in the event of computer system failure or downtime because of the critical nature of timely reporting of blood gas results and the need to be able to assess archived data at all times. Blood gas laboratories interface analyzers with HIS to make blood gas results immediately available at the point of care; additionally, this enables storage, retrieval, billing, and quality assurance.



Pulmonary Function Laboratories


Some hospitals interface their pulmonary function testing system with the HIS. Alternatively, other hospitals connect their desktop or notebook computer–based pulmonary function testing system to a local area network, which allows clinicians to access reports and graphics from multiple workstations. Most cardiopulmonary exercise and metabolic measurement systems use desktop or notebook computers.



Interpretation of Pulmonary Function Tests


Computer algorithms use standard reference predicted values to aid in the interpretation of pulmonary function tests (PFTs), including spirometry, lung volume, diffusing capacity, and bronchodilator response. The algorithms compare the patterns of the patient’s measured values with reference values based on age, height, gender, and race. The computer classifies the patterns of the patient’s measured values as either normal or abnormal with degrees of severity. However, qualified interpreters must consider the effect of patient effort on the computer-assisted interpretation of PFTs.


The American Thoracic Society recommended pulmonary function reference standards based on the National Health and Nutrition Examination Survey (NHANES). These standards for prediction of normal PFT values may differ from other reference values. This difference can confound the interpretation of successive PFTs in an individual patient when clinicians focus on the computer-assisted interpretation of percent-of-predicted values, rather than the actual observed values.38 Clinicians should have a clear understanding of which reference values were used for each test and interpret PFT results accordingly.



Mini Clini


Computer-Assisted Interpretations of Pulmonary Function Tests in an Individual Patient





Information Retrieval


Effective information retrieval is essential to evidence-based respiratory care. It enhances clinical expertise by providing information for the development of evidence-based, patient-driven protocols, and it aids in clinical decisions for individual patients.


Although assessment skills of RTs generally sharpen with experience, their knowledge of the most up-to-date therapies may diminish over time.39 However, the best available medical evidence is dynamic rather than static, and the amount of available information is staggering. A search with the Google search engine using the search word “smoking” yielded more than 169 million results in a fraction of a second. RTs need to be knowledgeable about efficient ways to access, filter, and retrieve information effectively. They must also be prepared to guide increasingly sophisticated patients, many of whom actively seek medical information on the Internet, in retrieving reliable information.


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Jun 12, 2016 | Posted by in RESPIRATORY | Comments Off on Computer Applications in Respiratory Care

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