Portal de Periódicos da CAPES

Is Wireless the Future of Monitoring?

2016; Lippincott Williams & Wilkins; Volume: 122; Issue: 2 Linguagem: Inglês

10.1213/ane.0000000000001058

1526-7598

Ira Hofer, Maxime Cannesson,

Anesthesia and Sedative Agents

In this issue of Anesthesia & Analgesia, Simpao et al.1 address a frustration of many anesthesiologists, tangled patient monitors. The authors were prompted to action by difficulties using an anesthesia information management system (AIMS) when providing anesthesia services in the neonatal intensive care unit. The authors transmitted data from a patient’s monitor to their electronic anesthesia record (AIMS) client wirelessly by using Bluetooth technology. Of their 30 cases, only 3 exhibited gaps in data transmission, and 2 of those gaps were for <2 minutes. Anesthesia in non-operating room (OR) locations accounts for approximately 40% of case volume and is projected to grow further.2 Growth in non-OR anesthesia services makes wireless solutions increasingly important. Unlike ORs, which are designed to meet anesthesiologists’ monitoring requirements, outlying areas (e.g., interventional radiology suites, magnetic resonance imaging scanners, radiation oncology rooms) are frequently built without consideration of the need to provide anesthesia care in these locations. It can be challenging to get an anesthesia machine and monitors close to the patient. An AIMS may be impossible. If the AIMS can be positioned close enough, it can link wirelessly to the patient monitors. This can eliminate a significant barrier to the use of an AIMS in these challenging locations. As first-month anesthesia residents can attest, the hazards of patient wiring are not limited to the outlying areas. The fifth postulate of anesthesia is “parallel lines cross.” Monitor wires frequently get tangled. The severity rises exponentially (as expected) with the number of monitors. Anesthesiologists spend precious minutes untangling lines and wires during each case, investing even more time if repositioning or monitored patient transport is required. Aside from ensuring frustration, tangled wires pose a hazard to both providers and patients. Untangling wires distracts the anesthesiologist from other tasks, such as assuring a smooth emergence from anesthesia or checking that the lungs are ventilated after rotating the bed 180°. Tangled wires create a tripping hazard. We are not likely to be injured by tripping on the wires, but the patient and monitors may not be so lucky. Tripping on tangled wires may avulse IV catheters, abruptly yank the neck via an attached electroencephalogram monitor, or damage the monitors themselves. Tripping on wires can also pull instruments off their shelves, creating an additional hazard for patients and equipment. Wires also carry electrical currents, leading to the possibility of electric shock and heat injury at the electrode site in the event that the electrosurgical return electrode (incorrectly called the “grounding pad”) has not been properly connected.3 Although limiting the number of monitoring wires would make our lives easier, the motivation is improving the safety of anesthesia care. The benefits of wireless monitoring extend beyond our ORs. Sun et al.4 recently demonstrated that postoperative hypoxemia is common. Monitored beds are typically limited, which could be addressed with wireless monitoring and distributed telemedicine services. Monitored patients are currently tethered to their beds, decreasing mobility and increasing the risk of complications (e.g., thromboembolism and delirium).5 Postoperative patients may require monitoring after they are ambulatory. In an interconnected wireless world, a patient could be sent home with their monitor connected to a telemedicine center through an app on their smart phone. Patients would be instructed to return to the hospital in the event of a complication.6 Manufacturers already offer wireless electrocardiograph telemetry. Some magnetic resonance imaging monitors are equipped with wireless pulse oximetry. Wireless temperature probes exist in a variety of formats. Inexpensive fitness trackers offer continuous heart rate monitoring, although without the precision and accuracy required of a medical device. Arterial blood pressure is more technically complicated, but self-contained blood pressure devices exist.7 Wireless monitoring is a reality. Why haven’t we deployed it? The barriers are primarily technical and financial. The technology may not be sufficiently accurate for high-acuity patients. If an Apple Watch records an erroneous heart rate for several minutes, it is merely inconvenient. In the OR or intensive care unit, the same error could prove fatal. This is why the Food and Drug Administration has stringent requirements for monitoring devices, requirements too demanding and expensive for consumer-oriented wireless devices. Wireless infrastructure creates an additional barrier to implementation. Simpao et al.1 used Bluetooth to connect their monitors. The range of Bluetooth is about 30 feet. It is adequate for connecting a monitor to a nearby AIMS, but not adequate for wireless communication throughout an entire building. To meet the requirements of a hospital ward requires Wi-Fi or a cellular data connection. Only recently have many hospitals built wireless networks that cover the entire campus. Even these may include “dead” zones, a common but possibly ominous term for the areas without wireless signals. The other problem is financial: What is the business case for wireless monitoring in hospitals? The demand for wireless monitors must be adequate to encourage device manufacturers to undergo expensive Food and Drug Administration testing and solve the networking challenges to create robust monitoring solutions. They must provide incentives for hospitals to invest in the necessary infrastructure. They must be resilient to hacking, electromagnetic field interference, and sabotage. Wireless networks will introduce both anticipated risks and “unknown unknowns.” These risks will expose hospitals, physicians, and manufacturers to new liability. What is the risk if the network goes down and leaves hundreds of patients without the continuous monitoring ordered by the physician? Who pays if network failure leads to patient injury? How can wireless devices create additional revenue, or provide sufficient patient safety benefits, to offset the potential costs and liability? Our homes may be playgrounds for wireless monitoring and automation, but the clinical workplace is uniformly hardwired. How do we move forward? Simpao et al.1 present survey data suggesting that physicians want the ability to use wireless monitors when clinically indicated. If we believe wireless monitoring will improve patient care, then we must act. We must lobby our hospitals to explore new technology. We must conduct research to better understand the risks and benefits of wireless monitoring. If such studies demonstrate clear benefits to our patients, then we must work with our hospitals to make wireless monitoring a clinical reality. DISCLOSURES Name: Ira Hofer, MD. Contribution: This author helped write the manuscript. Attestation: Ira Hofer approved the final manuscript. Name: Maxime Cannesson, MD, PhD. Contribution: This author helped write the manuscript. Attestation: Maxime Cannesson approved the final manuscript. This manuscript was handled by: Steven L. Shafer, MD. RECUSE NOTE Dr. Maxime Cannesson is the Section Editor for Technology, Computing, and Simulation for Anesthesia & Analgesia. This manuscript was handled by Dr. Steven L. Shafer, Editor-in-Chief, and Dr. Cannesson was not involved in any way with the editorial process or decision.