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Innovative Designs for the Smart ICUInnovative Designs for the Smart ICU: Part 3: Part 3: Advanced ICU Informatics FREE TO VIEW

Neil A. Halpern, MD, FCCP
Author and Funding Information

From the Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center; and Weill Cornell Medical College, New York, NY.

Correspondence to: Neil A. Halpern, MD, FCCP, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065; e-mail: halpernn@mskcc.org


Funding/Support: This work was funded by the Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(4):903-912. doi:10.1378/chest.13-0005
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This third and final installment of this series on innovative designs for the smart ICU addresses the steps involved in conceptualizing, actualizing, using, and maintaining the advanced ICU informatics infrastructure and systems. The smart ICU comprehensively and electronically integrates the patient in the ICU with all aspects of care, displays data in a variety of formats, converts data to actionable information, uses data proactively to enhance patient safety, and monitors the ICU environment to facilitate patient care and ICU management. The keys to success in this complex informatics design process include an understanding of advanced informatics concepts, sophisticated planning, installation of a robust infrastructure capable of both connectivity and interoperability, and implementation of middleware solutions that provide value. Although new technologies commonly appear compelling, they are also complicated and challenging to incorporate within existing or evolving hospital informatics systems. Therefore, careful analysis, deliberate testing, and a phased approach to the implementation of innovative technologies are necessary to achieve the multilevel solutions of the smart ICU.

Figures in this Article

Parts 1 and 2 of this three-part series on innovative designs for the smart ICU explored the roles of the ICU design team and the thought processes that accompany ICU design1 as well as the features and functionalities of patient rooms and shared spaces and services in the ICU.2 This third and final installment addresses the key ideas and steps involved in conceptualizing, actualizing, using, and maintaining the advanced ICU informatics environment.

The primary objectives when designing an ICU with advanced informatics center upon electronically integrating the patient with all aspects of care and transforming patient-related data into actionable information using “smart” or “intelligent” technologies.3-5 Designing and operationalizing the smart ICU needs to be done with great deliberation because much of the requisite systems and applications are manufactured piecemeal by a variety of vendors and are relatively new to the marketplace. The selection of these platforms, therefore, is challenging and should be jointly addressed with the hospital’s informatics and biomedical engineering teams. These two groups are usually highly cognizant of the hospital’s capabilities of testing, installing, and incorporating smart technologies.

The creation of a smart ICU requires the construction of a connectivity envelope around the patient (Fig 1). The first step in this five-step process (Fig 2) is the installation in the ICU of a robust wired and wireless infrastructure that is fully integrated with the hospital’s network. The second step is the placement of connectivity hardware in each patient room to communicate with all data sources. The third step is the placement of automatic identification (Auto-ID) tags on all data sources for tracking purposes.6,7 Auto-ID technologies convey source identification data to a computer system. The fourth is the attachment of adaptors and computers to the medical devices to transmit data and initiate interoperability protocols between the medical devices and the receiving systems.8-10 The final step is the addition of middleware (Table 1) to the hospital and ICU networks.

Figure Jump LinkFigure 1. The connectivity envelope includes hardware for source tracking and data acquisition (computers, wired or wireless access points, readers, bar code scanners [in the room or on devices], multiparameter and port integrators and concentrators, and nurse call systems). Data sources (devices, staff, and medical applications) are tracked by the connectivity envelope using Auto-ID tags (bar codes, IR, RFID, ultrasonic and hybrid tags) attached to the data sources. Adaptors (medical device adaptors, dongles, cables, and wireless transmitters) and computers (client bridges and data pollsters) attached to the output data ports of the medical devices (on the device itself or within the patient room) identify the devices and connect them to the network for data transmission. Conversion of device-specific proprietary data into a standardized language understood by hospital computer systems (interoperability) can be performed by computers on the devices, within the room’s connectivity envelope, in the multiport integrators, or by middleware on the ICU or hospital networks. The multiport concentrators and multimode integrators can connect to multiple devices and use various types of connectivity technologies, respectively. All data sources must be electronically associated with the patient so their data is linked to the patient in the ICU middleware and the electronic medical record. The RTLS monitor displays the location and movement of each Auto-ID-tagged provider, device, and medical application. Auto-ID = automatic identification; IR = infrared; Meds = medications; POCT = point-of-care testing; RFID = radio-frequency identification; RTLS = real-time location systems and solutions.Grahic Jump Location
Figure Jump LinkFigure 2. Five steps to building a smart ICU.Grahic Jump Location
Table Graphic Jump Location
Table 1 —Hospital and ICU Middleware

EMR = electronic medical record; RTLS = real-time location systems and solutions.

ICU middleware may be categorized as FDA class 1 medical device data systems (MDDS) or as FDA class 2 devices.11 MDDS capabilities include data storage, management, transfer, and display and conversion of data from proprietary device languages to standardized formats to provide interoperability.8,9,12 FDA class 2 applications are far more sophisticated than the MDDS and offer active patient monitoring and alarms.

ICU middleware (servers, applications, and gateways) are linked to hospital systems (Fig 3)7 and perform many functions that advance ICU care and unit management. These include transforming hospital- and ICU-based data and alarms to actionable information, managing devices, operationalizing real-time locating systems and solutions (RTLS), generating smart displays, providing decision support, and facilitating telemedicine programs. ICU middleware should be interfaced with the hospital’s bed management system so that ICU patient data (name, identifier, and bed number) automatically populate middleware applications. Privacy protocols need to be formulated with the hospital’s informatics security officers. Finally, server memory requirements and plans for backup systems that automatically take over mission critical operations in the event of catastrophic primary server failure must be delineated.

Figure Jump LinkFigure 3. Bedside devices are connected to the ICU (physiologic monitoring) and hospital networks. These networks are linked through servers, gateways, and routers. Middleware at all levels are interfaced and provide a host of advanced applications and displays for the ICU. See Figure 1 legend for expansion of abbreviation.Grahic Jump Location
Association

In order for device generated data to be linked to the patient, the medical devices and their data must be electronically associated with the patient (Fig 1). Patient association is achieved by using either the patient’s unique medical record number (patient centric) or the patient’s location (location centric).5 Although the location-centric solution is more popular and simpler to implement than the patient centric method, the latter solution is preferable because the data are permanently attached to the patient regardless of the patient’s location.

Interoperability

Interoperability implies that data generated by one device or system can be meaningfully accessed and used by another.8,9,13 This type of data sharing is promoted by the Integrating the Healthcare Enterprise initiative (www.ihe.net).

Interoperability requires data alignment (ie, data syntax and units of communication) between the proprietary data output languages of medical devices and the receiving middleware. Interoperability can be achieved at various levels of the connectivity tree (Fig 1). In the absence of interoperability, the data from the medical devices exist in virtual silos, even if the devices are properly connected to the network.

To date, the goals of interoperability across the broad spectrum of ICU technologies have not been broadly achieved because device vendors have viewed interoperability both as a low priority and a costly endeavor. Additionally, the medical community has been slow to understand and appreciate the need and benefits of interoperability possibly due to the arcane nature of the process.9,13

Time Synchronization

Time synchronization is vital for maintaining an accurate electronic flow sheet and tracking alarms and responses.14-16 However, time synchronization is difficult to attain because of the presence of many devices and applications in the ICU patient room and on the hospital network. Each has its own internal clock that may or may not be centrally managed by network gateways or time servers. Disparities in time between devices and systems may be exacerbated when data are transmitted across the hospital network or when seasonal time changes are not implemented.4,12 There is no easy solution to synchronizing time except to be aware of the problem and organizationally address each device and system.

Medical Devices Are Informatics Platforms

ICU devices are actually sophisticated informatics platforms.4 Only with this understanding can the design team incorporate the devices into the overall ICU informatics framework as relates to connectivity, association, interoperability, time synchronization, and integration with ICU middleware and other clinical systems. For example, infusion devices, historically considered as fluid pumps, are now infusion platforms. These platforms include infusion channels, device brains, drug libraries, medication dosing protection algorithms, connectivity software and hardware, and device management middleware. Thus, operationalizing and maintaining such a sophisticated system requires multidisciplinary coordination (nursing, pharmacy, informatics, and biomedical engineering).17,18 The selection process for an advanced informatics platform should also explore whether the system will be upgradeable and if the vendor is investigating cutting-edge applications. For infusion pump platforms, this may include closed-loop drug and fluid infusions for glucose control,19 hypovolemia,20 and burn resuscitation.21

Alarm Systems

ICU device data and alarms may overload and mentally fatigue the ICU staff22-24 to the point where the bedside teams may ignore or deactivate alarms or be incapable of discerning the relative importance of each alarm. Clinical alarm safety is now a Joint Commission 2014 national patient safety goal.23 Alarms can be partially handled at the device level; however, a systematic approach to alarm management requires the deployment of sophisticated alarm applications on the ICU or hospital networks.25

Three types of network-based systems capture device alarms and transmit them to central monitors, critical alert displays, or handheld devices. The first (ie, nurse call) transmits all alarms from linked devices across the ICU without a filtering application.24 The second converts alarms to actionable information by using a filtering algorithm prior to transmission.26 The third is an intelligent alarm system that processes streaming, raw device data and creates personalized patient alarms.27-29 The introduction of the latter two systems requires significant advanced testing.30

Device Servers

Device middleware (vendor specific or neutral) can link all devices to generate a virtual device community (Fig 4). Such systems provide a host of global applications and capabilities not possible at the device level.31,32 These include device monitoring; data storage, upload, and download; alarm transmission; and report generation (Fig 4). An important feature of such software is remote viewing by ICU staff on computers and handheld devices, thus creating a local telemedicine solution (Fig 5). Vendor-specific systems usually have a portal for the vendor to remotely troubleshoot their devices, servers, and applications and transmit software updates.31

Figure Jump LinkFigure 4. A-C, Virtual communities for providers (A), mechanical ventilators (B), infusion pumps (C), and POCT devices (D). The application middleware adds the functionalities demonstrated for each. QC = quality control. See Figure 1 legend for expansion of other abbreviation.Grahic Jump Location
Figure Jump LinkFigure 5. A, Web-based views of physiologic monitors (four-patient view) (Mobile Viewer; GE Healthcare). B, Mechanical ventilators (top, multipatient; bottom, data for selected patient) (Bernoulli Enterprise; Cardiopulmonary Corp). C, Webcams (four-patient view) (OnSSI NetGuard EVS; On-Net Surveillance Systems, Inc). These systems display systemwide and single-patient views; however, only the webcam system permits remote control (pan, tilt, and zoom) of the bedside device. All systems allow for web-based online viewing by multiple users. The webcam application also offers bookmarking, quarantining of images, and movement recognition alerts. Printed with permission of Memorial Sloan-Kettering.Grahic Jump Location
Real-time Locating Systems and Solutions

RTLS represents a wide variety of systems and solutions to improve workflow and management of all types of tagged assets (staff, patients, equipment, consumables, and patient rooms).33-35 RTLS is supported by many integrated technologies and communication protocols (ie, Bluetooth, dedicated radio frequencies, infrared, ultrawide band, wi-fi, ZigBee, and near-field communication).36 Location accuracy (macro or micro) is determined by the types of Auto-ID tags (Fig 1), software algorithms, and local tracking methodologies deployed.37,38 Operationalizing RTLS requires global installation of technologies that enable RTLS capabilities to flow across the enterprise (ie, follow patient or device from ICU to rest of hospital). For this to successfully occur, RTLS, bed management, staff, and device inventory data sets must also be aligned and terminologies coordinated to establish interoperability and a common language.39

RTLS may be used in real time to locate tagged devices (mobile asset tracking)40 and provide notification if these devices leave designated zones. RTLS can also be applied historically to monitor device use, harmonize device distribution and repair, validate ongoing processes, and create data and reports for future purchases.41 Consumable products can similarly be managed through RTLS. In this solution, tagged supplies are automatically tracked by RTLS scanners that are located within ICU supply cabinets and at the ICU bedsides. RTLS can likewise monitor the product inventory, identify products near expiration or subject to recall, and create reports for par-level determinations.

The integration of RTLS processes with existing ICU technologies can improve infection control, personnel and patient location, and oversight of the patient room. For example, staff hand-washing compliance may be enhanced through the automatic monitoring of tagged staff using RTLS sensors incorporated within hand-washing dispensers.42 RTLS and nurse-call systems can be joined to locate and communicate with the nearest tagged nurse when a patient activates the nurse-call system. The RTLS display can post the named of tagged individuals as they enter an ICU patient’s room (Fig 1). Tagged patients can similarly be tracked throughout their hospital travels. Permanent patient room sensors can be used to monitor the room’s status (vacant or occupied), environment (temperature and humidity), and housekeeping (clean or needs cleaning) needs.

Smart Displays

ICU middleware supports a variety of smart displays (integrated and intelligent medical displays, electronic greaseboards, RTLS, and dashboards) that supplement central physiologic monitoring stations and the electronic medical record (EMR). Integrated and intelligent medical displays merge and process data from multiple bedside devices and the EMR through artificial intelligence and cognitive work analysis algorithms.43-47 These systems project consolidated data in a mix of anatomic schematics and graphical and tabular views, thus enabling clinicians to rapidly identify changes in patient conditions. Electronic greaseboards track ICU bed use and may be interfaced with hospital bed management and patient tracking systems or managed locally in the ICU (Fig 6). RTLS displays can combine basic greaseboard information, active RTLS data,34 and family communications if an outside family portal is enabled (Fig 7). Dashboard middleware displays preselected data from a host of clinical applications, thereby efficiently and expeditiously providing the intensivist with the most current information without individualized searches across multiple systems (Fig 8).48,49 The dashboard application may reside within the EMR or above it.

Figure Jump LinkFigure 6. Electronic greaseboards used to manage the ICU are mounted in each central station (pods 1-4). Data may originate in hospital bed management systems or locally in the ICU. Individualized data can be transmitted to bedside greaseboards.Grahic Jump Location
Figure Jump LinkFigure 7. The RTLS monitor based in each patient room displays data from multiple sources (hospital bed management, RTLS, electronic medical record, and outside portals). See Figure 1 legend for expansion of abbreviations.Grahic Jump Location
Figure Jump LinkFigure 8. A dashboard server and application superimposed on existing hospital and ICU systems accesses patient-specific data and launches the most recent studies from preselected portions and applications of the electronic medical record and other systems. EKG = electrocardiogram.Grahic Jump Location
Data Integration and Support

ICU clinical care may be further supported by a variety of investigational, or commercially available middleware that integrates data across the ICU and hospital and provides various types of patient profiles and alerts. These include data sniffing50; real-time intelligent monitoring to automatically identify patients at risk for clinical deterioration51-53; as well as computerized decision support for sedation,54 infection and antibiotic control,55 and nutrition.56 Middleware can be used to collect ICU data for outcome predictions57 and research.58 Software is also being used to manage insulin infusions.59,60

Telemedicine

Telemedicine ICU coverage is becoming increasingly popular. Therefore, the ICU design team should think about installing the necessary telemedicine technologies, especially if the centralized outsourced approach that uses a designated site (closed-system architecture) is being considered.32,61-63 This solution requires local ICU and hospital interfaces and bidirectional communications to transmit data, clinician orders, video, and voice between the ICU (patient room and waiting room) and the telemedicine vendor’s bunker (proprietary EMR, decision support system, and alarm notification solution) (Table 2). Interoperability between the hospital’s and the telemedicine vendor’s systems is critical. If the hospital prefers the decentralized approach that uses local ICU clinicians and no centralized bunker, then the open, web-based middleware described previously will suffice (Figs 4, 5). Some hospitals use a hybrid (centralized and decentralized) model to ICU telemedicine and, thus, require a mix of off-site and local telemedicine arrangements. Finally, an ICU-based robot that communicates with an off-site team may be helpful in the absence of local ICU coverage.64,65

Table Graphic Jump Location
Table 2 —Components for ICU Telemedicine Solution

HL7 = Health Level Seven (www.hl7.org). See Table 1 legend for expansion of other abbreviation.

The ongoing maintenance needs of the advanced informatics ICU are extensive and should be addressed early in the design process. This type of support will be advanced through close collaboration between the design team and the informatics and biomedical engineering groups and the drafting of detailed schematics of all informatics components. Additionally, protocols need to be developed for continuous monitoring of network closets and middleware to guarantee that the systems are functioning to specification, interfacing properly, storing and backing up data, and rolling over if primary servers fail. Similarly, the wireless communications and medical devices should be periodically checked for transmission efficacy and electromagnetic field interference that may be caused by radio-frequency identification technologies and cellular phones.66-68

The more advanced the ICU informatics platform, the more problematic it is to maintain, repair, upgrade, or replace. These challenges especially apply when shifting from one medical device, server, application, or software version to another, whether from the same or an alternative vendor. The design team cannot assume that technological upgrades (new devices and middleware) for the new ICU will have all the capabilities, connectivity, and interoperability of the existing devices or even that the status quo of current systems will be maintained. Therefore, it is imperative for the design team to prepare its own gap analysis that compares the new with the old and to request a similar analysis from the vendor. Most importantly, all new technologies should be comprehensively tested in a simulation laboratory before purchase.12

Advanced informatics systems for the ICU are complex. The keys to their successful implementation include an appreciation of the underlying informatics concepts, finding the solutions that work best in the new ICU design, sophisticated planning, technology testing, and a deliberate and phased introduction of informatics platforms that make sense for the new ICU and interact well with the hospital.

Financial/nonfinancial disclosures: The author has reported to CHEST the following conflicts of interest: Dr Halpern is a consultant to Cardiopulmonary Corp; Pronia Medical Systems, LLC; and Instrumentation Laboratory. He is a member of the ICU Design Award Committee of the Society of Critical Care Medicine and The Intelligent Hospital Advisory Board of the RFID in Healthcare Consortium and is a principal of Critical Care Designs. The Memorial Sloan-Kettering Cancer Center ICU was the recipient of the 2009 ICU Design Citation award.

Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript.

Other contributions: The author thanks Elaine Ciccaroni, Medical Graphics, Memorial Sloan-Kettering Cancer Center, for preparation of the figures and tables and Paul Booth, Biomedical Engineering, for review of the connectivity and RTLS schematics.

Auto-ID

automatic identification

EMR

electronic medical record

FDA

US Food and Drug Administration

MDDS

medical device data systems

RTLS

real-time locating systems and solutions

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Juneja R, Roudebush CP, Nasraway SA, et al. Computerized intensive insulin dosing can mitigate hypoglycemia and achieve tight glycemic control when glucose measurement is performed frequently and on time. Crit Care. 2009;13(5):R163. [CrossRef]
 
Gamble KH. Critical care network. ICU telemedicine can help ease the burden of caring for critically ill patients—provided all the right pieces are in place. Healthc Inform. 2009;26(12):26, 28-30.
 
Groves RH Jr, Holcomb BW Jr, Smith ML. Intensive care telemedicine: evaluating a model for proactive remote monitoring and intervention in the critical care setting. Stud Health Technol Inform. 2008;131:131-146.
 
Reynolds HN, Rogove H, Bander J, McCambridge M, Cowboy E, Niemeier M. A working lexicon for the tele-intensive care unit: we need to define tele-intensive care unit to grow and understand it. Telemed J E Health. 2011;17(10):773-783. [CrossRef]
 
Reynolds EM, Grujovski A, Wright T, Foster M, Reynolds HN. Utilization of robotic “remote presence” technology within North American intensive care units. Telemed J E Health. 2012;18(7):507-515. [CrossRef]
 
Vespa P. Robotic telepresence in the intensive care unit. Crit Care. 2005;9(4):319-320. [CrossRef]
 
van der Togt R, van Lieshout EJ, Hensbroek R, Beinat E, Binnekade JM, Bakker PJ. Electromagnetic interference from radio frequency identification inducing potentially hazardous incidents in critical care medical equipment. JAMA. 2008;299(24):2884-2890. [CrossRef]
 
Censi F, Mattei E, Triventi M, Bartolini P, Calcagnini G. Radiofrequency identification and medical devices: the regulatory framework on electromagnetic compatibility. Part I: medical devices. Expert Rev Med Devices. 2012;9(3):283-288. [CrossRef]
 
van Lieshout EJ, van der Veer SN, Hensbroek R, Korevaar JC, Vroom MB, Schultz MJ. Interference by new-generation mobile phones on critical care medical equipment. Crit Care. 2007;11(5):R98. [CrossRef]
 

Figures

Figure Jump LinkFigure 1. The connectivity envelope includes hardware for source tracking and data acquisition (computers, wired or wireless access points, readers, bar code scanners [in the room or on devices], multiparameter and port integrators and concentrators, and nurse call systems). Data sources (devices, staff, and medical applications) are tracked by the connectivity envelope using Auto-ID tags (bar codes, IR, RFID, ultrasonic and hybrid tags) attached to the data sources. Adaptors (medical device adaptors, dongles, cables, and wireless transmitters) and computers (client bridges and data pollsters) attached to the output data ports of the medical devices (on the device itself or within the patient room) identify the devices and connect them to the network for data transmission. Conversion of device-specific proprietary data into a standardized language understood by hospital computer systems (interoperability) can be performed by computers on the devices, within the room’s connectivity envelope, in the multiport integrators, or by middleware on the ICU or hospital networks. The multiport concentrators and multimode integrators can connect to multiple devices and use various types of connectivity technologies, respectively. All data sources must be electronically associated with the patient so their data is linked to the patient in the ICU middleware and the electronic medical record. The RTLS monitor displays the location and movement of each Auto-ID-tagged provider, device, and medical application. Auto-ID = automatic identification; IR = infrared; Meds = medications; POCT = point-of-care testing; RFID = radio-frequency identification; RTLS = real-time location systems and solutions.Grahic Jump Location
Figure Jump LinkFigure 2. Five steps to building a smart ICU.Grahic Jump Location
Figure Jump LinkFigure 3. Bedside devices are connected to the ICU (physiologic monitoring) and hospital networks. These networks are linked through servers, gateways, and routers. Middleware at all levels are interfaced and provide a host of advanced applications and displays for the ICU. See Figure 1 legend for expansion of abbreviation.Grahic Jump Location
Figure Jump LinkFigure 4. A-C, Virtual communities for providers (A), mechanical ventilators (B), infusion pumps (C), and POCT devices (D). The application middleware adds the functionalities demonstrated for each. QC = quality control. See Figure 1 legend for expansion of other abbreviation.Grahic Jump Location
Figure Jump LinkFigure 5. A, Web-based views of physiologic monitors (four-patient view) (Mobile Viewer; GE Healthcare). B, Mechanical ventilators (top, multipatient; bottom, data for selected patient) (Bernoulli Enterprise; Cardiopulmonary Corp). C, Webcams (four-patient view) (OnSSI NetGuard EVS; On-Net Surveillance Systems, Inc). These systems display systemwide and single-patient views; however, only the webcam system permits remote control (pan, tilt, and zoom) of the bedside device. All systems allow for web-based online viewing by multiple users. The webcam application also offers bookmarking, quarantining of images, and movement recognition alerts. Printed with permission of Memorial Sloan-Kettering.Grahic Jump Location
Figure Jump LinkFigure 6. Electronic greaseboards used to manage the ICU are mounted in each central station (pods 1-4). Data may originate in hospital bed management systems or locally in the ICU. Individualized data can be transmitted to bedside greaseboards.Grahic Jump Location
Figure Jump LinkFigure 7. The RTLS monitor based in each patient room displays data from multiple sources (hospital bed management, RTLS, electronic medical record, and outside portals). See Figure 1 legend for expansion of abbreviations.Grahic Jump Location
Figure Jump LinkFigure 8. A dashboard server and application superimposed on existing hospital and ICU systems accesses patient-specific data and launches the most recent studies from preselected portions and applications of the electronic medical record and other systems. EKG = electrocardiogram.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 —Hospital and ICU Middleware

EMR = electronic medical record; RTLS = real-time location systems and solutions.

Table Graphic Jump Location
Table 2 —Components for ICU Telemedicine Solution

HL7 = Health Level Seven (www.hl7.org). See Table 1 legend for expansion of other abbreviation.

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Marvin MR, Inzucchi SE, Besterman BJ. Computerization of the Yale insulin infusion protocol and potential insights into causes of hypoglycemia with intravenous insulin. Diabetes Technol Ther. 2013;15(3):246-252. [CrossRef]
 
Juneja R, Roudebush CP, Nasraway SA, et al. Computerized intensive insulin dosing can mitigate hypoglycemia and achieve tight glycemic control when glucose measurement is performed frequently and on time. Crit Care. 2009;13(5):R163. [CrossRef]
 
Gamble KH. Critical care network. ICU telemedicine can help ease the burden of caring for critically ill patients—provided all the right pieces are in place. Healthc Inform. 2009;26(12):26, 28-30.
 
Groves RH Jr, Holcomb BW Jr, Smith ML. Intensive care telemedicine: evaluating a model for proactive remote monitoring and intervention in the critical care setting. Stud Health Technol Inform. 2008;131:131-146.
 
Reynolds HN, Rogove H, Bander J, McCambridge M, Cowboy E, Niemeier M. A working lexicon for the tele-intensive care unit: we need to define tele-intensive care unit to grow and understand it. Telemed J E Health. 2011;17(10):773-783. [CrossRef]
 
Reynolds EM, Grujovski A, Wright T, Foster M, Reynolds HN. Utilization of robotic “remote presence” technology within North American intensive care units. Telemed J E Health. 2012;18(7):507-515. [CrossRef]
 
Vespa P. Robotic telepresence in the intensive care unit. Crit Care. 2005;9(4):319-320. [CrossRef]
 
van der Togt R, van Lieshout EJ, Hensbroek R, Beinat E, Binnekade JM, Bakker PJ. Electromagnetic interference from radio frequency identification inducing potentially hazardous incidents in critical care medical equipment. JAMA. 2008;299(24):2884-2890. [CrossRef]
 
Censi F, Mattei E, Triventi M, Bartolini P, Calcagnini G. Radiofrequency identification and medical devices: the regulatory framework on electromagnetic compatibility. Part I: medical devices. Expert Rev Med Devices. 2012;9(3):283-288. [CrossRef]
 
van Lieshout EJ, van der Veer SN, Hensbroek R, Korevaar JC, Vroom MB, Schultz MJ. Interference by new-generation mobile phones on critical care medical equipment. Crit Care. 2007;11(5):R98. [CrossRef]
 
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