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Since the beginning of modern anaesthesia, in 1846 (the first public demonstration of modern anaesthesia in Boston in 1846), there has been a tremendous increase in monitoring devices, especially in the past 30 years.

Modern technology has provided a large number of sophisticated monitors and therapeutic instruments, particularly in the past decade. The most important aspect in monitoring the critically ill patient is the detection of life-threatening derangements of vital functions.

There are two different computer systems currently in use in a General Hospital:

• System A, the Hospital Information System (HIS) that includes the Electronic Hospital Records (EHR), is a large multi-access system used for many aspects of hospital administration, such as keeping patient records, managing waiting lists, monitoring the availability of beds and controlling drug stocks.

Terminals located in the offices, wards and laboratories are connected to a mainframe computer. 

• System B is a real-time system used in the intensive-care unit of the hospital. Monitoring systems communicate information about each patient to a small minicomputer. Information about each patient’s condition is continuously displayed.

The system is also able to report immediately any significant changes in a patient’s condition to nursing staff through an audio and visual alarm system. The two systems use different o perating systems and they are usually not connected.

There have been many attempts in time to make a computerized system that would integrate the two actual systems and help the medical staff to improve medical services. Here are some of them:

• S/5 Arrhythmia Workstation (ARRWS) provides one compact, PC-based solution for both bedside and telemetry monitored patients. It connects to GE Healthcare Network and supports advanced arrhythmia analysis for up to 16 beds;
• S/5 iCentral offers centralized monitoring, clinical information integration and continuity of data throughout the patient care process. All different types of GE Healthcare monitors are connectable to the S/5 iCentral - from the S/5 Light monitor to the complete, modular S/5 Critical Care Monitor and integrated Anesthesia Care Stations. All data is automatically collected and stored to the S/5 iCentral also from interfaced equipment and systems to form an integrated patient record. When the patient travels through the care process, the full patient history is always available where it is needed - at the bedside and in remote viewing locations;
• S/5 Critical Care Monitor is a multiparameter monitor that offers a flexible solution for the varying needs of critical care. The S/5 Critical Care Monitor helps to gain a comprehensive hemodynamic monitoring and cardiac monitoring with up to 12-lead ST and arrhythmia analysis, the S/5 Critical Care Monitor integrates the unique capabilities of patient spirometry, continuous gas exchange/metabolics, automated tonometry and monitoring the level of neuromuscular block. For neurological cases, EEG completes the picture;
• S/5 Telemetry System is an advanced ambulatory monitoring of cardiac arrhythmias with advanced ischemic detection. The multi-lead arrhythmia analysis ensures accurate identification of cardiac arrhythmias and full 12-lead ST segment analysis for ischemic changes. Conventional patient telemetry tells only part of the story. To augment ECG analysis, S/5 Telemetry System provides the option of monitoring ambulatory patients with continuous diagnostic 12-lead, readily identifying clinically significant silent ischemic injuries or infarctions;
• The European EPI-MEDICS project has developed an intelligent Personal ECG Monitor (PEM) for the early detection of cardiac events. The PEM embeds advanced decision making techniques, generates different alarm levels and forwards alarm messages to the relevant care providers by means of new generation wireless communication. It is cost saving, involving care provider only if necessary and requiring no specific infrastructure. This solution is a typical example of pervasive computing and ambient intelligence that demonstrates how personalized, wearable, ubiquitous devices could improve healthcare. 

Our SAPHIRE Project also tries to integrate the two medical systems.

However, more than integrating real-time data coming from the monitoring sensors with the EHR data, the system will run medical protocols that were designed based on the European Society of Cardiology (ESC) Guidelines for the management of Acute Coronary Syndromes.

Cardiology is one of the most regulated fields in medicine and up-dating the guidelines every 2-5 years has become the usual practice.

Even if they have no legal force, guidelines are assimilated as standards of medical practice.

The national societies from the European countries have endorsed the European Society of Cardiology Guidelines and their implementation has become a target for the healthcare policies.

The guidelines, together with a central body of cardiologic knowledge contained in the Core Syllabus and Core Curriculum, form the basis for uniform continuing medical education in cardiology.

The ESC Guidelines employ a classification of levels of evidence and strength of evidence well-known to the practicing Cardiologist, which is important to understanding the guidelines.

The strength of evidence related to a particular treatment depends on the available data. Accordingly, in this document, the strength of evidence will be ranked according to three levels:

• Level of evidence A : Data derived from multiple randomized trials or meta-analyses.
• Level of evidence B : Data derived from a single randomized trial or non-randomized studies.
• Level of evidence C: Consensus opinion of the ex perts.

The strength of recommendations is presented using the following classification:

• Class I : Conditions for which there is evidence that a given therapy is useful and effective.
• Class II : Conditions for which there is conflicting evidence and/or divergence about the efficacy/usefulness of a given treatment.
• Class III : Contra-indications.

The 2 sets of guidelines chosen to be modeled for the SAPHIRE Project are the latest ESC Guidelines for the management of acute coronary syndromes:

• GUIDELINES 1: The Task Force on the Management of Acute Myocardial Infarction of the European Society of Cardiology, Frans Van de Werf, Diego Ardissino, Amadeo Betriu, Dennis V. Cokkinos, Erling Falk, Keith A.A. Fox, Desmond Julian, Maria Lengyel, Franz-Josef Neumann, Witold Ruzyllo, Christian Thygesen, S. Richard Underwood, Alec Vahanian, Freek W.A. Verheugt, and William Wijns, Management of acute myocardial infarction in patients presenting with ST-segment elevation, Eur. Heart J., January 2003; 24: 28 – 66

• GUIDELINES 2: Michel E. Bertrand, Maarten L. Simoons, Keith A.A. Fox, Lars C. Wallentin, Christian W. Hamm, Eugene McFadden, Pim J. De Feyter, Giuseppe Specchia, and Witold Ruzyllo, Management of acute coronary syndromes in patients presenting without persistent ST-segment elevation, Eur. Heart J., December 2002; 23: 1809 - 1840.

Considering all the medical realities listed above, the SAPHIRE Project will find its way to the medical community and into the hospital medical practice, to assist patient-specific, guidelines-driven clinical decision in a state-of-the-art healthcare system of a new enlarged Europe.

 

 

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