MONITORING CHRONIC RESPIRATORY PATIENTS BY CONTROL CHARTS

WITH VARIABLE LIMITS R&D CENTRE

ALGORITMI

University of Minho Author* FLORBELA CORREIA

School of Engineering
Centre of Biological Engineering Supervisor: Pedro Oliveira
* florbelacorreia@esce.ipvc.pt

Introduction Bootstrap Limits

Patient B
The main objective of our work is to use Statistical Process The reason behind using 10 observations for the construction of the
Techniques in the control and follow up of respiratory patients, since control limits lies in the fact that this set of observations corresponds,
in clinical practice it has been observed that the variation between approximately, to two and half years of patient follow-up. However,

PaCO2 (mm Hg)

PaO2 (mm Hg)
patients is much larger than the variations within each patient. this approach might be questioned on the basis that, statistically, this
So, we have built control charts to monitor patients suffering from is a small sample. Thus, parameter estimation might be arguable. In
Respiratory Insufficiency (RI). RI is, in general, an evolutive disease, order to overcome some of the problems mentioned previously we
characterized by a worsening, along time, of the pulmonary have used bootstrap resampling.
function, even in the cases where quality care is provided. The The Bootstrap method, first presented by Efron in 1979, is a
variables that will be controlled in the analysis will be the oxygen resampling technique that, starting from a single sample, uses In these figures we present the control charts with variable limits for
partial pressure (PaO2) and the carbon dioxide partial pressure simulation to generate the sampling distribution. the variables PaO2 and PaCO2 for another patient (patient B). As we
(PaCO2). For each bootstrap sample created the respective statistics are can see, there is an increasing tendency on the last observed values
In the traditional control charts, for controlling means of individual calculated. For a large number of samples, it can be shown that the of PaCO2, with greater variability in variable PaO2, which indicates a
observations, the limits stay unchanged throughout the time, statistics distribution obtained from the bootstrap samples converges worsening of the patient´s health. On the other hand, the chart with
regardless the positive or negative evolution that the patient might to the real sampling distribution. Thus, for each set of ten varying limits registers also an out of control event for the variables
exhibit. However, because the patient´s health indicators are dynamic observations used in each time instant t, 1000 bootstrap samples PaO2 and PaCO2 at time instant t=26; it can be noticed that it is from
over time, the limits used in the control charts must suffer a constant have been generated, for the definition of the 95% confidence this very time instant that the worsening of the patient status is
actualization, based on the recent past of the patient himself. interval limits . observed.
So, in accordance to a positive or negative evolution of the disease,
we have built, for each patient, the control charts with varying limits. Test Cases

Control Charts with Variable limits On the other hand, we can see the bootstrap limits (dotted lines in
Patient A figures), generated by the bootstrap method, are very close to the
Moving Average Limits variable limits (continuous lines in figures) based on the moving
average of the standard deviations. This validates the adopted
methodology for the construction of the control charts with varying

PaCO2 (mm Hg)

PaO2 (mm Hg)

In order to calculate the variable control limits, we have used the

recent past data from the patient. We represent, in the control charts limits.
with varying limits, the observed value of the variable at time instant t,
with the respective control limits and central line calculated from the Conclusions
previous 10 observations. It should be noted that the variable control
limits are represented starting from the 11th observation. The limits We have observed that the control charts with varying limits explicitly
previous to this 11th observation are fixed and calculated from the show the tendency for worsening or improving of the patient´s health
These figures represent the control charts with variable control limits
mean and standard deviation of the first 10 observations. Thus: status, throughout the time. Furthermore, these charts permit the
for variables PaO2 and PaCO2 for patient A. Considering the positive
identification of abnormal values for the corresponding phase in the
evolution of the patient, new limits are calculated, adjusted to the new
patient´s status, at each time instant. Thus, the control chart with
health status of this patient. Consequently, for instance, if a value of
UCLt = CLt + 2σ t PaCO2 equal to the one observed at time instant t=9 was observed at
varying limits can be perceived as a tool for decision making, by
 medical doctors, in the follow-up of chronic respiratory patients since
with  LCLt = CLt − 2σ t time instant t=32, this would be considered now an out of control
it provides an easy, intuitive and adequate interpretation, by the
event, requiring the analysis of the causes that originated this event.
health professionals, over all the historical data and the evolution of
We can observe that the patient presents a favorable peak for the
the patient´s health status, as well as the detection of acute

variable PaO2, relatively to the past, at time instant t=22, as well as a
10
 10 situations.
 ∑ xt − i
 ∑ σ t −i constant tendency for improvement from that time moment.
CLt = i =1 if t > 10 and σ = i =1 if t > 10
 10  t 10
 x1 + x2 + x3 + ... + x10 
 CLt = if t ≤ 10  σ t =σ ( x1 , x2 ,..., x10 ) if t ≤ 10
 10

References •Montgomery, D. (2001), Introduction to Statistical Quality Control, 4ed , Wiley.

•Correia F, Nêveda R, Oliveira P. (2010), Chronic Respiratory Patients Control by Multivariate Charts, International Journal of Health Care Quality Assurance (accepted for publication). •Queraltó, J.M. (2004), “Intraindividual references values”, Clin. Chem. Lab. Med., Vol 42, No. 7, pp. 765-777.
•Efron B. (1979), Bootstrap Methods: Another Look at the Jackknife, Annals of Statistics, 7, 1-26. •Quesenberry,C. (1997), SPC Methods for quality improvement, Wiley.
•Lucas, J.M. e Saccucci, M.S (1990), Exponentially Weighted Moving Average Control Schemes: Properties and Enhancements, Technometrics, 32, (1), 1-12. •Woodal W. (2006), The Use of Control Charts in Health-Care and Public-Health Surveillance, Journal of Quality Technology, 38, (2), 89-104.

Engenharia para a Qualidade de Vida: SAÚDE, LAZER E AMBIENTE– Semana da Escola de Engenharia -11 a 16 de Outubro de 2010