1 Decision-support for Mechanical Ventilation Alan H. Morris, M.D. European Society for Computing and Technology in Anesthesia and Intensive Care, Amsterdam,

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Decision-support for Mechanical Ventilation

Alan H. Morris, M.D.

European Society for Computing and Technology in Anesthesia and Intensive

Care, Amsterdam, 8 October 2010

No Conflict of InterestNo Commercial Association

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1.Need for decision-support (clinician uncertainty, human performance)

2.Science and reproducibility

3.Decision-support (influence clinician behavior)

PCIRV… LFPPV-ECCO2R

Mechanical Ventilation

ARDS

Randomize

Extubation DeathExtubationDeath

NIH N01-HL 46062 Alan H. Morris, M.D.

Computerized Protocols Developed1985-87

1987-91

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Clinical Uncertainty- Complexity: >236 Variable Categories

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1.Need for decision-support (clinician uncertainty)



Douglas C. Giancoli. Physics. prentice Hall, Englewood Cliffs, NJ 1995:3

Science:testing..experiments..distinguish science from other creative fields

(key is the belief that true results can be reproduced by others.

Reproducibility requires a detailed and explicit method)

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• High-quality clinical trials require consistent compliance with evidence-based guidelines.

• High compliance makes the clinical trial more reproducible – a requirement of good science.

• Differences in clinician compliance with guidelines/study protocol could influence the results of clinical trials

8

Requirement of good science:• Reproducibility is what confirms the

proper description of nature’s behavior.

• If one scientist has properly described nature's behavior, another scientist using the same method should obtain the same result.

Requirement of good science:• Replication of experimental results

is a primary requirement before new scientific information is embraced by the standard works of the domain (e.g., textbooks).

• Replication of results depends on reproducible methods.

10

The hospital, the operating room, and the

wards should be laboratories, laboratories

of the highest order.William S. Halsted, M.D.

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Experimental Human Clinical Outcomes Research Laboratory:

1. Good Clinical Care2. Ethical Care

3. Reliable Data Capture4. Standardized Clinician Response

(Reproducible Method)

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1.Need for decision-support (clinician uncertainty)


3.Decision-support (influence clinician behavior) – adaptive expert system

Medical subject headings - Ovid®:• Guideline: “A systematic statement of policy rules or principles”-where to go but not how to get there

• Protocol: “Precise and detailed plans for the study of a medical or biomedical problem and/or for a regimen of therapy.”-how to get there

(Adequately explicit protocol: enough detail to lead different clinicians to the same patient-specific decision - reproducible clinical decision method) 13

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王皓在比赛中

马琳在比赛中

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Guideline“Win the point”

Inadequately explicit protocol“Hit the left corner”

Adequately explicit protocol“Wait for a high return and hit the

ball hard with a left spin, curving to the opponent’s left, to land within 1 inch of the left corner of the table.”

Meehl P. Clinical versus statistical prediction - a theoretical analysis and a review of the evidence. Minneapolis: University of Minnesota Press 1954.

McDonald C, Overhage J. JAMA 1994;271(11):872-873.Tierney WM et al. J Am Med Informatics Assn 1995;2(5):316-22.Zielstorff R. J Am Med Informatics Assn 1998;5(3):227-236.

Inadequately explicit

Try to return to FIO2=0.4 and PEEP=5 as soon as

possible.

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Decline 5% of recommendations

Accept 95% of recommendations

Patient data:• SpO2, PaO2, pH• Respiratory Care

Patient-specific instructions:Mode, Tidal Volume, Rate,

FIO2, Ppeak, PEEP

Capture reason for decliningClinician

Accepts or DeclinesPatient

Computer Protocol Continual Operation (Mechanical Ventilation Protocol Example)

eProtocol-Mechanical-Ventilation vs. Controls (usual care)

Unpublished data from an RCT

Box = interquartile range (IQR) and median

Bars = IQR limits ± ~1.5 IQR

97 Patients

FIO2 ≤0.6Pplateau ≤35 cm H2OTarget VT =7 ml/kg PBW

103 Patients

Goals

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Pplateau >35 cm H2O x Days

Inspired %O2 >60 x Days

AHCPR #HS06954 (T East, PhD, PI)

Patient is ready for a 5 min test for inspiratory effort. Reduce Ventilator Set Rate to 10. Enter Total Ventilatory Rate when it exceeds 10 or at the end of 5 min.

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Complexity is transparent (hidden)

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MAP 60 mm Hg

Avg. 4 hour Urine < 0.5

ml/kg/hr

Avg. 4 hr Urine ≥0.5

ml/kg/hr

PAOP

(mm Hg)

MAP

< 60 mm Hg

(See shock protocol

on reverse)

Ineffective Circulation

C.I. < 2.5

Effective

Circulation C.I. 2.5

Ineffective Circulation

C.I. < 2.5

Effective

Circulation C.I. 2.5

> 24

KVO IV 3 DobutamineA FurosemideB

KVO IV 7 FurosemidB

KVO IV 11 DobutamineA FurosemideB

KVO IV 15 FurosemidB

19-24

Vasopressor KVO IV 4 DobutamineA

KVO IV 8 FurosemideB

KVO IV 12 DobutamineA

KVO IV 16 Furosemide

B

14-18 Fluid bolusC 5 Fluid bolusC 9

Fluid bolusC

13 KVO IV 17

< 14

Fluid bolusD

Fluid bolusC 6 Fluid bolusC

10 Fluid bolusC

14 Fluid bolusC

19

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C. Fluid Bolus (Non-shock, except cell #19):1. Administer 15 ml/kg PBW normal saline, Plasmalyte,

or Ringer’s lactate (rounded to the nearest 250 ml) or 1 unit RBCs or 25 grams albumin (choice at discretion of physician) over <= 1 hour then reassess patient.For cells 5, 6, 9, 10, reassess within one hour. Administer up to 3 boluses over 24 hours if indicated by protocol.This 24 hour period begins with the first protocol-mandated non-shock bolus OR the first protocol-mandated bolus following shock reversal.

2. Additional fluid boluses are allowed at the discretion of the physician.

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Blood Glucose/Insulin Protocol: Adults and Children

Blood Glucose/Insulin Protocol: Adults and Children

% M

easu

rem

ents

Blood Glucose (mg/dl)

8

6

4

2

0 0 40 80 120 160 200 240 280 320

Bedside Computer ProtocolBedside Paper Protocol

Simple Guideline

P<0.0001786 Patients

44,979 Measurements

→Target

Range

% M

easu

rem

ents


8

6

4

2

0 0 40 80 120 160 200 240 280 320

Western USASoutheast USANortheast USASingapore

P=0.18753 Patients

36,302 Measurements

→Target

Range

Blood Glucose Computer Protocol

1Mar07

Thompson, BT et al. J Diabetes Sci Technol 2008;2(3):357-68

99 Adults - 6 ICUs48 Children - 5 ICUs

% Blood Glucose Measurements9876543210

0 40 80 120 160 200 240 280 320Blood Glucose (mg/dl by 5 mg/dl groups)

ΔAdultPediatric

Translation: ResearchPractice

13 Adult ICUs: Intermountain Healthcare Intensive Medicine Clinical Program in 7 hospitals ranging from a:

72 bed primary care hospitalto a

480 bed tertiary care hospital

% M

easu

rem

ents


8

6

4

2

0 0 40 80 120 160 200 240 280 320

ICU Type Pa-tients

Measure-ments

Research 493 21,321Clinical Care 2,296 109,458

→Target

Range

Blood Glucose Computer Protocol

eProtocols: reproducible method

• Adult and pediatric ICUs(bridge different disciplines)• In usual clinical care(translate research to practice)

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35

36

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Statistic Adult Pediatric Tota l Patients 99 48 147 Measurements 8269 4617 12,886 % Instructions

Accepted 95

(7786/8230) 91

(4165/4603) 93

(11951/12833) Blood glucose:

Baseline 157 180 164 Mean 116 118 117

SD 38 39 38 Maximum 556 580 580 Minimum 29 20 20 % 70-110

mg/dL 47

(3888/8269) 48

(2208/4617) 47

(6096/12886)

NIH Roadmap contract # HHSN268200425210C: 1Mar07

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% ≤ 40 mg/dL (2.22 mmol/L):

ICU all glucose

measurements

patients with ≥1

measurement

Adult 0.10 (8/8269) 7 (7/99)

Pediatric 0.32 (15/4617) 19 (9/48)

Tota l 0.18 (23/12886) 11 (16/147)

NIH Roadmap contract # HHSN268200425210C: 1Mar07

0.5% stop - a priori

CPAP weaning trial successful. Click red CONFIRM button and switch ventilator to Pressure Support mode with PS=20 cm H2O, PEEP=5 and FIO2=0.5 if you want to proceed. Then wait and enter total ventilatory rate, SpO2 and evaluate for respiratory distress within 5 min.

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40

41

Crit Care Med ‘08;361787–95)

% M

easu

rem

ents


• Bedside Computer Protocol∆ Bedside Paper Protocol+ Simple Guideline

P<0.0001

→Target

Range 8

6

4

2

0 0 40 80 120 160 200 240 280 320

Local research group

Multiple IH sites

Multiple sites- geographically dispersed

Increasing levels of clinician trust - must abandon personal style

Clinician leader

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• Unnecessary variation, and error, exist in medical care.

• Computer protocols help clinicians deliver consistent, evidence-based, care with a reproducible method.

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% of 15,381 Heart Failure Outpatients ReceivingAppropriate Guideline-

Based Treatment In 165 clinics

Maximum90% of clinics

Median

10% of clinicsMinimum

Legend:Range of results bystudy clinic

%

52

0

1234

Sur

viva

l

Months Following DischargeRe: (Kfoury, French – Intermountain Nov 2008)

Adherence to Heart Failure Core Measures

53

%

0

20

40

60

80

100

Audit 4

Interview92

1816141210876543210

40

30

20

10

0

N

VT (ml/kg PBW)

Evidence

Adhere to “Best Practice?“

Brunkhorst F, Engel C, Ragaller M, Welte T, Rossaint R, Gerlach H, et al. Practice and perception—A nationwide survey of therapy habits in sepsis. Crit Care Med. 2008;36(10):1-6

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Miller, GA. Psychological Review 1956;63(2):81-97

East, TD et al. Chest 1992;101:697-710 (PCIRV)

Cowan N. Behav Brain Sci 2001;24:87

# Conceptual Objects Humans Can Accommodate (“Chunks” in Short

Term Memory) Before Decisions are Degraded

~ 7

~ 4

Proteomics

Functional Genetics

Structural Genetics

Clinical Phenotype

Fac

ts /

Dec

isio

n

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The Roundtable on Evidence-Based Medicine: Learning Healthcare System Concepts v. 2008. Annual Report, IOM, Nat Acad Sci . P9, IOM Meeting, 8 October 2007. Growth in facts affecting provider decisions versus human cognitive capacity .

This limit makes protocol rule generation easier, and manageable.

1000

100

10Human Cognitive 5 Capacity

William Stead, MD – Challenges to Providers

Decision-support (patient-clinician encounter scale)

•Involve end-users•Quick testing of an idea•Trust

R Clemente

H Aaron L Gehrig

“Strike him out”57W Mays

B Ruth

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Guideline“Strike him out”

Inadequately explicit protocol“Curve ball low and inside”

Adequately explicit protocol“Throw a 67 mile per hour curve

ball low and inside within 1 inch of the back corner of the plate and 2 inches above the left knee, after a 45 second pause”

Documents

1 Decision-support for Mechanical Ventilation Alan H. Morris, M.D. European Society for Computing and Technology in Anesthesia and Intensive Care, Amsterdam,