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Wireless in the ICU: Introduction
Many hospitals have begun the difficult task of developing a wireless network. The Intensive Care Unit (ICU) at Memorial Sloan- Kettering Cancer Center (MSKCC) in New York City, NY, has been a leader in the use of this new technology, and Neil A. Halpern, MD, FCCP, Chief of Critical Care Medicine and Director of the ICU at MSKCC, moderated a symposium discussing how a wireless network can be developed to improve efficiency and safety within a hospital. “In Memorial, as in many other hospitals, we have been faced with a series of challenges at the bedside and institutionally,” stated Dr. Halpern, adding, “these include an increasing number of networked and stand-alone bedside medical devices, and the installation of multiple parallel wired and wireless networks that do not communicate with each other or transmit their information to the electronic medical record.” In addition, nurses are besieged with a myriad of alarms that conflict with one another. Therefore, MSKCC began implementing a hospital-wide wireless network to alleviate some of these problems. To this end, the hospital established a “wireless laboratory” to study the effects of introducing wireless medical devices. To help caregivers understand the multitude of challenges facing the hospital when developing a wireless network, Dr. Halpern introduced Pat Carragee, Director of Information Systems at MSKCC, to discuss the basics of wireless networks and some of the challenges faced by hospitals in implementing them.
Wireless Networking: Definitions and Challenges of Hospital-Wide Implementation
In the traditional hard-wired ICU, all rooms are fitted with data jacks, and each device is connected by cable to the jack and subsequently to the network(Figure 1A). Unfortunately, the addition of new bedside medical devices requires the installation of more data jacks and more cable in the walls and ceilings. Equally important is that device mobility is limited to the length of the cable. With wireless connectivity, each medical device is connected to the network remotely, via a wireless transmitter. No additional cabling is required, and the plethora of cables lining the walls/ceilings can be replaced by antennas that capture the data from the medical devices “wirelessly” and relay it to caregivers (Figure 1B). Another improvement is that the device can be located anywhere within the wireless coverage zone and still remain on the network. In addition, the accelerating use of PDAs, cell phones, laptops, and pagers by caregivers makes it necessary for hospitals to begin changing their current hard-wired systems to a wireless network. By allowing doctors and nurses unlimited access to the patient’s monitors, via a wireless network, the patient can receive faster and more efficient care. All of these advantages to a hospital implementing a wireless network, however, do require that caregivers be knowledgeable of some of the terminology, as well as some of the difficulties in developing a wireless network.
Figure 1
Wireless Fidelity Antennas
“Wireless Fidelity (Wi-Fi) is the standard for Ethernet traffic, or, basically, cable traffic over radio frequencies that the government has designated as free-radio frequencies,” said Mr. Carragee, adding that most traffic would use the 802.11b Wi-Fi standard (2.4 GHz 11 Mbps), but that 802.11 g (2.4 GHz 54 Mbps)and 802.11 a (5.0 GHz; 54 Mbps) standards are also used. Mr. Carragee stated, “The antennas and network adaptor cards that are now being deployed tend to work in 802.11 b and g,” adding, “802.11 a may be used more often in the future. Combo antennas that support all three Wi-Fi standards would then be installed.”
Wireless access points can cover 150- to 200-foot area in the hospital. To ensure continuity of the transmitted signals, each floor at MSKCC has six antennas (Figure 1B). The antennas terminate in special communications closets filled with wireless switches. These closets also contain the many wires that represent the proximal ends of the standard wired jacks that are located at each bedside. Although the wireless network in the hospital is focused on medical devices, the reality of our communicative world requires that each antenna has two additional functions: patient internet access and cell phone use. Therefore, antennas at MSKCC also provide patients’ family and friends access to the Internet, as well as telephony services. These three wireless services can be overlaid on the same antenna, but they do require different security measures.
Specific Challenges
There is a plethora of challenges in developing and maintaining a wireless network in a hospital. Some of the challenges discussed by Mr. Carragee included:
Troubleshooting (Surveying)
Prior to installing the wireless network, a site survey that assesses the area to be “wired for wireless” must be performed. Once the wireless network is installed, Mr. Carragee stressed that it is very important to constantly perform additional surveys to ensure that the wireless signals continue to be strong. “Every time a facility is renovated, every time there is any kind of equipment that is brought into it, or if you are opening up a new floor, you have to redo the survey,” said Mr. Carragee, adding, “you walk around with a Geiger Counter-type device to see exactly the signal strength.” Interference is also a constant parameter that needs to be monitored. “Hospitals are often in urban areas and ‘hot spots’ outside the hospital may interfere with the hospital’s network.”
Data Size
There is a finite amount of information that can go through an access point. Knowledge of the size of data being transmitted (e.g., large picture files vs small text messages) needs to be understood and appropriate measures employed to ensure all data are quickly transferred. “As you add dense applications for monitoring, you have to continually track the capacity of any given wireless access point to handle the wireless load,” said Mr. Carragee.
Figure 2
Troubleshooting (Performance)
Mr. Carragee discussed the challenges of assuring the integrity of the wireless network. With all the wired or wireless devices/monitors connected to the network, it is important that the caregiver be aware when any aspect of the system is not functioning properly.
Mr. Carragee credited the Cardiopulmonary Corporation for developing a technique to assess this problem. “If a medical device is registered as online on the network, the system informs the caregiver if the device dropped off the network, just as it would tell a caregiver if there is a patient alarm,” said Mr. Carragee.
Security
A proper balance needs to be developed in a hospital that prevents hackers from getting into the wireless system but still allows doctors, scientists, and nurses to freely use the network to communicate. Mr. Carragee acknowledged that it is possible to create this balance, but it is time consuming, ever-changing, and expensive.
Concluding Remarks
Mr. Carragee concluded his presentation by stating that the expanding use of wireless technology requires hospitals to quickly develop wireless networks. Patient care can greatly improve with this technology, but the implementation of wireless systems requires that caregivers be knowledgeable of how these networks operate, as well as their advantages and limitations. It is a very challenging endeavor, but at MSKCC it has been a success story.
The Wireless ICU: The Underlying Concepts
“Our vision at MSKCC is to have a hospital-wide, unified, shared network, with both wired and wireless connectivity,” began Paul Frisch, Director of Biomedical Engineering at MSKCC, adding, “ideally, all the medical devices in the hospital would automatically load their data onto this network.” Device-specific servers on the network would process data and send data to the electronic medical record. Additionally, the network servers would transmit device and patient-related alarms to intelligent communication servers that prioritize and direct these alarms to the appropriate caregivers.
To illustrate why a wireless network is a safer and more efficient method to monitor patients, Mr. Frisch first described typical ICU connectivity and network infrastructure. Each ICU bed has a nurse-call system that provides voice communication and code-blue alarms over a dedicated nurse-call network. A second-layer proprietary network links all the bedside physiological monitors and alarms. A third layer of networking involves video monitoring. “By this time, we see that there are three overlapping networks with their own servers and communication systems that do not talk to each other,” said Mr. Frisch. There is a significant overutilization of space, both at the bedside for cables and jacks and at the nursing station for each network’s server and central station. The addition of networking capabilities for other bedside devices, like mechanical ventilators and infusion pumps, however, would require the installation of additional, dedicated networks.
At MSKCC, this latter problem was addressed by setting up a wireless network. With the help of the Cardiopulmonary Corporation, MSKCC implemented the Bernoulli® Remote Ventilator Monitoring Network, which connects the ventilators (upgraded with wireless transmitters) to the hospital-wide wireless network. The MSKCC wireless laboratory also assessed the feasibility of adding infusion pumps and ECG recorders with wireless capabilities to the network. The goal is to collapse all the typical dedicated networks (nursecall, physiological monitoring, and video) to one hospital network, capable of wired and wireless connectivity, and to add new medical devices to that network (Figure 2).
Furthermore, “the current architecture, consisting of parallel multiple networks with redundant infrastructures, leads to inefficiency,” stated Mr. Frisch, adding, “multiple paging systems and lack of alarm prioritization leads to an increased risk of errors.” Currently, each medical device has its own paging system. The ideal network of the future would be designed to have a single communications device access to all the medical devices on the network. To achieve this, MSKCC is currently working to develop an intelligent server system that processes all the alarms on the unified network and prioritizes their transmission.
Dynamic Association
“Adopting a wireless network allows the staff to get directed communications and handle information on a patient level, rather than on a unit-type level,” stated Mr. Frisch. A key component to achieving this is through the “dynamic association” of the caregiver with the patient, all the devices at the bedside, and the hospital pharmacy (Figure 3). “We utilize a bar-coding system, where each staff member, patient, and device are bar coded.” Mr. Frisch also stated that other aspects of patient care, such as medication use, can also be added to the bar coding network.
Figure 3
Concluding Remarks
The wireless network allows all the devices, including mechanical ventilators, infusion pumps, physiologic monitors, nurse-call, and so forth to share clinical and diagnostic information on a single network infrastructure. A data management server can monitor alarms, track the location of each device within the facility, and permit biomedical engineering personnel to perform remote diagnostics.
Live Demonstration
The symposium concluded with a live demonstration of a wireless network used at MSKCC, by Saul Miodownik, MEE, Director of Clinical Engineering, and Paul Booth, Director of Surgical Engineering, at MSKCC. Using a wireless bar-code scanner, Mr. Miodownik scanned his identity badge, as well as bar codes associated with the patient and equipment. “So all the alarms that are generated can be directed to a specific caregiver and shown with both voice enunciation and a text message of what is going on,” stated Mr. Miodownik. The demonstration showed that by using one network for all of the devices, the caregiver was able to process all the data and make a quick and appropriate decision. “By having all these systems tied together in the same network, you have the ability to archive information, store it, process it, analyze it, mine the data you collect from it, and give the patient generally better care,” concluded Mr. Miodownik.
Source: Annual Meeting of the American College of Chest Physicians in Seattle, WA (CHEST 2004)
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Last Updated ( Thursday, 24 January 2008 )
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