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The Crisis and Disaster Management process (CDMP) is composed of several clearly defined phases. Strategic risk assessment; preparation and planning, effective response and recovery, and post-crisis evaluation. It is essential for those facing such threats to understand, appreciate, and implement the appropriate responses for each phase. Public service organizations, or PSOs, are increasingly charged with additional duties and responsibilities that historically were not part of their original purview. PSOs are currently forced to operate within an environment of increasing political unrest and social chaos. Events of international magnitude now impact the domestic environment. These organizations must deal with negative media, hostile public backlash, increased scrutiny, and calls for greater accountability. Service organizations are currently faced with increasing political and social chaos, with widespread civil unrest, domestic and international threats of terrorism, human trafficking and illegal migration, public health emergencies, natural disasters, and diverse climate-related challenges. These conditions have fostered additional layers of responsibility to already overburdened first responders and their civil support partners. The consequences are significant. These previously mentioned burdens are further compounded by budgetary constraints, greater regulatory compliance, and organizational accountability. In other words, agencies and departments are expected to do more with less, much more with much less.

Continual vital sign assessment on the general care, medical-surgical floor is expected to provide early indication of patient deterioration and increase the effectiveness of rapid response teams. However, there is concern that continual, multi-parameter vital sign monitoring will produce alarm fatigue. The objective of this study was the development of a methodology to help care teams optimize alarm settings. An on-body wireless monitoring system was used to continually assess heart rate, respiratory rate, SpO2 and noninvasive blood pressure in the general ward of ten hospitals between April 1, 2014 and January 19, 2015. These data, 94,575 h for 3430 patients are contained in a large database, accessible with cloud computing tools. Simulation scenarios assessed the total alarm rate as a function of threshold and annunciation delay (s). The total alarm rate of ten alarms/patient/day predicted from the cloud-hosted database was the same as the total alarm rate for a 10 day evaluation (1550 h for 36 patients) in an independent hospital. Plots of vital sign distributions in the cloud-hosted database were similar to other large databases published by different authors. The cloud-hosted database can be used to run simulations for various alarm thresholds and annunciation delays to predict the total alarm burden experienced by nursing staff. This methodology might, in the future, be used to help reduce alarm fatigue without sacrificing the ability to continually monitor all vital signs. Electronic supplementary material The online version of this article (doi:10.1007/s10877-015-9790-8) contains supplementary material, which is available to authorized users.

Scott McCombie, BSBSE, is research engineer at Sotera Wireless, San Diego, CA. E-mail: scott.mccombie@ soterawireless.com Effective, efficient, and safe delivery of healthcare is dependent on the timely identification and treatment of a deteriorating patient condition. Failure to rescue patients in the early stage of physiological deterioration can result in permanent organ injury, extended medical treatment, increased recovery time, or death. These avoidable adverse events drive healthcare costs up and quality down. The primary indicator of failure to rescue is unsuccessful cardiopulmonary resuscitation. The American Heart Association created a national registry of cardiopulmonary resuscitation (NPCPR) in 2000 as a voluntary evidence-based patient safety initiative. A review by Peberdy and colleagues of 14,720 cases of cardiopulmonary arrest from the NPCPR database collected between 2000 and 2002 shows the following breakdown of physiology, immediate cause, and discovery.

decisions about where to program alarm settings, Masimo Corp. based in Irvine, CA conducted an analysis of 32 million pulse oximetry (SpO 2 ) data points from 10 hospital general post-surgical care areas. Each hospital was equipped with a Masimo Patient SafetyNetTM remote monitoring and clinician notification system, which continuously captures and stores time-stamped SpO 2 data with a one-second resolution. This paper reports on the results of a retrospective analysis conducted by the company to determine the incidence of alarms at various alarm threshold and delay settings.

The primary goal of this study is to quantify the communications reliability of telemetry systems using ISM-band two-way communications technology and contrast it to that of VHF/UHF-based systems from an empirical and clinical perspective. The principal criterion variable of communications reliability was total dropout proportion: the percentage of wireless patient monitoring time attributable to a loss of patient signal. Data from 17 institutions across the United States were included in this research. The data from this study were also used to explore potential relationships between communications reliability and various institutional factors. The institutional variables evaluated for possible adverse impact on ISM-band communications reliability included wireless coverage area, the number of telemetry transmitters supported, institutional experience with the product, gross institution size, and the number of telemetry systems within each hospital. The frequency-hopping communication technology utilized by the ISM-band products was not adversely affected by coexisting ISM-band devices. Institutions with shared ISM-band environments demonstrated a better - but statistically insignificant - performance difference both in terms of total dropout proportion and mean time between dropouts. Analysis showed no adverse affect on the communications reliability of ISM-band systems as a function of the number of telemetry transmitters supported, institution size, number of ISM-band telemetry systems within an institution, coverage area, or institutional experience with the system. In contrast, VHF/UHF installations showed statistically significant adverse impact on dropout proportion from two sources: the more transmitters supported, or the greater the coverage area, the higher the dropout proportion. The results from regression analysis at the institution-level should be interpreted cautiously since the statistical power was limited by the number of hospitals in the sample.

A single channel wireless, wearable ECG smart sensor has been developed for long-term monitoring of patients at risk of life-threatening cardiac arrhythmias. The battery-operated sensor can be applied in virtually any orientation on the upper left quadrant of the chest, and monitors patient health continuously for up to three days. An embedded microcontroller calculates heart rate and monitors the ECG signal for life-threatening arrhythmias, which are transmitted wirelessly to a central server and relayed to a respondent device. Tests on human subjects demonstrated signal amplitude from the closely-spaced smart sensor electrodes to be one-half that of the best vector from traditional limb lead placement. Tests with motion and muscle artifact showed superior noise immunity by the smart sensor as compared to a state-of-the-art telemetry monitor.

An adaptive, real-time algorithm that detects clinically important features of blood pressure (BP) waveforms and yields accurate BP measurements during intra-aortic balloon pump (IABP) support is presented. The algorithm uses an existing electrocardiogram (ECG) or ECG synch output signal in identifying BP beat features. The algorithm is compared with algorithms used in four commercial cardiovascular monitors, using data previously recorded from patients on IABP support. The features extracted by the present algorithm are found to estimate BP parameters better than commercial monitors. >

Existing bedside cardiovascular monitors often inaccurately measure arterial blood pressure during intra-aortic balloon pump (IABP) assist. We have developed an algorithm that correctly identifies features of arterial pressure waveforms in the presence of IABP. The algorithm is adaptive, functions in real-time, and uses information from the electrocardiographic (ECG) and arterial blood pressure signals to extract features and numeric values from the arterial blood pressure waveform. In its current form, it requires reliable ECG beat detection and was not intended to operate under conditions of extremely poor balloon timing. The algorithm was evaluated by an expert (P.F-C.) on a limited data set, which consisted of 12 1-minute epochs of data recorded from 6 intensive care unit patients. A criterion for selection of patients was that the ECG beat detector could detect ECG beats correctly from the waveforms. The overall sensitivity and positive predictivity for beat detection were 94.04% and 100%, respectively. For feature identification, the overall sensitivity was greater than 89%, positive predictivity was 100%, and the false-positive rate was 0%. The performance measures may be biased by the criteria for patient selection. This approach to identifying waveform features during IABP improves the accuracy of measurements. The utility of using 2 sources of information to improve measurement accuracy has been demonstrated and should be applicable to other physiologic signal-processing applications.

Summary A device was developed to measure the evoked tensions of the rectus abdominis muscle which consisted of a fluid-filled reservoir wedged between the rectus abdominis muscle and a self-retaining retractor. The evoked contractions of the rectus muscle were compared with that of the tibialis anterior muscle in twelve dogs anaesthetised with pentobarbitone. Significantly greater amounts of tubocurarine were required to depress the response to train-of-four stimuli and the twitch tensions of the rectus muscle than the tibialis. The tibialis recovered faster, spontaneously or after neostigmine, than the rectus in eight of the animals; the opposite occurred in the other four. The present device can be useful during surgery for the evaluation of abdominal muscle tension.

Compression of gases (Boyle's law) and circuit compliance are major determinants of anesthesia circuit function. The materials of which circuits are constructed and the use of heated humidifiers may result in clinically important variations in delivered minute ventilation (VE) secondary to variations in compression volume. We examined eight anesthetic circuits both with and without a heated humidifier in an in vitro setting. Compression volume was determined with a large calibrated syringe. Circuit efficiency was determined by measuring VE at multiple peak inflation pressures (PIP) while using a pediatric ventilator with fixed VE, respiratory rate, fresh gas flow, and I/E ratio. As expected, both compression volume and delivered VE highly correlated with the type of circuit and the pressure at which it was examined (P less than 0.001). Mapleson D circuits had the lowest compression volume and were the most efficient circuits (P less than 0.0001). Pediatric circle systems were intermediate and adult circle systems had the largest compression volume and were the least efficient. Humidifiers uniformly increased compression volume. The following conclusions were drawn: 1) the anesthetic circuit, its material, and the pressure at which it operates are important determinants of circuit function; 2) humidifiers increase compression volume; 3) Mapleson D circuits had the lowest compression volume and therefore were the most efficient; 4) highly compliant adult circuits may result in compression volume losses that exceed the tidal volume of a pediatric ventilator; 5) humidifiers with low volume and rigid tubing should have the least effect on minute ventilation; and 6) highly compliant adult circuits when used in the care of infants and small children must be used with caution.

Expired carbon dioxide measurements (PeCO2) were used (1) to assess the adequacy of initial alveolar ventilation, and (2) to document intraoperative airway events and metabolic trends. Three hundred and thirty-one children were studied. Thirty-five intraoperative events were diagnosed by continuous PeCO2 monitoring; 20 were potentially life-threatening problems (malignant hyperthermia, circuit disconnection or leak, equipment failure, accidental extubation, endobronchial intubation, or kinked tube); only two of these were also diagnosed clinically. The duration of anaesthesia may be a factor: 3.9 hours for cases with events vs. 2.5 hours for cases without events (p less than 0.002). There was a higher incidence of hypercarbia (peak expired PeCO2 greater than or equal to 50) in children who were not intubated (29 per cent) compared to those who had an endotracheal tube in place (12 per cent) (p = 0.0001). Hypocarbia (peak expired PeCO2 less than or equal to 30) was more frequent in intubated cases (11 per cent) than in unintubated cases (three per cent) (p = 0.03). There was a high incidence of hypocarbia in infants less than one year of age (p = 0.02). We conclude: (1) life-threatening airway problems are common during anaesthesia in paediatric patients; (2) quantitative measurement of PeCO2 provides an early warning of potentially catastrophic anaesthetic mishaps; (3) the incidence of events increases with duration of anaesthesia.