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EdwardS.RogersSr.DepartmentofElectrical&ComputerEngineering
UniversityofToronto
ECE1778-CreativeApplicationsforMobileDevices
FinalReportMoniToddler–AndroidappforContinuousReal-timeMonitoringofinfantpatients
Professor JonathanRose
TeamMembersAsadSiddiqui(996132616)-SpecialistHatifSattar(997063387)-ProgrammerYasserKhan(996835572)-Programmer
Date April7th,2016WordCount 2429
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IntroductionWhyMoniToddler?IntheIntensiveCareUnit(ICU),theclinicalstatusofpediatricpatientsisfollowedextremelycloselythroughcontinuousmonitoringofvitalsigns(i.e.heartrate,respiratoryrate,bloodpressure,oxygensaturation,etc.).Inthesesettings,atrainedhealthcareprovider(HCP)isatthebedsidemonitoringfortrendsindicativeofclinicalimprovementordeterioration.Whentheclinicalstatusofapatientimproves,theyaresenttoawardsettingwheretheywillhavetheirvitalsignsmonitored(atmost)onceevery2hours,withthemorelikelysituationbeingonceevery4-6hours.Thiscanleadtomissedsignsofdeteriorationandtheoccurrenceofcriticalevents.AnIn-HospitalCardiacArrest(IHCA)isanexampleofthemostsignificantcriticalevent.Singhetal(2016)foundthattherateofsurvivaltodischargeafteranIHCAwas7.1%withonly3.9%ofpatientsshowinggoodneurologicaloutcome1.Thegroupalsofoundapositivecorrelationbetweenresponsetimeandchancetosurvival.Inaddition,witnessedIHCAhadahigherchanceofsurvivalthanunwitnessedIHCA2,3.Furthermore,38%ofIHCAwerefoundtobepotentiallypreventablewithrespiratoryinsufficiencybeingthemostcommonpreventablecauseofIHCA2.Inadditiontohavingpreventablecauses,clinicaldeteriorationonthewardscanbepredictedearlierwithhigheraccuracyusingvitalsigntrends4.Basedontheliterature,itisevidentthatreal-timenotificationofacriticaleventcanleadtoimprovedpatientoutcomes.Forthisreason,wechosetodevelopanappthatmonitorscontinuousvitalsignsandprovidesimmediatewarningstoHCPswhentherearesignsofdeterioration.WhatisMoniToddler?MoniToddlerisanimportantappbecauseitfillsthegapofmonitoringpediatricpatientsbyallowingproactiveinsteadofreactiveresponsestoclinicalstatuschanges.Itdoesthisbyprovidingthreekeyfunctions:
1. ContinuousMonitoring-MoniToddlermonitorscontinuousvitalsignsforpediatricpatientsonthewardthatwouldotherwisebemonitoredlessfrequently(approx.onceevery2-8hours).Specifically,theprototypewillmonitorcontinuousrespiratoryrateandheartrate.
2. EarlyNotifications-Theappisalsoimportantbecauseitnotonlyallowsremotecontinuousmonitoring,butalsoprovidesameansforHCPstobenotifiedofclinicalchangesinpatientssothattheycanprovideinterventionstopreventdelayedcriticaleventsanddeterioration.
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3. Communication-MoniToddlerprovidesacentralizedcommunicationtoolsurroundingpatients.ThisallowsformanualentryofkeyclinicalinformationthatcouldnotbemonitoredcontinuouslyandcommunicationbetweenHCPsthroughnotes/chat.
SpecialistContextAsadisathirdyearresidenttraineespecializinginAnesthesiologywithaspecialinterestinPediatricCriticalCare.WhenpediatricpatientsaredischargedfromtheICU,aphysicianandanursefromtheICUfollow-uponthepatientsonthewardforseveraldays.Whenthisoccurs,patientsaredispersedthroughoutthehospitalindifferentlocationsandareonlyintermittentlyfollowedbytheICUextensionteam.TheMoniToddlerappcanhelpfillthisgap.Iftheappwerefurtherdevelopedtoincorporatesecurity/privacyandexpandthevitalsignsbeingmonitored,itcouldhaveadirectclinicalimpactthroughwiththeICUfollow-upteam.Specifically,iftheappcontinuestobedevelopedtoincorporatesaturation,temperatureandbloodpressure,aswellasbevalidatedforaccuracy,itcanbeusedtoimplementthepredictivealgorithm(BedsidePEWS)remotelyforat-riskpatients5.However,itwouldtakeasignificantamountoffutureworktodevelopthesefeaturesandvalidatetheiraccuracyforhealthcareuse.Theproductdevelopedinthecoursewillserveasaprototypeforpotentiallyattainingfundingtofurtherdeveloptheappinthefuture.Inthiscontext,whatwehaveachievedinthecoursecanbeusedtoconductpatientsafetyresearchtoassesstheimpactofusingcontinuousvitalsignsmonitoringandearlypredictionalgorithmstopreventcriticalevents.Overall,iftheappisfurtherdevelopedandvalidated,itcanhaveanimpactthrough(1)directclinicalapplicationand(2)patientsafetyresearchregardinganoveltooltopreventcriticalevents.
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OverallDesignThissectiondescribestheoveralldesignanddescriptionsofeachofitscomponents.BlockDiagramThefollowingdiagramshowstheblockdiagram.
BlockDescriptionsIntheblockdiagram,the“MainPage”consistsofthefollowingthreeoptions:
• AddNewPatient:Inthispage,theHCPcancreateanewpatientprofile.Thispagerequiresstandardpatientdemographicinformationtocreateanewfile.ThiswillbeinstantaneouslyuploadedandwillbevisibletoallusersusingtheFirebaseserver.
• ViewAllPatients:Thispageshowsalistofallthecurrentpatientsbeingmonitored.HCPscanclickonanypatientandviewvitalsindetail.Notificationscanbeenabledon“MainPage”undermenuoptions“EnableNotifications”.
o PatientDetails:Thispageshowsdetailsofallthereal-timeandnon-real-
timevitalscollectedfromthepatient.Agraphdisplaysthebreathingpatternofthepatient.“Add”buttoncanbeusedtoaddNotesforthepatient,whichwillsendanotificationtoallindividualswiththeapp.
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• Transmit/Monitor:ThispageallowsthepatienttoconnecttoBluetoothdevices(SensortagandTickr)andobtainvitals(RespiratoryandHeartRate).Aftersensorsareturnedon,theuserpresses“scan.”Theappwillconnecttodevicesandstartuploadingvitals.Areal-timegraphwillshowrespiratorypattern.TheHCPcanmodifyparametersthatindicatethe“critical”rangeonthe“MainPage”underthemenuoption“UpdateParams.”
o SensorDataAnalysis:ThismodulecollectsaccelerometerdataobtainedfromSensortagandanalyzesthechangesinaccelerationafterapplyingaLow-PassFilter.Itdetectspeaksfor10sandthenmultipliesthenumberofpeaksby6toobtainrespiratoryrate“perminute.”Tickrdirectlyprovidestheheartrate.
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FunctionalityOverall,theMoniToddlerappfulfilledthethreemaingoalsthatwereoutlinedabove–continuousmonitoring,earlynotification,andcommunication.Thissectionwillprovideanoverviewofenduserfunctionality.FigurescorrespondtotheScreenshotssection.AddingaPatientOncetheappopens,themainpage(Fig1a)withthreeoptionsisshown:addapatient,viewexistingpatients,andtransmitdata.Thefirststepistoaddanewpatienttothedatabasesothatappownerscanviewtheirstatus.Clickingon“AddNewPatient”willnavigatetheHCPtotheAddPatientpage(Fig3a).HeretheHCPcanfillinallrequiredinformation.TheHospitalFilingNumberisunique,sonotwopatientscanhavethesameinformationinthedatabaseatthesametime.TransmittingDataOnthemainpage,theHCPcanopentheoverflowmenu(Fig1b)andclickon“UpdateParameters”.ThiswillnavigatethemtotheUpdateParameterspage(Fig1c).HeretheHCPcanupdatethepatient’snormalHeartRateandRespiratoryRaterangeforthespecificpatienttheywillbetransmittingdatafor-iftheratesgobeyondtherangespecifiedthenthepatientwillbeconsideredcritical.ThenextpagewillallowtheHCPtoselectwhichpatiententryinthedatabasewillshowthedatatobetransmitted(Fig3b).ThisallowsthetransmittingAndroiddevicetobereusedfordifferentpatients.TheHCPwillselectthecorrectuser,andthatwillleadthemtothemaintransmitpage(Fig3c).TheHCPwillthenattachallrelevanthardwaretothepatient,suchastheWahooTickrandtheSensortagdevice.OncethatissettheHCPcantap“Scan”whichwillstarttheBluetoothconnection.Thereexistsabuttonfor“Sensortag1”,whichwillchangeto“Sensortag2”oncepressedtoallowforselectivityiftwoSensortagsareinthesamearea(Fig3c).TheHCPwillleavethetransmittingAndroiddevicenearthepatientsodatacanbecollectedbytheAndroiddeviceandtransmittedtothedatabase.Areal-timegraphisalsoprovidedtogivetheHCPimmediateinformation.Leavingthispagewilldisconnectthedevicefromthepatienthardware,anddisabletransmissionfromthatpatiententry.ViewPatientsNowthattheHCPhassetupthetransmissionofapatient’sstatus,anyonewiththeappthatisnottransmittingcanviewthedataofanypatientinthedatabase.ThesupervisingphysicianwillopentheMoniToddlerapp,willentertheoverflowmenu(Fig1b),andwillclickon“EnableNotification”toallowthephonetovibrateandshowanotificationifapatientgoescriticaloranewnoteisadded.Thephysiciancanthenclickonthe“ViewPatients”buttontobetakentotheViewPatientspage(Fig3b).Herethephysicianwillseereal-timegeneralinformationabouteverypatientinthedatabase.TheycantaponapatienttobetakentothePatientDetailspage(Fig2a).Thispagegivesmoredetailedinformationandadditionalvitalsthatwouldbemanuallyadded.
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ScrollingdownontheViewPatientpage,thephysicianwillseeareal-timegraphoftherespiratoryrateofthepatient,whichistransmittedfromthephonenearthepatientuptothedatabasetobeviewedbyanyonewiththeapp.IntheAdditionalVitalsblockonthispagethereisan“Add”button,whichtakesthephysiciantotheAdditionalVitalspage(Fig2c).Heretheycanenteranotewiththeirnametospecifytheywantinformationupdated.AHCP(i.e.nurse)onthewardwillreceiveanotificationaboutthisnote(Fig4a)andcannavigatetothesamepagetomanuallyenterthisinformationforthephysiciantoviewremotely(i.e.BloodPressure,Temperature,andSaturation).AtthetopoftheViewPatientpageisthecriticalstatus.Ifthepatient’smonitoredvitalsgobeyondtherangespecifiedbytheHCP,thiswillchangeto“PatientCritical”andanotificationwillbesenttoallusers(Fig4b)whohavenotificationsenabled.ThiswillallowHCPstorespondtoemergenciesquicklytopreventcriticalevents.IncompleteandMissingFeaturesMostofwhattheteamplannedtoachievewassuccessfullyimplemented.Someancillaryfeaturessuchasrealtimechatfunctionalitywasremovedduetotimeconstraints.Also,somepages(suchasthetransmitpage)werenotasuserfriendlyastheteamwanted.Timeconstraintspreventedthosepagesfrombeingoverhauled,butitdidallowforeasierdebugging.
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ScreenshotsBelowareseveralscreenshots,whicharereferredtointheabovesections.
Figure–2(a)PatientDetails 2(b)PatientDetails 2(c)AdditionalVitals/Note
Figure–1(a)MainPage 1(b)MainPage–Menu 1(c)UpdateParameters
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Figure–3(a)AddaPatient 3(b)ViewAllPatients 3(c)TransmitPatientVitals
Figure–4(a)NewNote 4(b)CriticalWarning
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LearningPointsandReflectionThissectionhighlightswhattheteamlearnedinthecourseoftheproject.LearningPointsOneareathattheMoniToddlergrouprealizedwasimportantinthistypeofprojectwasinregardstoNon-TechnicalSkills.Specifically,ourgrouplearnedthevalueofstrongcommunicationandthebarriersthatcanoccurinamultidisciplinaryteam.Onethingthatwedidwellwashavefrequentmeetingswithcentralizedcommunication(i.e.throughcentralizedMoniToddlere-mailaccountandWhatsAppgroup).Also,welearnedto“speakthelanguage”ofone-another’sspecialties.Forexample,itwasimportantforustorealizethatAsadhadnoprogrammingbackgroundandYasser/Hatifhadnomedicalbackground.Thiswasinitiallyachallengeasitwasacommonmistaketomaketheassumptionthattheothersunderstoodthejargonbeingusedinconversation;however,wehadtohaveconstantreminderstoourselvesabouttheimportanceofexplainingalljargon.Thishelpeduslearnagreatamountaboutoneanother’sfieldsandthedelicacy/difficultysurroundingeffectivecommunicationofaspecialtyfieldtonon-specialists.ChangesfortheFutureFortheMoniToddlerapp,weusedtheSensortagtomeasurerespiratoryrate.Inordertodothis,itwasnecessaryforustogatherdatafromtheSensortag,parsetheinformation,anddeterminewhatwasmeaningfulinformationtodeducetherespiratoryrate.Thereareseveraldevicescurrentlyavailablethatcanmeasurethisandmorevitalsigns.Ifwecoulddotheprojectdifferently,wewouldfocusonattainingsensorsthatwerealreadycalibratedforcertainvitalsignsratherthanfiguringoutanewalgorithmfortheSensortag.Thiswouldhavesavedustimeandallowedforustofocusmoretowardsdevelopingwarningalgorithmsusingtheinformationratherthanongatheringtheinformationitself.
ContributionsThissectionliststhespecificcontributionseachmembermadefortheMoniToddlerapp.AsadSiddiqui(specialist)
- LiteratureReviewsurroundingwearabletechinhealthcareandoutcomesfromcriticalevents
- InceptionofMockUpforMoniToddler- Datacollection&analysisofSensortagforrespiratoryrateusinghigh-fidelity
pediatricsimulator+humanparticipants- Documentation,PresentationCreation/Editing- Testing
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HatifSattar(programmer)
- SetupDatabaseandBackend- CustomizedUIandLogoDesign- Low-PassFilteringandDataAnalysis- EmergencyNotifications- Designed“additionalvitalsandnotes”mechanism- ImplementationforCriticalLimitsforIndividualPatients- Testing
YasserKhan(programmer)
- ConnectiontoBluetoothsensors(Tickr,Sensortag)- Obtainandparsesensordata- Low-PassFilteringandDataAnalysis- Dataloggingintotextfile(foranalysis)- DatalogginginVisualgraphs- Testing
FutureWorkTherearefourfeaturesthatwewouldcontinuetodevelopifwehadtheopportunityinthefuture:
1. ExpandVitalSignsMonitoring:MoniToddleriscurrentlycapableofmonitoringcontinuousHeartRateandRespiratoryRate.Theothervitalsignsthatwouldbevaluabletomonitorcontinuouslyinclude:bloodoxygensaturation,bloodpressureandtemperature.Ofthesevitalsigns,continuous,non-invasivebloodpressuremonitoringwouldbethemostdifficulttoachieveasthereiscurrentlynowearabletechnologycapableofdoingthisaccurately.
2. ValidateVitalSigns:TheSensortagwasprogrammedforMoniToddlertomonitor
continuousrespiratoryrate.ItwouldbeimportanttovalidatetheaccuracyoftheSensortagformeasuringrespiratoryrateinordertouseitforclinicalpurposes.
3. ImplementPredictiveAlgorithm:Vitalsignstrendsareusefulinpredictingclinical
deteriorationinpatients.ThroughcontinuousvitalsignmonitoringwithMoniToddler,HCPsaremorecloselyabletomonitorvitalsigntrendsinpatientsontheward.TheBedsidePEWSscoreisanalgorithmcurrentlybeingvalidatedthatincorporatesvitalsignstrendsinpredictingpatientdeterioration5.Theintegration
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ofthispredictivealgorithmwithMoniToddlerisanimportantnextstepinhelpingpreventcriticalevents.
4. Security/Privacy:TheMoniToddlerappstoresvulnerablepatientinformation.In
orderfortheapptobeusedinaclinicalscenario,itwouldbenecessarytoensurethatinformationenteredinMoniToddlerwasprivateandsecure.
DisclaimerforSourceCodeAsad,HatifandYasserareinagreementwiththepostingofthevideoonline.Wewouldlikethesourcecodetonotbereportedonthewebatthispoint;howeverwewillcontactProf.Roseifanythingchanges.
SourceCodehttps://github.com/hatifsattar/MoniToddler.git
References
1. SinghS,Namrata,GrewalA,etal.EvaluationofCardiopulmonaryResuscitation(CPR)forPatientOutcomesandtheirPredictors.JClinDiagnRes2016;10:UC01-4.2. ChonGR,LeeJ,ShinY,etal.Clinicaloutcomesofwitnessedandmonitoredcasesofin-hospitalcardiacarrestinthegeneralwardofauniversityhospitalinKorea.RespirCare2013;58:1937-44.3. PeberdyMA,KayeW,OrnatoJP,etal.Cardiopulmonaryresuscitationofadultsinthehospital:areportof14720cardiacarrestsfromtheNationalRegistryofCardiopulmonaryResuscitation.Resuscitation2003;58:297-308.4. ChurpekMM,AdhikariR,EdelsonDP.Thevalueofvitalsigntrendsfordetectingclinicaldeteriorationonthewards.Resuscitation2016;102:1-5.5. ParshuramCS,Dryden-PalmerK,FarrellC,etal.Evaluatingprocessesofcareandoutcomesofchildreninhospital(EPOCH):studyprotocolforarandomizedcontrolledtrial.Trials2015;16:245.