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Nuvon Vital Charting System (NVCS)

Medical Device Integration (MDI) with Clinical Rules and Decision Support

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Migrating Focus of Medical Device Integration (MDI)

• MDI for charting & Electronic Health Records / Electronic Medical Records (EHRs/EMRs) is the starting point, but not the ultimate objective– Use of data for near-real-time clinical use– Data availability outside of EMR/EHR framework, for

research, real-time early warning notifications– Provides a more direct route to support early

notification of higher acuity & higher risk patients• Nuvon is taking steps in this direction, and working

with existing and new clients

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Nuvon Medical Device Integration

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Nuvon Vitals Charting System• Overlays existing medical device integration framework• Provides capability to store data for recall, export for a posteriori

analysis.• Active rules & thresholds can operate on one or more of the medical

device parameters or complex methods involving multiple parameters.• Tailored, role-based notifications and integrates with alarm management

systems• The following policies apply to rules:

– Simple expressions and conditions that apply to parameters so as to notify on occurrence of a condition.

– Rules can be stored / recalled and used to notify on email, HL7 when certain conditions are met.

– Notifications can be displayed on occurrence of a condition of one or more parameter observations received from medical devices.

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Configuration & ComponentsReal-Time

Information Sources

Enterprise EHR /Alarm Management

Vitals

Specialty Medical Devices

Labs

Rx

ADT

Notes

Informatics Engine

• Real-time feed from existing data sources;• Provides user-defined & default rules that can be created and

managed by end users;• Can communicate to existing EHR or alarm management system;• Can provide notification visualization via Web to support call

centers, handheld appliances, desktop computers

Currently Supported

Future

KEY:

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Example Use Cases

• Rapid Response Notification• Shock index in medical / surgical patients• Capnography monitoring for PCA• Head-of-Bed angle compliance in mechanically

ventilated patients• Rapid shallow breathing monitoring to

determine viability to wean• …

NUVON CONFIDENTIAL 7

Earlier Intervention in General Wards

• “Research indicates that up to 40% of unexpected deaths in hospitals occur on the general floor. While the signs of clinical instability typically occur six to eight hours prior to an adverse event, large patient volumes and limited staffing can make it difficult for care providers in the medical surgical areas of the hospital to anticipate which patients to watch more closely.” [1]

• “Up to 17% of patients in the medical surgical areas of the hospital will face an unexpected complication …in two-thirds of cases, patients demonstrate abnormal signs and symptoms within six hours of cardiac arrest, while an MD is notified only 25% of the time. [2]

[1] http://healthcaresolutions.philips.com/earlier-intervention-on-the-general-ward#clinical[2] Bellomo R, Goldsmith D, Russell S, Uchino S. Postoperative serious adverse events in a teaching hospital: a prospective study. Med J Aust. 2002: 176:216-218

NUVON CONFIDENTIAL 8

Rapid Response Criteria

NUVON CONFIDENTIAL 9

Rapid Response Notification Methods

• Rapid Response Notification when patient meets multiple criteria– Superposition of multiple parameter values

simultaneously, or– Additive or sum total of scoring system requirements

• Rapid Response Notification based on single criteria– Individual parameters thresholds, or– Notification upon cascaded criteria (e.g.: when SpO2 <

92%, check ETCO2, …)

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Rule for Rapid Response

hrScore=IF(HR<=40, 2, IF(HR>40 & HR<=50, 1, IF(HR>50 & HR<=100, 0, IF(HR>100 & HR<=110, 1, IF(HR>110 & HR<=130, 2, 3)))))rrScore=IF(RR<8, 2, IF(RR>=8 & RR<=11, 1, IF(RR>11 & RR<=20, 0, IF(RR>20 & RR<=25, 1, IF(RR>25 & RR<=30, 2, 3)))))allScore=hrScore + rrScoreIF(allScore>=3, 1, 0)

NUVON CONFIDENTIAL 11

Rules for Rapid Response Scoring

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Weaning, Head-of-Bed (HoB) angle management, ARDS management

• On-board predictive analytics software trained on source data and subject to algorithms developed by end users.

• Provide notifications and warnings based on near real-time data state in comparison with algorithmic expectations.

• Provide web-based access to algorithms, data and results and tailored view of output in end-user desired formats.

Note: have developed relationships (including driver) with vendor partners such as Covidien, Sizewise (beds) to support more complex workflows involving critical patient data

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Increasing Rates of HoB Compliance Linked to Reduced VAP

Ventilator-associated pneumonia (VAP) is the most common hospital-acquired infection in the intensive care unit (ICU). [1] It occurs in 9% to 40% of all ICU patients and has an incidence of 5 to 35 cases per 1000 ventilator days. [2] The consequences of VAP are severe: a three-fold increased duration of mechanical ventilation, a two- to six-fold increase in ICU stay, a 2- to 3-day increase in hospital stay. [3] Each case of VAP increases hospital costs by $40,000 to $50,000 and results in a 15% to 45% increase in attributable mortality. [2,4]

Elevation of the head-of-bed (HOB) of intubated patients is an effective method for reducing rates of aspiration pneumonia. In a randomized two-period crossover study, Torres et al. [5] demonstrated that the semirecumbent position decreased rates of aspiration of gastric contents four-fold. Kollef [6]

A Simple Device to Increase Rates of Compliance in Maintaining 30-Degree Head-of-bed Elevation in Ventilated Patients Zev Williams, MD, PhD, Rodney Chan, MD, Edward Kelly, MDDisclosuresCrit Care Med. 2008;36(4):1155-1157.

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Modified Shock Index

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Rapid Shallow Breathing Index

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Chart View

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Chart View, Trending, Thresholds

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THANK YOU

John R. Zaleski, Ph.D., CPHIMSChief Informatics OfficerNuvon, Inc.4801 S. Broad StreetSuite 120Philadelphia, PA 19112E: jzaleski@nuvon.comT: @johnrzaleskiO: 215-600-2627 x102

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References1. Vincent JL, Bihari D, Suter PM, et al: The prevalence of nosocomial infection in intensive care units in Europe: Results of the

European Prevalence of Infection in Intensive Care (EPIC) Study. EPIC International Advisory Committee. JAMA 1995; 274:639-644 2. Ibrahim EH, Tracy L, Hill C, et al: The occurrence of ventilator-associated pneumonia in a community hospital: Risk factors and

clinical outcomes. Chest 2001; 120:555-561 3. Rello J, Ollendorf DA, Oster G, et al: Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest

2002; 122:2115-2121 4. Tablan OC, Anderson LJ, Besser R, et al: Guidelines for preventing health-care-associated pneumonia, 2003: Recommendations of

CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep 2004; 53:1-36 5. Torres A, Serra-Batlles J, Jos E, et al: Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: The

effect of body position. Ann Intern Med 1992; 116:540-5436. Kollef MH: Ventilator-associated pneumonia: A multivariate analysis. JAMA 1993; 270:1965-1970 7. Drakulovic MB, Torres A, Bauer TT, et al: Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated

patients: A randomised trial. Lancet 1999; 354:1851-1858 8. Critical Care. http://www.ihi.org/IHI/Topics/CriticalCare/ . Accessed October 26, 20079. Curtis JR, Cook DJ, Wall RJ, et al: Intensive care unit quality improvement: A how-to guide for the interdisciplinary team. Crit Care

Med 2006; 34:211-218 10. Evans D: The use of position during critical illness: Current practice and review of the literature. Aust Crit Care 1994; 7:16-21 11. Grap MJ, Munro CL, Bryant S, et al: Predictors of backrest elevation incritical care. Intensive Crit Care Nurs 2003; 19:68-74 12. van Nieuwenhoven CA, Vandenbroucke-Grauls C, van Tiel FH, et al: Feasibility and effects of the semirecumbent position to

prevent ventilator-associated pneumonia: A randomized study. Crit Care Med 2006; 34:396-402 13. McMullin JP, Cook DJ, Meade MO, et al: Clinical estimation of trunk position among mechanically ventilated patients. Intensive

Care Med 2002; 28:304-309