Conclusion and Outlook

This chapter looks back to the other chapters of this book, briefly mentioning some of the highlights. At the same time, this chapter attempts to create a larger picture, showing where the field is going and how it fits into a larger societal context. In order to structure the presentation, this chapter considers six main trends which are important in health care and in neonatal care in particular.

Smart Jacket Design for Improving Comfort of Neonatal Monitoring

Health monitoring is crucial for the survival of ill and premature infants admitted at the neonatal intensive care unit (NICU) in a hospital. The reliability and comfort of monitoring systems will impact on the quality of life and long-term health prospects of the neonates. This chapter presents the ongoing design work of a smart jacket for improving comfort of neonatal monitoring. Textile sensors, a reflectance pulse oximeter, and a wearable temperature sensor are developed to be embedded into the smart jacket. The authors also report a power supply and wireless communication system developed for the smart jacket. Sensor locations, materials, and appearance are designed to optimize the functionality, patient comfort and the possibilities for aesthetic features. Prototypes are presented for demonstrating the design concept, and experimental results for functional performance are shown from the tests on premature babies at the NICU of Máxima Medical Centre (MMC) in Veldhoven, the Netherlands.

Designing Remote Connectedness between Parents and their Premature Newly Born

During a 6 month graduation project a design concept is proposed and developed that is expected to support the parent-child bonding while parents are at home and their child is in the NICU. In collaboration with medical practitioners from the Maxima Medical Centere Veldhoven (MMC) the new system for remote bonding was developed through a multi-iterative design process. The proposed system is designed to enable parents to detect their baby’s need for consoling and to interact with the baby, comforting the child on a physical remote basis. A working proof of principle prototype is build and evaluated with 15 parents of incubator children through a focus group. The goal of the focus group was to evaluate key aspects of the proposed design concept like the need for such a system and the interaction quality with the different products. Although the design has reached a working proof of principle status, more research and development is needed before the system can be tested in the hospital together with babies. Topics to address in the future are the child’s safety and interaction of parents with the system.

Clinical Decision Support Systems for ‘Making It Easy to Do It Right’

Medical guidelines and best practises are used in medicine to increase the quality of the health-care delivery system. To support implementation and application of these guidelines, clinical decision support systems (CDSS) have been developed. These systems are defined as ‘Computer-based information systems used to integrate clinical and patient information and provide support for decision-making in patient care’ (MeSH) These are integrated with so-called Electronic Health Records (EHR), which have been developed by companies and National Governmental Institutes, and are used to register and present the patient medical data. The integration of an EHR with CDSS modules will revolutionize the way medicine will be practiced. In pediatrics, as well as geriatrics, such systems might prove to be even more needed. The development, use, and maintenance of CDSS in a hospital are complex and far from trivial. This chapter focuses on several aspects and challenges of EHR’s and CDSS-modules in daily clinical practice in the hospital.

Automated Neonatal Brain Monitoring

Monitoring the electroencephalogram (EEG) in sick newborn babies in the neonatal intensive care units (NICU) gives important information about brain function. Seizures are frequently seen in the EEG of the sick neonate, and usually denote serious underlying brain dysfunction. Current clinical practice assumes that neonatal seizures have to be treated to prevent further injury to the brain. Recording of amplitude integrated EEG (aEEG) or the full EEG supports treatment decisions as well as prognostication has become standard practice in many NICUs. aEEG has become popular in recent years due to its user friendliness. A full EEG offers a more reliable window to study the ongoing activity in the newborn brain with high temporal and relatively good spatial resolution. However, the expertise required to register and interpret EEG is not available around the clock in the NICUs. For this purpose, automated monitoring devices have been developed, to assist neonatologists at the bedside and neurophysiologists in reviewing large amounts of monitoring data. The main topic of this chapter is automated detection of neonatal seizures and its possible impact in clinical practice. Three different detection approaches are reviewed: model-based, heuristic and classifier-based. Also a futuristic view on automated EEG analysis systems will be given.

Heart Rate Characteristics Monitoring in the NICU

Heart rate variability (HRV), a marker of autonomic nervous system function, is depressed in sepsis and other acute and chronic diseases. Preterm neonates with sepsis have been shown to have both depressed HRV and repetitive transient heart rate decelerations. These abnormal heart rate characteristics (HRC) of depressed variability and decelerations may precede other clinical signs and symptoms of sepsis and usually are not apparent to clinicians using conventional vital signs monitoring. In order to quantitate these changes associated with sepsis, a heart rate characteristics monitor was developed which continuously calculates an HRC index from the conventional electrocardiogram waveform tracing. This HRC index is the fold-increase in risk that a baby will experience a clinical deterioration consistent with proven or clinical sepsis in the next 24 hours. This HRC or HeRO™ (Heart Rate Observation) Monitor can alert clinicians to carefully evaluate a patient and consider antibiotic therapy or other interventions. The impact of continuous HRC monitoring on outcomes of preterm infants was the subject of a multicenter randomized clinical trial of 3003 very low birth weight infants, completed in 2010, which showed a significant reduction in mortality in neonates whose HRC index, or “HeRO Score” was displayed to clinicians in the NICU. Continuous HRC monitoring is an important new tool for both clinical care and research in the NICU.

Neonatal Infrared Thermography Monitoring

For critically ill preterm infants, there is a clinical need for contact-free monitoring technologies, which would eliminate discomfort and potential harm (e.g., necrosis) due to adhesive electrodes, temperature and saturation sensors. Hence, this chapter focuses on non-contact physiological monitoring of infants based on infrared (IR) thermography. This technique has the potential to replace the conventional temperature sensing by detecting radiated thermal energy emitted from the baby’s surface according to black-body radiation principle. This allows the application of a less invasive method giving more detailed information about the thermoregulation status of newborn infants. As an illustrative example, an investigation into thermoregulation physiology during kangaroo care method has been chosen to illustrate the benefit of this method for standardized neonatal intensive care unit (NICU) procedures. Furthermore, this technique may have a large impact on non-contact respiratory monitoring, as it allows quantitative evaluation of the heat transfer processes over nostrils region. Moreover, the ability to detect infrared respiration (IRTR) signature with thermography imaging, will pave the road toward a non-contact breathing monitoring. This in turn will influence the development efforts for wireless and smart incubator solutions.

Pain Assessment in Neonates

In the U.S. it is mandatory to assess and treat pain. Italy, France, and Russia are establishing standards that mean pain assessment and treatment may become mandatory. Physiological, behavioural, and biochemical tools have been used for pain assessment but no gold standard is yet available. These tools have both limits and benefits. The topic of this chapter is to discuss these tools for different infant groups and to conclude if they can fulfill a gold standard for pain assessment. This gold standard should be independent of the infant’s level of maturity and level of illness, should give accurate pain measurement, be in real time, give an immediate response, and the index should be valid for all infants.

Monitoring Brain Development in Preterm Infants

As neurocognitive deficits a still common in preterm infants and the exact etiology of these problems is not elucidated, investigation of preterm brain development is warranted. Electroencephalography (EEG) can provide important information about brain development, although it is hard and time consuming to interpret for neonatologists. Automated EEG analysis can overcome these problems, making brain monitoring more feasible in the neonatal intensive care unit. This chapter discusses different aspects of EEG maturation which are suitable for automated analysis: 1. changes in continuity and 2. changes in frequency. The most important pitfalls for automated EEG analysis are the complex validation process, the lack of a good gold standard, and EEG artifacts. However, when these limitations are addressed, automated EEG analysis can be the cornerstone for a brain monitor, which helps in evaluating premature brain development, in identifying factors which endanger or interfere with normal brain development and in evaluating neuroprotective strategies.

Overview of the ISO/IEEE11073 Family of Standards and their Applications to Health Monitoring

Traditional fields in health delivery such as chronic diseases or independent aging are evolving to novel healthcare applications like intra-hospital ecosystems and Neonatal Intensive Care Units (NICUs). Furthermore, emerging trends in Information and Communication Technologies (ICTs) and evolution of the Medical Devices (MDs) to Personal Health Devices (PHDs) led towards the interoperability of new health services. In this patient-centered context, the international ISO/IEEE11073 (X73) family of standards is proposed to provide device usability enhancements. In this chapter, the X73 technical features and the new transport technology profiles specifically designed for X73 are introduced to provide an updated framework for developing highly efficient portable and wearable MDs and PHDs. Moreover, these protocol guidelines and technology features are applied to vital signs monitoring, pointing out some potential advantages for adopting new use cases such as NICUs where design requirements like ergonomics, reliability, size, power consumption and signal transmission become strict implementation constraints.