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Biomedical subjects

A Seiver

Publications and source records attributed to A Seiver.

13 recordsLinked to original sources
PubMed2000

Critical care computing. Past, present, and future.

With rapidly increasing processing power, networks, and bandwidth, we have ever more powerful tools for ICU computing. The challenge is to use these tools to build on the work of the Innovators and Early Adopters, who pioneered the first three generations of systems, and extend computing to the Majority, who still rely on paper. What is needed is compelling evidence that these systems reduce cost and improve quality. The experience of other industries suggests that we need to address fundamental issues, such as clinical organization, roles, behavior, and incentives, before we will be able to prove the benefits of computing technology. When these preconditions are met, the promise of computing will be realized, perhaps with the upcoming fourth-generation systems. ICU computing can then finally cross the chasm and become the standard of care.

Computer Communication Networks↗
PubMed1998

Covering the "open abdomen": a better technique.

"Damage control" in severe abdominal trauma, abdominal compartment syndrome, necrotizing fasciitis of the abdominal wall, and necrotizing pancreatitis often preclude closure of the fascia after laparotomy. Many techniques have been reported for temporary coverage of the exposed viscera, but most have had documented problems. We report the successful use, since 1989, of a temporary sutureless coverage. The viscera are covered with omentum when possible, then with a clear plastic sheet. Sump drains are placed over this layer. The entire abdomen is then covered with two layers of iodophor-impregnated adhesive plastic drape. The last 50 patients managed with this technique are reported. The most common indication (27 patients) was for treatment of severe abdominal trauma. There were no wound infections, fasciitis, or bowel obstruction. Eighteen patients died; no deaths were related to abdominal closure. Temporary abdominal covering with adhesive plastic sheeting is a rapid, safe, and readily available method for managing the open abdomen. This technique provides a physiologic milieu for the abdominal viscera, simplifies nursing care, and promotes safe closure of the abdomen at a later time.

Abdomen↗
PubMed1996

Optimizing physician access to surgical intensive care unit laboratory information through mobile computing.

Approximately 30 minutes of computer access time are required by surgical residents at Stanford University Medical Center (SUMC) to examine the lab values of all patients on a surgical intensive care unit (ICU) service, a task that must be performed several times a day. To reduce the time accessing this information and simultaneously increase the readability and currency of the data, we have created a mobile, pen-based user interface and software system that delivers lab results to surgeons in the ICU. The ScroungeMaster system, loaded on a portable tablet computer, retrieves lab results for a subset of patients from the central laboratory computer and stores them in a local database cache. The cache can be updated on command; this update takes approximately 2.7 minutes for all ICU patients being followed by the surgeon, and can be performed as a background task while the user continues to access selected lab results. The user interface presents lab results according to physiologic system. Which labs are displayed first is governed by a layout selection algorithm based on previous accesses to the patient's lab information, physician preferences, and the nature of the patient's medical condition. Initial evaluation of the system has shown that physicians prefer the ScroungeMaster interface to that of existing systems at SUMC and are satisfied with the system's performance. We discuss the evolution of ScroungeMaster and make observations on changes to physician work flow with the presence of mobile, pen-based computing in the ICU.

Algorithms↗
PubMed1995

Support for information management in critical care: a new approach to identify needs.

Managing information is necessary to support clinical decision making and action in critical care. By understanding the nature of information management and its relationship to sound clinical practice, we should come to use technology more wisely. We demonstrated that a new approach inspired by ethnographic research methods could identify useful and unexpected findings about clinical information management. In this approach, a clinician experienced in a specific domain (critical care), with advice from a medical anthropologist, made short-term observations of information management in that domain. We identified 8 areas in a critical care Unit in which information management was seriously in need of better support. We also found interesting differences in how these needs were viewed by nurses and physicians. Our interest in this approach was at two levels: 1. Identify and describe representative instances of sub-optimal information management in a critical care Unit. 2. Investigate the effectiveness of such short-term observations by clinicians. Our long-range goal is to explore the use of this approach and the information it reveals to optimize the process of developing and selecting new information support tools, preparing for their introduction, and optimizing clinical outcomes.

Critical Care↗
PubMed1994

Multisite evaluation of a continuous intraarterial blood gas monitoring system.

BACKGROUND: We compared the performance of a new, continuous intraarterial blood gas (CIABG) monitor with arterial values obtained periodically and analyzed by conventional equipment. METHODS: A CIABG monitoring system consisting of a sterile, disposable, fiberoptic sensor and a microprocessor-controlled monitor with a self-contained calibration unit and detachable display panel was used. The sensor was inserted through a 20-G radial artery cannula. Light was transmitted from the monitor to the sensor tip where it reacted with fluorescent dyes sensitive to oxygen or hydrogen ions (analytes). The change in the intensity of the photoluminescent radiation caused by the analytes was measured every 20 s and derived blood gas values were displayed. Twenty-nine sensors were evaluated in 29 surgical or intensive care unit patients at one of three institutions (Stanford University Hospital, Evanston Memorial Hospital, and the Palo Alto Veterans Administration Hospital). The duration of study averaged 6 h (5-8 h) in the operating room, and 46 h (7-121 h) in the intensive care unit. A total of 552 values were compared with those obtained at regular intervals and analyzed in the hospital blood gas laboratory. Average bias (mean difference between lab value and CIABG), precision (SD of difference), and drift (change in the bias with time were determined. RESULTS: At arterial oxygen tension (PO2) values of 32-528 mmHg, the average bias was -1% meaning that the average CIABG monitor values were 1% lower than those obtained by conventional equipment. The precision was 15%. At arterial PO2 values of 32-99 mmHg, average bias and precision were -0.3 +/- 8.9 mmHg. At arterial carbon dioxide tension (PCO2) values of 24-54 mmHg, average bias and precision were 1.3 +/- 3.3 mmHg, and at pHa values of 7.23-7.57, average bias and precision were 0.01 +/- 0.04. Observed drift per day was -1.2% for arterial PO2, 0.3 mmHg for arterial PCO2, and 0.01 for pH. Bias and precision for samples compared in two pairs of like-model in vitro blood gas analyzers were 0.4 +/- 4.6% for arterial PO2 over the full range, and 0.4 +/- 3.7 mmHg for values less than 100 mmHg, -0.5 +/- 1.8 mmHg for arterial PCO2, and 0.01 +/- 0.01 for pHa. Although the occasional marked discrepancies between one or more CIABG and in vitro values could sometimes be corrected by flushing the arterial catheter or repositioning the sensor, usually we could not determine the cause of the discrepancy or which values were the more accurate. CONCLUSIONS: Over the range of values and under the clinical conditions studied, CIABG monitoring provides immediate blood gas results and trend information with sufficient agreement with in vitro results to be reliable for decision making in most clinical circumstances. Generally, the differences in the values between the two methods of analysis were the result of the combination of the inherent errors of each method. Additional studies need to be undertaken to evaluate the performance of the CIABG monitor across wider ranges of blood gas values, especially for arterial PO2 values less than 60 mmHg and arterial PCO2 values greater than 50 mmHg.

Adult↗
PubMed1993

A decision class analysis of critical care life-support decision-making.

Decision analysis is a powerful methodology that can help clinicians make good decisions. Because it is not practical to place a decision analyst at the bedside in critical care units, the application of this methodology will require leveraging the analyst through computer-based systems. A decision class analysis is a collective analysis of a group of decisions that provides the high-level specification for such a computer system. This paper presents a decision class analysis of critical care life-support decisions. Key elements of this analysis are: the simplification of an otherwise extremely complex multistage sequential decision problem by using a sequence of two-stage models, and the use of six generic knowledge maps that capture the extremely complex relevant medical knowledge.

Artificial Intelligence↗
PubMed1993

Guaranteeing real-time response with limited resources.

Unanticipated problems detected by patient-monitoring systems may sometimes require real-time response in order to provide high-quality care and avoid catastrophic outcomes. In this paper, we present an approach for guaranteeing a response to such events by a monitoring agent even in situations where we have limited problem-solving resources. We show that an action-based hierarchy can accomplish this goal. We also analyze the performance of this hierarchy under varying resource availability and discuss decision-theoretic approaches to enable us to best structure such a hierarchy. We also describe an implementation of these ideas, called ReAct, in the BB1 architecture. All the ideas are illustrated with examples from the surgical intensive care unit (SICU).

Algorithms↗
PubMed1991

Workstations speed care delivery to critically ill.

A busy intensive-care unit in the Veterans Affairs Medical Center in Palo Alto, Calif., has begun to put the power of workstation technology to good use in caring for the facility's sickest patients. Adam Seiver, M.D., chief of general surgery, told Computers in Healthcare that the system tracks patient information far more accurately than the manual methods used previously. Before the system, a patient's ICU records were filed away after each 48-hour period. Now a complete history of the patient's ICU stay is accessible at the beside through the duration of the episode.

Beds↗
PubMed1989

Decision analysis: a framework for critical care decision assistance.

The ultimate goal of medical computer systems is to help clinicians make good decisions. Such systems must be based on sound principles. Decision analysis is a 25-year-old discipline that provides the needed rigorous foundation for decision assistance. Decision analysis comprises the philosophy, procedures, and tools that can correct the flaws in existing critical care decision-making practice. Intelligent decision systems--computer-based systems that automate decision analysis--make it practical to apply decision analysis to critical care. Orchestra is a pilot intelligent decision system (now under development) that coordinates the efforts of the critical care specialist, the bedside physician, and the bedside nurse in building decision models that can provide recommendations and insight for ventilator management decisions. Decision analysis delivered by intelligent decision systems has great potential for improving critical care decision-making.

Algorithms↗
PubMed1987

Bedside computers in the surgical intensive care unit.

User "friendly" computers are becoming available for increased usage in the medical arena. The Surgical Intensive Care Unit (SICU) has a large number of items to identify, quantify, manage, and record frequently, often on a continuing basis. At the Palo Alto Veterans Hospital, a program has been developed (A.S.) to change ventilator requirements as an aid to medical staff. Fewer laboratory studies such as blood gas determinations are required. Trending of information is critical in making appropriate plans of care. Twenty patients with a variety of surgical problems have been evaluated by utilizing a bedside computer.

Decision Making, Computer-Assisted↗
PubMed1980

Utilization of diagnostic radiologic examinations in the emergency department of a teaching hospital.

A study to document the utilization by house officers of the Diagnostic Radiologic Examination (DRE) in trauma patients was carried out over 2 years at Stanford University Medical Center. Physicians recorded the likelihood of a fracture being present for patients requiring DRE's to evaluate traumatic injuries. The physician's opinion and the radiologist's final interpretation of the DRE were compared for 24 anatomic regions. Preliminary findings reveal: for almost half the DRE's the officer indicated that the reason for the DRE was medicolegal; 7% of the medicolegal cases had fractures present; less than 4% of these fractures was important enough to change the medical treatment. The levels of house officer experience are suggested as possible causes of excessive DRE utilization, as well as the influence of defensive medicine. Using Green and Swets' Theory of Signal Detection, it is possible to mathematically describe an accuracy index, and a "fear" index for each physician. We plan to use this model in analysis of the study data.

California↗