Critical care bioinformatics at ucsf
Download
1 / 29

Critical Care Bioinformatics at UCSF - PowerPoint PPT Presentation


  • 118 Views
  • Uploaded on

Critical Care Bioinformatics at UCSF. J. Claude Hemphill III, MD, MAS Kenneth Rainin Chair in Neurocritical Care Associate Professor of Clinical Neurology and Neurological Surgery University of California, San Francisco Director, Neurocritical Care San Francisco General Hospital.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Critical Care Bioinformatics at UCSF' - zanthe


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Critical care bioinformatics at ucsf

Critical Care Bioinformatics at UCSF

J. Claude Hemphill III, MD, MAS

Kenneth Rainin Chair in Neurocritical Care

Associate Professor of Clinical Neurology and Neurological Surgery

University of California, San Francisco

Director, Neurocritical Care

San Francisco General Hospital

Disclosures

Research Support: NIH/NINDS

Consulting: UCB Pharma

Stock (options): Cardium Therapeutics (Innercool Therapies), Ornim


So what s the problem
So What’s the Problem?

  • Some of what we don’t know

  • Do secondary brain insults have a dose-response relationship with outcome?

  • We treat univariate in a multivariate world

    • Interaction and relationship between various physiologic parameters?

    • Event signatures?

  • How do we integrate new measures (e.g. PbtO2)?

  • How often do we need to collect physiologic data to optimize patient care?

This is complicated


Looking at icu data bedside
Looking at ICU Data Bedside

Paper charts in most ICUs,

electronic charts in some


ICU

Informatics

2009


Neurocritical Care Database/Informatics

GOALS

  • Identify physiological signatures to diagnose patients and predict outcomes

  • Use real-time data to rationally drive clinical decisions and treatment based on the specific physiologic abnormality

  • Determine dosage and delivery for commonly used NICU medications

  • Suggest new clinically-relevant experimental research models

  • Develop user-friendly “behind the scenes” data analysis that aids interpretability and clinical applicability


Ucsf approach to critical care informatics
UCSF Approach to Critical Care Informatics

  • Centered at SFGH

    • Trauma Center

    • Stroke Center

  • Driven by interest of specific clinicians

    • Claude Hemphill, MD,MAS - neurointensivist

    • Geoff Manley, MD,PhD - neurosurgeon

    • Mitch Cohen, MD – trauma surgeon

  • Focus on neurotrauma

  • “Ground up” approach

    • Develop infrastructure

    • Knowledge discovery (research driven)

    • Not trying to feed back immediately into clinical care – too early


Ucsf initial efforts
UCSF Initial Efforts

  • Gather some data

    • Kiosk method

    • “Home grown” software

  • Analyze in novel, but simple ways

    • Detection of secondary brain insults

    • Improved univariate measures – AUC (area under the curve)

  • Identify and engage collaborators with expertise (generally not clinicians)

  • Publish


Nicu data acquisition 2003
NICU Data Acquisition 2003

  • Independent CPU

  • Multiple serial ports

    • Overhead monitor (Philips)

    • Ventilator (Draeger)

    • Brain O2 (Licox)

    • CBF (Hemedex)

  • Data time-synched

  • Operator must initiate data acquisition


How often do we need to collect this data
How Often Do We Need to Collect this Data?

  • Current standard

    • Paper chart - Q 1 hour and as needed

    • CareVue (electronic medical record) – up to Q 15 min

  • Study comparing Q 1 min v. medical record (MR) for SBI identification and dose (n=16; 72 hours each)

Hemphill, Physiological Measurement, 2005


Borrowing from pharmacokinetics
Borrowing from Pharmacokinetics

  • “Dose” is area under the curve (AUC)


Does it matter how we define dose

+

Does It Matter How we Define Dose?

Impact of ED episodes and dose of hypotension on risk of in-hospital death after severe TBI (n=107)

*

* Manley, Arch Surg, 2001

+Barton, Acad Emerg Med, 2005


Mannitol dose response
Mannitol Dose-Response

Sorani J Neurotrauma 2008


SBP

DBPMAP

PbtO2

ETCO2

Physiology Cluster Analysis

Self-organizing map reduces high-dimensional information to a two-dimensional grid

Sorani Neurocritical Care 2007


Ucsf next and current efforts
UCSF Next (and Current) Efforts

  • Create group identity

    • C-BICC – Center for Biomedical Informatics in Critical Care

  • Obtain funding

  • Develop data warehouse

  • Undertake advanced informatics and statistical analyses to

    • Remove artifacts

    • Identify event signatures

    • Improve data visualization

  • Allow some use for hospital QA (helps with administrative buy-in)

  • Publish


Neuroicu physiological informatics
NeuroICU Physiological Informatics

  • Collaborative Project

    • Admit it: this is beyond bedside clinicians

    • Clinicians, computer scientists, informatics, industry

  • UC Discovery Grant

    • Pilot project between UCSF, UC Berkeley, Intel

    • Two years: develop data warehouse methods, pilot data analysis

    • Expand to multi-center project (will require large numbers of patients with long-term outcome)

  • NIH/NINDS SBIR – Scott Winterstein, PhD

    • Data acquisition methodology and device library


Nicu data acquisition 2009
NICU Data Acquisition 2009

  • The primary data are:

    • Bedside physiological data (Aristein-”homemade”)

    • ICU Patient Care Chart (Carevue-Philips)

    • Lifetime Clinical Record (Invision-Siemens)

  • No kiosk – each bed with networked data acquisition

  • Bedside physiological data collected continuously (Q1 minute) and automatically into Data Registry Server

  • Must have contextual data (e.g. medications and timing) in order to make sense of physiological data



  • Current database

    • CareVue data on ~11,000 patients

    • Physiology data on ~1000 patients


Novel data visualization tools
Novel Data Visualization Tools

  • Viewing large amounts of data in clinically useful way

  • Medications and events

  • Compressed time scales

  • Physiological “signatures”


Patient Applications: Data Visualization

36 days of continuous physiological data



Pattern Recognition

State 1

State 2

State 3

State 4

States 5,6

State 7

PHYSIOLOGIC SIGNATURES


Dynamic Bayesian Networks

We treat patients as if we are practicing DBN state theory.

No really, we do.


Our problems
Our Problems

  • Paying for all this

    • Personnel

    • Data warehousing (ongoing)

    • Business models of for-profit companies (“just contract with Oracle”) don’t currently work for research needs

  • Balance

    • Just like doctors have different specialties, so do engineers, programmers, database/informatics experts, statisticians, computer scientists

    • Clinical coordination – responsible for publishing in clinical journals


Evidence based neurocritical care
Evidence-based Neurocritical Care

  • Expertise matters

  • Pronovost, JAMA, 2002 – systematic review of 26 studies

    • Presence of intensivist ass. w/ better outcomes

    • Only 1 neuroICU studied

  • Neurointensivists – improved outcome

    • Suarez, Critical Care Medicine, 2004

    • Varelas, Critical Care Medicine, 2004

      • Semi-closed unit; 30% TBI

  • Understanding

    • Why expertise makes a difference even without a specific obvious treatment

    • How to harness and “export” expertise


Ucsf icu informatics guiding principles
UCSF ICU Informatics – Guiding Principles

  • NeuroICU monitoring tools have advanced beyond our current ability to understand how to use them

  • This is due to the disconnect between data generation and data analysis

  • Advances in real-time user-friendly data analysis must accompany advances in neuromonitoring techniques

  • This will be a “long haul”

  • This is a large-scale collaborative effort across institutions

  • Avoid the temptations to

    • Be impatient and give up

    • Assume the data we want is easily obtained/acquired

    • Expect big answers right away

    • Read too much into early simple analyses

    • Assume large companies will provide us with the solutions

  • Publish – interim experience and results must be disseminated


Acknowledgements

UCSF Neurosurgery

Geoff Manley, MD, PhD

Diane Morabito, RN MPH

Guy Rosenthal, MD

Michele Meeker, RN

Scott Winterstein, PhD

Intel Corporation

Doug Busch

Kevin Conlon

UCSF Neuroradiology

Pratik Mukherjee, MD PhD

Alisa Gean, MD

UCSF Neurology

Wade Smith, MD,PhD

UC Berkeley Neuroscience Institute

Robert Knight, MD

UCSF Medical Informatics

Marco Sorani

Brain Trauma Foundation

Jam Ghajar, MD PhD

UC Berkeley Computer Science

Stuart Russell

Norm Aleks

NIH R01NS050173, CDC R49CE000460, NIH K23NS041240 , NIH U10NS058931, NIH R43NS056639 , UC Discovery Program,

McDonnell-Pew Foundation


ad