Episode 304: Continuous Vital Sign Monitoring with Drs. Meyhoff and Breteler
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Hello and welcome back to ACRAC. I'm Jed Wolpaw and we've got a really interesting show for you today. I'm really excited. I have two fabulous guests and we are going to explore both the pros and cons of the idea of continuous vital sign monitoring and

after surgery on the wards, at home even. This is going to be a really hot topic moving forward. It already is. And I've got two experts to talk about it today. This is something I think anesthesiologists and intensivists are going to be getting more and more involved in. We'll hear about that. But I think this is a really interesting topic to explore. I have with me, again, listeners will know that he's been on the show before, Dr. Christian Mayhoff, who is the chief physician and clinical professor at the Department of Anesthesiology and Intensive Care at Copenhagen.

Copenhagen University Hospital in Denmark. Since 2002, he's conducted clinical research to prevent post-op cardiopulmonary complications, and he founded the WARD project, which stands for Wireless Assessment of Respiratory and Circulatory Distress, which is about remote wireless monitoring of vital signs. He did that together with some colleagues across Europe. And the WARD clinical support system is now a fully implemented monitoring system of vital signs for in-hospital and hospital at-home patients and has obtained...

CE mark and is expected to obtain FDA clearance soon. So that is Christian's conflict of interest is to disclose that, that he did found this system and it is awaiting FDA clearance. I think he's absolutely not going to be influenced in his opinions on that. He's going to share the data as he is a true scientist who has really done a lot of great work with this. And then

I also have with me Dr. Martina Breitler, who is a postdoctoral researcher and technical physician at the Department of Anesthesiology, Internal Medicine, and Digital Health at the University Medical Center Utrecht in the Netherlands. She's doing translational research focused on safety embedding of continuous vital sign monitoring with wearable sensor technology,

in clinical practice on the general wards, but also in looking at the possibility of deploying it 24-7, this continuous monitoring technology in patients who are discharged home early or are treated at home instead of admission to the hospital. So both of them doing really fascinating work, really at the cutting edge of this, and I'm excited to talk to them. Both of you, welcome to the show. Thank you, Jeff. Thank you.

So I want to explain to the audience that rather than kind of a traditional pro-con debate, what we're going to really do is explore with both of you. First, the pros of continuous vital sign monitoring, what we know about it, what are some of the advantages of thinking about doing this, and then we'll let both of you talk about your thoughts on this, and then we'll go back and have both of you explore some of the pros.

limitations or drawbacks are where we are right now so that the audience can hear from both of you on both of these topics. The idea here is not to pick a winner, not to say we should or shouldn't do this, but to explore both sides so people are aware of what's going on and where this may be headed in the future. So let's start with the pro, and Christian, maybe we'll start with you. What are some of the reasons why you think it's a good idea to think about continuous vital sign monitoring for patients?

It's really obvious to consider continuous vital sign monitoring for the future care of our patients. Let me just explain from the beginning my conflict of interest in this public-private partnership we have created in Copenhagen, Denmark.

It was actually based upon a clinical frustration as working anesthesiologists. My colleague, Professor Eske Osvang from Copenhagen and technical associate professor from our technical university, Helge Sampson, the three of us

We really sat together with a frustration of patients becoming so ill and we were not notified as on-call doctors in anesthesiology and ICU.

For example, the patient that has an asthmatic leak and needs second surgery for that, that would take several hours, half a day, maybe most of the day, to really get recognized by the staff at the surgical force and do the scans, do the procedure, the clearing for second surgery.

And at that time, the patient likely ended up in septic shock and severe worsening of the disease. Although if the patients would have been in our care, in the PACU or in the ICU, the time to recognition of the disease would have been much, much smaller. And that is due to the lack of monitoring.

in the surgical floors. And we began our project in 2016 with the intent to apply wearable smart sensors monitoring traditional vital signs, but we also recognized we needed to communicate that to the clinicians in a smart way because the staff is not as present in the post-operative

surgical floors as they are in the PACU and the ICU. So we needed to do something in order not to over alert. But being able to do that really is the major step forward in patient safety because then we can recognize at the time the disease progresses to become severe in terms of the vital signs deviate and also avoid the over alerting to the staff.

Yeah, I mean, it has always shocked me since the time I became an anesthesiologist that we –

monitor most patients on the floors with vital signs every four hours. So you could easily find out four hours in to them becoming septic that they were because that's when you check and find out that they're tachycardic hypotensive, right? And that is an incredible delay. So it's always seemed so obvious. And we'll get to some of the reasons why maybe we haven't already done it. But

It does seem like early detection of vital sign deterioration is a pretty clear one. And let me ask you, Christian, is there data to show that early detection of vital signs does improve outcomes for patients?

It's definitely becoming available now, data. Obviously, the trials are really difficult in many ways to conduct, but fortunately we have seen in the recent years some also very large observational before and after studies coming out, really

underlining the lowering of morbidity after implementation of continuous vital sign monitoring systems, and also less fatalities, less ICU admissions. And the intriguing part of those studies is that the number of calls for rapid response teams

they actually seem to be not changing, which from my perspective is good because we need to activate more senior staff from the ICU when a complication arises.

And the monitoring part in my part, my take on that is that it likely will not make all complications go away, but it will detect them much earlier so we can intervene and avoid them progress to very severe and disabling complications.

So the data is about to be there and definitely more clinical trials will be published in the years to come. Yeah, fabulous. And I know that there definitely has been data for a while now that we do miss significant things. When we only monitor every four hours, we miss hypotension, we miss bradycardia, we miss tachycardia. So all this stuff is happening in between the vital sign checks. Yeah.

And we're missing it. So we know that. And then it sounds like the data to show that those misses do, in fact, impact morbidity and mortality that is emerging.

You can even take it to a higher level because to some extent the outcomes such as hypertension or bradycardia or bradypnea at the postoperative floors, they are surrogate outcomes. They come before the severe adverse events of the patients and eventually the cardiac arrest cases or unintended admission to ICU, second surgery, etc.

And if you analyze those big important outcomes for the patients, it's actually estimated that approximately 40% of these, if we knew what was approaching, we could have prevented these 40%.

So if you compare that potential development in patient safety with all various other good interventions that are being tested now and coming into clinical care and optimizing treatment, then the potential to avoid these serious outcomes progressing without us knowing them is really the next major step forward. Yeah, absolutely. And, you know, my understanding is that while intra-op treatments

anesthesia is incredibly safe. We've reduced mortality from anesthesia in the operating room to very close to zero. And yet, the post-op period on the floor is where there's still a lot of issues, right? The morbidity and mortality associated with the first, I think it's 30 days maybe after surgery, is much higher than it is in the operating room. So that seems like the area we need to focus on more. Definitely. And obviously, the success of

over our safety and anesthesia safety has led us to include older people with more and more comorbidity into surgical procedure and that in terms does not lower the risk of having a complication.

And the complication, it just takes days and for some complication weeks in order to develop. So if you have pneumonia in progression, you would not be able to recognize it in the PACU. That's way too early. So a couple of days later, you need to detect it at the time it occurred. And the current standard of monitoring globally

early warning score, early warning scores, they are with so many hours apart and many of the deviations can occur in between. Yeah, absolutely. Martina, let's turn to you. Are there other advantages or things that really make this idea of doing continuous vital sign monitoring really appealing? Well, I think what is also important to mention to the information that Christian is telling us is that

Indeed, we are right now able to continuously monitor those vital signs in patients outside critical care units. And that's also because due to the developments in technology over the recent years. So when I started with my PhD back in 2016,

there were a few wireless sensors available. So sensors, for example, smart patches that patients could wear without compromising mobility, for example. And suddenly you were able to

continuously monitor or see heart rate or respiratory rate, for example. But we realized back then, and that was together when I started my PhD, that was together with Professor Carl Kaplan. He's also an anesthesiologist, currently retired.

But we realized that the manufacturers that were developing these sensors, they came to us and they told us, okay, look, we have these fantastic sensors. They have, for example, a CE mark or FDA approval. So you can use it in clinical practice together with patients. And then we thought, okay, but why?

can these sensors really detect these abnormal deviations in vital signs? And then we found out that most sensors or some sensors were not clinically, really clinically validated, or at least the data was not published in literature. So back then, yeah,

The fact that, for example, a sensor was CE cleared or FDA approval didn't really mean that, for example, a complication could be recognized on time. So that was something we had to realize and we had to find out during clinical validation studies ourselves with new sensor technology. Maybe that's not really an answer to your question yet. And I almost forgot.

The question you were... No, so that's, first of all, that's really important, right? To think about that it's fine to say on one hand, we need, it's good to monitor vital signs continuously, but then the question is, can we do it, right? It may be good to do, but we may not be able to do it well. And I would imagine that if you have poor, poorly functional monitors, then not only are you going to get all kinds of false alarms, but you're going to have just, you're going to be overwhelmed with data that's not useful.

So I think what you're saying, and it makes total sense, is that you have to figure out, you have to validate the instruments and decide, do these actually work? And it sounds like they do. And so I guess the question is, is there –

We talked about what seems like the major advantage to continuous vital sign monitoring, which is that we can catch perturbations in vital signs, identify when a patient may be headed towards a significant complication from their surgery, and hopefully intervene earlier. Are there other advantages to doing this that you think are important to mention?

I think what would be important to mention is the fact that you suddenly are able to view or to recognize improvements or deteriorations in trends patterns of phytoscience. So on the ICU or maybe during the OR, you are

really monitoring, real-time monitoring the condition of a patient. And if a phytosign is deviating, you're immediately intervening. That's completely different on a low-care ward or on the floor. There you have nurses who are really busy. And that means that

They need to work differently. But if you're able to provide really a trend pattern of a patient that is deteriorating over the past few minutes or hours, that's very useful information for floor nurses or for clinicians on the ward. Yeah, absolutely. Yeah.

And I think that's a different situation as compared to the ICU or OR. Definitely. Now, let's talk about the monitors you mentioned. What are we talking about? Are they watches? Are they something you wear around your chest? Like what kind of monitors are people using both on the wards and then at home?

Well, they could be different. So the technology is really improving at the moment. So it could be watches. It could be chest-based sensors that are using electrodes.

It could even be upper arm brace, upper arm monitors. So it's a variety of different sensors. But what they have in common is that they're wireless and wearable. So the patient can walk and can do whatever he wants.

Yeah, fabulous. Okay. And so the idea is patients obviously would get monitored. Is it the entire time that they're in the hospital? Is it just for a certain number of days? Is it until they kind of achieve a certain, you know, number of days of stability in a row? Like, when do we know? I guess the question is, how do we know when to stop? Are we doing it from the moment they get to the floor and then for how long?

I think that's a difficult question. We cannot answer it yet. I also think it's different compared to surgical patients as opposed to medical patients. I think patients after major surgery, well, we do know that certain complications do occur in the first few post-operative days. So you do know that monitoring patients in this period is very important.

In medical patients that are at risk of an infection or a bleeding or something difficult that we don't understand yet, it might be different.

Yes, somehow we don't know yet when to stop, maybe also not when to start. So I haven't figured this out yet. And so maybe this is another advantage of doing this is that it allows us to actually figure these things out, right? Because it's almost impossible to know without doing it to be able to figure out when is it most useful. You kind of have to do it to figure that out, right? Yeah.

Exactly. And you can also imagine that once you're doing this, that maybe you're able to see earlier that a patient is reaching a certain stable phase so that this patient, in terms of his vital signs, his physical condition, is ready to go home, for example.

And that could maybe be earlier than we thought that that patient would be for other reasons. Yeah, absolutely. Christian, anything to add there? When we talk about this, are you in your mind, do you think, okay, I think it's going to be this long after surgery or who would go home with monitoring? Was it only people who, you know, are outpatient, they're having outpatient surgery, maybe they wear these monitors at home for a day or these patients who've been in the hospital for a while, now they're going to go home, but home with monitoring, maybe that lets them go home a little earlier? Yeah.

Definitely. I think there are two answers to your question. First, in future care, if you sort of in hospital dare to go new pathways with patients, maybe discharge earlier, maybe discharge at the same day as surgery, wouldn't you want the best security for those patients if you accelerate care even more? And then continuous vital sign monitoring will definitely be part of those pathways.

pathways. My interpretation of how many patients in hospital that should be eligible for continuous monitoring in the med-surg floors, I would expect around a quarter of all patients in hospital because you may triage based on the type of admission, the type of surgical procedure, if it is a

medium or high-risk surgery, then you would likely consider continuous monitoring. Or you could consider it for the patient risk. If the patient has severe cardiac or pulmonary disease, then it would also turn out to be a good decision. Obviously, some low-risk cases, such as minor procedures,

they shouldn't have continuous vital sign monitoring. So a major portion of the hospital population and the same for those discharged after surgery or medical admission. Yeah.

Absolutely. And so what would happen? Let's say, OK, this patient normally in today's world, they would stay, you know, three days. But since we are going to be able to do at home monitoring, they're going to go home after a day. And then let's say they go home and their monitoring is concerning. They had their attack. They're getting tachycardic, hypotensive, whatever it is.

Is the idea that there would be a monitoring clinician who would get this alert and would then call the patient and say, we need you to come in? How does that work? We've tested various options in our clinic.

Research in Copenhagen, both the discharging department, you can have the coordinating nurse reply to the deviating vital signs 24-7 and then taking appropriate actions such as calling the patients, getting information of current condition and eventually if the patient is not replying or the condition is very severe, then dispatch an ambulance.

Or you can have more professionalized units that would be up to the hospital system. Yeah. So, yeah, Martina, go ahead.

Yeah, I totally agree. I also do think so. So we have our own monitoring center as well in our university hospital. We are monitoring patients in the home setting and we are starting a program for continuous vital signs monitoring 24/7 of patients with acute respiratory tract infections early next year.

And what we do believe is that the treating physician who admits the patient, who does see the patient on the emergency department, he or she is responsible for the medical treatment, even when that patient is being monitored and treated in the home setting.

But it's the monitoring center that uses protocols and who is monitoring the condition of the patient in a home setting. And once, well, phytoscience deviates too much, they need to contact the physician on duty and they need to bring in, for example, the patient again. So I do think that

still the treating physician is still responsible also for the patient in the home situation. May I also just add another example? Now we have talked a lot about hospital discharges, but patients also come into the hospital and those acute medical admissions

We saw that during the COVID pandemic that we were not able to admit all patients to hospital and some ended up dying in hotel rooms without monitoring. We see now, for example, in the UK a huge problem with the capacity of the hospital system

and ambulances waiting for just dropping off patients in the ER. So some of those patients that are sort of by routine just being admitted every time they have a certain amount of acute medical disease, they could be equipped with continuous monitoring systems at home if they don't need a CAT scan or blood samples or other surgical procedures in hospital and then being monitored and then

admitted only if their visal signs become severely deviating. Yeah, fabulous. You know, another advantage, it seems to me, is that

We don't really know what types of vital sign perturbations necessarily lead to complications. I mean, we know it for patients in the ICU probably, but for patients on the floor, I think we assume they probably get tachycardic and hypotensive, but, you know, maybe not. Maybe there's something else that happens. And so it seems to me like doing this continuous vital sign monitoring will allow for

a lot of learning on the part of clinicians as to what exactly it is that we should be looking for. Is that true?

Now we actually have the opportunity to base monitoring practice on quite hard evidence. That was not the case when we implemented the national early warning score globally. One of our very bright PhD students, he was able to locate the original abstract from which the different scores in the news was based upon. That was 100 patients and a conference abstract.

based on some very logical vital sign deviations, mainly around sepsis and our

a common agreement around that but we have built a global system around that and I'm sure we can do a lot better now because much of our research actually indicate that it's not all severe complications that are preceded by the traditional deviations in vital signs and on the other hand also a lot of patients have a lot of vital sign deviations without getting serious complications

So we likely can use this evidence also to provide much smarter alerts in the future for vital sign deviations. Yeah, that makes a ton of sense. Stay with us. We'll be right back.

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Welcome to It Takes Energy, presented by Energy Transfer, where we talk all things oil and natural gas. Oil and gas drive our economy, ensure our country's security, and open pathways to brighter futures.

Did you know the first oil well was drilled almost 1700 years ago? The first American well was drilled in Pennsylvania in 1859, and the Texas oil boom began in 1901, when the Lucas Gusher produced an astonishing geyser that flowed for nine days. This oil boom helped launch the widespread use of the automobile and grease the wheels of the modern machine age.

Today, the U.S. is the world's top producer of oil and gas, supporting 11 million jobs and contributing $2 trillion to the American economy. Look around and you'll see the essential role oil and gas plays in our modern lives. Our world needs oil and gas, and people rely on us to deliver it. To learn more, visit ItTakesEnergy.com. All right, and we're back.

Yeah, and I think this also makes it more difficult right now to really implement these kind of systems because exactly this information is currently lacking. So we need to learn from this. But it also means that, for example, nurses on the floor,

they're not used to really interpret this flood of data yet. And that's, yeah, I mean, ICU nurses, you as anesthesiologists or ICU physicians, you're completely used to it, but it's different compared to the clinicians who are working outside the critical care units. And that's

and maybe a sort of an interbellum until we exactly know how to deal with this huge amount of data and how until we have really the smart systems there to really act upon the necessary deviations that need actions.

Yeah, absolutely. The other thing that occurs to me that is an advantage of this is that, you know, we have all the time patients who were trying to decide, do they need to go to the ICU or not? And we're kind of right on the borderline. Maybe we don't have a lot of open ICU beds, so it's not we can't put everybody there.

And so we end up sending them to the floor, but then we're really nervous about it. Right. We're like, oh, my goodness, was this a mistake? Are they going to do badly? And so the sense of kind of security that would come with knowing, OK, I can send them to the floor, but at least I'll know if something is going badly. We'll know right away and we can change it and move them to the ICU. That seems like a big advantage, too.

I really agree on that. It's important. And of course, as doctors and ICU doctors, and if we discharge patients from the PACU, we care and we worry about the patients. But to make this visal sign monitoring into a clinical support system, that is a new technical solution for nurses,

And the nurses, I mean, if we care and worry about the patients, the nurses on the med-surg floors, they really care about the patients. And if they have patients ending up in cardiac arrest,

on their night shift, they may quit the job. It is really serious. And at this moment, we have the opportunity and have actually built and created a new technical solution for the nurses. And the satisfaction of actually having technical equipment that works in their daily routines

It saves time for them if they need to go check vitals often, then continuous monitoring system alone, not before, even preventing complication. It saves the time to collect vital signs and document in the electronic medical record, and it provides a sense of security during treatment.

their day and it's also providing sense of security to the patients. Yeah, absolutely. All right. So lots of positive things coming along with this. Let's talk about some of the drawbacks or cons. What do you think, Christian, we'll start with you. What do you think are some important things to keep in mind in terms of cons to continuous vital sign monitoring? Most important is that

We talked about the level of evidence of what does a deviating vitasign really mean. Is that equivalent to the patient having a disease or even having requirement for, let's say, intravenous fluids or more opioids? We don't have that exact knowledge at all. So the current systems of vitasign monitoring

They are alerting the staff and we hope and expect the staff will interpret them in the correct manner and do the interventions that are appropriate. But as with all screening tools, there are risks of over-alerting and also misinterpreting the alerts. The alerts does not say you should give fluids.

But definitely a risk if you provide a lot of alerts for tachycardia, then some of the patients, they will end up having fluids. And is that a good intervention then? We will see. So that's definitely a challenge we need to address in future trials as well. Yeah, that makes a lot of sense, right? You don't want a situation where all of a sudden any patient whose heart rate

goes above 100 for any reason automatically gets a liter of fluid, right? I mean, that would be a major downside. So you'd want to have a system of being able to interpret this data and make decisions based on it in an evidence-based way and not just willy-nilly kind of, you know, try to make the numbers look better. All right. So that makes a lot of sense.

We talked a little bit already, both of you mentioned in the earlier discussion about how this is going to produce a lot of data. And so, you know, that could be overwhelming, both in terms of you could imagine if alerts are going off every second, it's going to cause alarm fatigue. People are going to stop paying attention. It's just going to be exhausting. So how do we I mean, that that's obviously a potential con. You know, are there ways that we can address that?

I'm sorry. I mean, in a podcast like this,

It is really our specialty that has years and decades of experience in interpreting continuous vital signs. So why don't we give our medical knowledge to the nurses on the med-surg floors? And if we're able to do so, and I know we can do that in algorithms and incorporate into the clinical support systems,

in order to lower the amount of alerts. So every time I perform general anesthesia in the OR, I don't recognize when SpO2 drops below 90.

Because I know that most of the times it will be normal again quite suddenly after. And therefore, a continuous vital sign monitoring system should not alert every time SpO2 is below 90. It should be based on evidence. So we need to collect that in order to not over alert. And it's possible to create that in a clinical support system. Yeah. Martina, were you going to say something before?

Yeah, I fully agree with you, Christian. And I think right now this is still a little bit difficult because there are systems out there that are producing these smarter alerts, either rule-based or we even have scoring systems. And I think these developments are very important because right now we have implemented continuous vital signs monitoring on our wards.

But we do experience difficulties with huge amounts of alert fatigue. And actually what we have done is we don't look at these alerts. Well, we basically have an approach, an hybrid approach that we both look at alerts, but we widen the levels. So that's obviously not the way to go. But we are combining it with protocols to watch for certain trends in deviations. And that's the way how we're currently looking. But it's not

possible to really upscale. So within our monitoring center, we are monitoring patient home setting and they're actually also monitoring patients on our ward, on the distance.

At the moment, it's about 10, 20. It's not a big number of patients yet. But once you will increase this volume of patients to 100 patients, 200, 300, then you really need those smart scissors. Otherwise, you will never be able to take care of a larger amount of patients in a proper way. Yeah. When we think about

The the way to kind of deal with all this data, it seems to me like AI. I mean, this is like the future. Right. I mean, AI is going to be able to handle this and learn from it and be able to tell us, you know, what we need to pay attention to and whatnot. Right. Is that being worked into these as a way to deal with this over overwhelming amount of data?

That's the obvious way for it, and I strongly believe that the AI interpretation of the alerts together with the medical knowledge and most importantly, annotation up to which really important events are being there. So we need to collect data first and then perform AI algorithms first.

then I am sure this can reduce the number of alerts significantly. However, now we're talking about the cons.

If you perform AI algorithms in a very small subset of patients, maybe it will be biased towards those patients that were in that subset. And if you use it in a totally different population, receiving other types of treatments, that may be a limitation to that. So bias in AI is important to recognize as a limitation.

Yeah, absolutely. That's a great point. And then what about you could imagine for the home monitoring, let's say that a patient's vital signs are normal, but they are throwing up, they feel terrible, right? You wouldn't know that from the vital sign monitor necessarily. And so you could kind of feel quite reassured. Their vital signs are all great and not

act early enough because they, you know, have a developing, you know, small bowel obstruction or something, but you're not aware because the vitals are normal. So that, I mean, another example would be a patient on a beta blocker, right? They may not get tachycardic even though they're getting septic. So how do we, is that just a drawback of this or is there, you know, what do we think about that?

Well, I don't think it's a drawback. I think this is a huge, this is a complete new field to be able to actually monitor those patients in the home setting. So what we do miss is that we don't have any context information of that patient in the home setting.

So right now we do have the clinicians on the ward or on the floor who can walk to the patient at the bedside and they immediately have the information of the vital signs, would look normal, but they have the clinical judgment and they can provide appropriate treatments. We don't have this at home. So we need to find solutions how to get some available context information of the patient in the home setting

together with these normal phytosites, because indeed, once the phytosites are all in the green, but the patient in fact is feeling terrible, yeah, that's not the way to go.

So you need to incorporate context information. So the patient at first needs to be able to contact 24/7, comparable to the current floor when the patient is also, when he's not feeling well, he can push the button to ask for a nurse. That needs to be possible at home as well. And there are other ways to capture other context information, for example,

patterns of activity. Once you know the patient is completely lying still for a while already and the heart rate is increasing, respiratory rate is increasing, that's completely different as opposed to a patient who was becoming more active. And these smart patterns, also day and night patterns, for example, need to be included in AI, in smart alarms to deal with this problem.

I may add just a small comment to that. It's not really the main goal of continuous vital sign monitoring to be a computer that takes care of the patients. That could be doctors and nurses still. Of course they should. But continuous vital sign monitoring, that should take away the worry of patient deterioration in between our contact with the patients, and it should automate a lot of the things we do

and it should monitor some of the signs of patient well-being. You know, risk of aspiration, we don't measure that in our current early warning score because there are no tools to measure that risk.

And currently continuous vital sign monitoring, they cannot measure risk of aspiration either. So of course, we should attend the patients and watch and do all our best practice. But this would be a great help and safety for the future. Yeah, absolutely.

What about ethical considerations? It seems like there could be some ethical potential drawbacks to this. For example, you know, maybe patients don't want to feel that they're being kind of watched, quote unquote, watched at all times, especially at home. Maybe there's extra stress on clinicians feeling like they have to be on top of these vital signs all the time. And if they miss, you know, even one set of bad vital signs and somehow that they've failed, you know, is that are those potential drawbacks?

I think these could definitely be potential drawbacks. We don't know everything, every part of this yet. I think a patient, for example, they, well, usually we do hear more positive things, that they are feeling less worried because they know someone is watching their condition. But we also have here, our research also, we also have

experience that patients want to have access to this data and they become more worried because they do see their vital signs but they don't know how to interpret it and they suddenly become more worried. So that's also not the way forwards. And I can also imagine that patients are not feeling comfortable when someone is watching over their shoulders.

Yeah, there's quite some research that needs to be done to study this. Christian, anything to add there? Of course, the...

the worry of the screening tools and how do we handle if the doctor is not attending a patient that has an alert for tachycardia that needs to be considered, the medical oath and the ability to do our best. Of course, we should assess the information available

It's not the same as an alert requires you to do certain things about the patient. And that is equivalent to how we assess patients at the moment. But it could feel as a pressure both for nurses and doctors that now we have a record of exactly what went on in the method flaws. And that should be handled by hospital management, how we deal with this.

Yeah, yeah. I think this will be really interesting. I mean, it feels to me like this is coming, right? It's not like this is not going to happen. So as it happens, so many of these things will have to get figured out kind of along the way, right? How do we deal with these ethical issues? Do we let patients opt out of this?

You know, they certainly like a patient in the ICU cannot opt out of monitoring. Do we let patients in this situation opt out? Maybe they can opt out from the home part, but not the hospital part. I mean, this is all stuff that's going to have to get hashed out, right?

Yes, indeed. I also think on top of this, it's really important how do you inform those patients. So I think right now with continuous phytoscience monitoring, it might give the feeling to a patient that they will be monitored second by second.

But in fact, that's not even the case because those patients are moving, they're walking. There are lots of artifacts in the data. We have data gaps. We didn't even talk about that, for example. So we also have periods without data from that particular patient. So they need to understand that.

We are monitoring their condition, but it's not always second to second. But we try to recognize when we need to take appropriate action. Yeah. All right. Well, I think we've covered a lot of great stuff for the pros and cons of this. Is there anything we didn't cover that either of you wants to bring up?

I think the way forward is a combination of requiring better and better sensors for the patients and also combining that with software that interprets the continuous visual signs.

And both of these aspects needs and will improve in the future. So a drawback is that sensor fit is not always optimal and sensor data validity is not always optimal. We don't have an easy continuous blood pressure device, for example, that is easy to wear. And also the AI interpretation.

is developing and becoming more and more specific to the relevant alerts and sensitive, of course. We know the sensitivity is high, but the specificity is a way to improve in the future. And I think a combination of these two better sensors, better algorithms to interpret them, that will lead to a better and more worldwide implementation of this. And as you mentioned, Gep,

it will be there. So if we don't develop something that has our anesthesia ICU logic in it, we'll have some really terrible continuous vital signs systems in the future. So we better get out there and give our input. Absolutely. Martina, anything you want to add?

No, I fully agree with Christian. I think we have covered quite some topics. So there's a major window for opportunities to do also some proper research on this topic. Yeah. And, you know, I should have asked before, but so you brought this up, Christian. Obviously, in the hospital, we can do blood pressure, we can do heart rate, we can do pulse ox. Right.

When we are talking about the wearable monitors at home, what are we measuring? Obviously, heart rate is kind of the easy one. Are they measuring pulse ox? And it sounds like they're not measuring blood pressure.

Well, blood pressure depends on the severity of the condition at home, but basically you can monitor with the same equipment as in hospital because the connection currently we use in our project a sim card, a secured sim card that just sends data to the hospital and the servers there so we can use the same equipment at home and in hospital.

Okay. Yeah, I do. So there are some, some variable systems out there already that also can give a proper estimation of also of continuous blood pressure monitoring. So based for example, on a combination of ECG and, and, and PPG. So there are some first systems out there that, that, that can do this job. So I think we will, um,

have some opportunities there. Well, this is very cool, very exciting. I'm looking forward to seeing this as it develops. And as hopefully, as you said, Christian, as we on the anesthesia and critical care side really take the lead on this. Well, let's turn to the portion of our show where we make random recommendations. Do you have something you guys would recommend that the audience check out or think about for fun? Martina, we'll start with you.

Well, maybe not to check out, but just something fun to share. So we had a patient who was being monitored at home for his chronic condition. And next to the vital signs, at certain periods, he often gets the question, how do you feel? And then he suddenly responded. It was within the chat.

I'm in love. So, yeah, he was feeling well. And the point I want to make is that it's not only about phytoscience monitoring. It's also about using the context information and really use the condition of the patient, the well-being of the patient.

Absolutely. And that's so important, right, to know not only what's the heart rate, but how's the patient feeling and what are their interpretations. And if they're in love, all the better. Fabulous. Christian, how about you? I would also recommend something in the personal relations category.

I'm a great fan of the Danish Academy Award winning instructor Thomas Winterberg. And the TV show that currently has a huge audience in Denmark is actually very dramatic in terms of climate changes, because it illustrates what would we do in Denmark if our country gets flooded and we need to recover.

evacuate the entire country and go across Europe and suddenly it changes the dramatics of we are used to having refugees from all other parts of the world coming to us, but what if we ended up being refugees?

I would highly recommend it. It's called Families Like Ours. If it is not available in the US, then I would recommend watching his Academy Award winning film Another Round another time because it's really great.

Fabulous. Well, that's a great recommendation. Thank you. I'm going to recommend a perspective piece that was in the New England Journal last week, and I thought it was really great. It's by Sarah McCarthy, who's a pediatric psychologist, and she published a piece called The Care That Saved Me. It's short. It's really worth a read. It's about when she had twins. One of them died of cancer, and she talks about

Going through that experience, but how much of a difference it made to her and her family to have the compassion that was shown and the things that were done to kind of bring out the humanity and recognize the humanity in both her and her family and her the other twin families.

And that it was so impactful, actually, that she then goes on to change her practice and the way she interacts with patients to really both honor the child she lost, but also to think about how impactful this care was. I think it's really in keeping with what you were saying, Martina, about, you know, how important it is to think about the patient as a person, too, and what they're feeling. I mean, it really, I think, is important and a great read. So check that out. The care that saved me by Sarah McCarthy from the New England Journal.

All right. We are going to sign off. Thank you both. This was great. Thanks for coming on the show. Thank you very much. Thank you. All right. Hopefully you got as much out of that as I did. That was really fantastic. Let us know what you thought. Go to the website, acrac.com, where you can leave a comment. Others can learn from what you have to say.

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Sonia Amanat is our tech lead. Taylor Duggan is our social media manager. And William Mao is our production assistant. Thanks so much for all you do. Our original ACRAC music is by Dr. Dennis Kuo. You can check out his website at studymusicproject.com. All right. That is it for today. For the ACRAC podcast, I'm Jed Wolpaw. Thanks for listening. Remember, what you're doing out there every day is really important and valued.

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