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.