New patients or current patients with a large data gap require up to 4 hours of data before a HeRO Score will be generated A rising HeRO Score is not a diagnosis. But if the rise cannot be explained clinically, consider a physical exam and lab work.
When HeRO rises? Nurses often ask: The HeRO Score is rising and there is no clinical explanation. What else should I do before I confer with the provider? Consider the following: Have ventilatory requirements increased? Are apneas and bradycardias increased? Any trouble with feeds? Is the patient lethargic? Is the patient's temperature instable Any abnormal labs? Be prepared with specifics if any of the answers are 'Yes'
A general HeRO workflow Note: This general protocol is offered. However, many hospitals develop their own protocol Clinical considerations: Regardless of the HeRO Score, if a patient appears sick then the patient must be treated promptly as indicated If the HeRO Score is rising significantly (eg. by 2 points in the last 24 hours above that patient's previously established baseline score), and if the rise can't be explained clinically, then: Perform a physical exam, get labs, and review the patient's status with parents and other caregivers If those are abnormal, perform a sepsis work-up and consider antibiotics Reference: HeRO Best Practices: An Implementation Guide to Maximize Clinical Benefit
How does HeRO work? Every hour, the HeRO System produces a new HeRO Score. Each hourly score is based on the last 12 hours of heart rate variability data. The HeRO System identifies and quantifies abnormal heart rate characteristics that have been observed early in the course of neonatal infection. It takes about four hours for a patient’s first HeRO Score to be rendered. At what HeRO Score do I take action for the patient? Check the procedure(s) created by your facility, as it will give specific details on when and how to react to elevated HeRO scores. The most important goal of HeRO is to allow for an earlier physical assessment of a declining infant. From the peer reviewed publications, we know that patients with HeRO average 18 hours earlier identification than those without. A basic guideline used to create procedures is when a patient has an increase of one point over his/her prior baseline, or the first time the HeRO score rise above 2, evaluate the patient by performing a physical examination or obtaining lab tests.
Does a high HeRO Score mean that a patient has sepsis? No. An elevated HeRO Score (HeRO Score > 2.0) reflects only that the patient has heart rate patterns matching those of patient more likely to develop sepsis. Clinicians must determine any diagnosis through standard diagnostic techniques, such as a physical exam, laboratory results, and cultures. Remember that the HeRO Score is a relative risk number. That is a patient with a score of 3.0 is 3 times more likely than average to be developing an infection. Does a low HeRO Score mean that the patient is healthy? No. A patient that is presenting as sick should be treated as sick. A low HeRO Score should never be used to withhold treatment from a patient.
Novel Uses of HeRO Respiratory deterioration is a major cause of spikes in HeRO Score [1] HeRO is an excellent predictor of need for intubation [2] HeRO predicts extubation success [3,4] Online calculators for extubation readiness and extubation success at: www.heroscore.com/extubation 1-Infection and Other Clinical Correlates of Abnormal Heart Rate Characteristics in Preterm Infants 2-Predictive monitoring for respiratory decompensation leading to urgent unplanned intubation in the neonatal intensive care unit 3-Predicting Extubation Outcomes—A Model Incorporating Heart Rate Characteristics Index 4-Predicting extubation outcomes using Heart Rate Characteristics Index in Preterm Infants: a cohort study.
HeRO User Reports Rio et al, in Switzerland, found “An increase of HRC index > 2 has a significant association with the diagnosis of [late onset sepsis (LOS)], supporting the use of HRC monitoring to assist early detection of LOS.” Kurul and colleagues, in the Netherlands, found that after implementing HeRO: Morbidity at the time of sepsis diagnosis was reduced “suggesting that patients were diagnosed earlier and less severely ill” Mortality after infection trended down (p=0.13) Antibiotic usage per 1000 NICU days trended down (p=0.06) There were more labs but no increase in blood cultures
Neurodevelopmental Outcomes were improved with HeRO Extremely low birthweight patients from the HeRO RCT had 18-22 month follow-up assessments at three study centers The in-NICU mortality improvement for HeRO-monitored patients was durable Among septic patients, rates of both death and death-or-NDI were decreased among HeRO-monitored patients Among non-septic patients, there were no differences in outcomes comparing HeRO-monitored patients with controls (indicating false positives had no impact on healthy patients)
Demonstrated that HeRO is cost effective and generates a positive Return On Investment to the hospital An economic analysis was performed using multiple study centers. It showed that HeRO was cost-effective for all rates of sepsis Although HeRO is a cost to the hospital, revenue was increased for additional patients who survived an infection Based upon US costs, the use of HeRO increased hospital revenue greater than the cost of HeRO itself
In earlier studies, HeRO had been shown to "work." That is, HeRO scores were shown to be an important predictor of sepsis, but that did not mean that it would improve outcomes. Thus, a very large RCT was undertaken to evaluate the effectiveness of HeRO. RCT Overview: 3,003 VLBW (very low birthweight at <1500g at birth) infants were enrolled at 8 centers (9 hospitals). They were evenly placed into either the control arm (HeRO blinded) or the treated arm (HeRO Score displayed). The patients were followed for the first 120 days of life. The group of ELBW (extremely low birthweight infants at <1000g at birth) infants were pre-specified to be analyzed as a subset of the entire trial population. Results: The HeRO Display group demonstrated a 22% reduction in mortality across the entire VLBW patient population. For the subset analysis of the extremely low birthweight (ELBW) infants, the ELBW patients demonstrated an even greater mortality reduction of 26%. No increase in antibiotic usage. Number of patients needed to treat and save a life: For VLBWs : 48 For ELBWs : 23 For patients who had an infection and survived, the length of stay in the hospital was decreased by 3.2 days. Reference: Mortality Reduction by Heart Rate Characteristic Monitoring in Very Low Birth Weight Neonates: A Randomized Trial
The following pathologic conditions are associated with an increased HeRO Score: Sepsis - both clinical and culture proven Necrotizing enterocolitis Focal infections, eg. UTI, pneumonia, meningitis, cellulitis, and abscess. Acute respiratory decompensation - some patients with severe chronic lung disease have recurrent, self-resolved elevations in the HeRO Score. Brain pathology - some patients with grade 3-4 IVH have HeRO spikes for several weeks after birth. Idiopathic Reference: Heart rate characteristics in the NICU: what nurses need to know.
HeRO Scores of a Healthy Infant In the upper portion of the screen, the 5 day HeRO Score trend shows that the HeRO Score has been low (less than 1) for 5 days, indicating normal Heart Rate Characteristics and low probability of sepsis. Heart Rate Characteristics in the NICU
At the top of each hour, HeRO will create a score in the range from 0.00 to 7.00. Each hourly HeRO score represents the risk of infection in the next 24 hours, where 1.00 indicates average risk Low Risk: HeRO Score below 1.00 ( 70% of scores ) Intermediate Risk: HeRO Score between 1.00 and 2.00 ( 20% of the scores ) High Risk: HeRO Score above 2.00 ( 10% of scores ) For example, a patient with a HeRO Score of 3.1 is about three times more likely to develop sepsis than the average NICU patient. Reference: Heart Rate Characteristics: Novel Physiomarkers to Predict Neonatal Infection and Death
The HeRO Score measures the amount of abnormal heart rate characteristics (decelerations and reduced variability) present in a patient's heart rate pattern. The HeRO Score is updated every hour and is shown as a numeric value with a corresponding trend over the last five days. An elevated HeRO Score reflects the increased presence of abnormal heart rate characteristics.
Cytokines mediate the inflammatory response, with effects throughout the body, including abnormal heart rate characteristics (HRC) Normal characteristics Abnormal characteristics 1 Cardiovascular oscillations at the bedside: early diagnosis of neonatal sepsis using heart rate characteristics monitoring
When the patient appears sick but has a low HeRO Score? A low HeRO Score should never be used to deny or reduce treatment on a patient that is exhibiting clinical signs of sepsis
MPSC HeRO Technical Support Please contact MPSC Technical Support with any questions or concerns about HeRO. Phone: 800-394-1625 option 5 International dial: +1-434-220-0714 option 5 Email: support@heroscore.com Web: https://www.heroscore.com/support/
Troubleshooting - No Hero Score is shown Issue: HeRO Score is not displayed for the current patient. Cause: New patients or current patients with a large data gap require up to 4 hours of data before a HeRO score will be generated.
Troubleshooting - No ECG Wave Issue: HeRO Score is not displayed for the current patient due to lack of waveform or noisy waveform displayed in the Patient View. Note: If your system does not have an ECG waveform window in the bottom right, then it collects data using networking with the physiological monitor and does not rely on a HeRO cable. Resolution: Check connection for HeRO cable at monitor. Replace cable if necessary. Looking just at the waveform window - An example of a Flatline or No Waveform Looking at just the waveform windows - An example of a Noisy waveform with little amplitude. Physiological monitor showing the HeRO cable properly connected.
Troubleshooting - A Poor Waveform Issue: HeRO Score is not displayed for the current patient due to small or erratic waveform. This condition only occurs for customers who have HeRO cables connected to their physiological monitors. Resolution: Change lead displayed on physiological monitor.
HeRO Patient View The Patient View shows the detailed information for a single patient. This view can be accessed by clicking on the bed in the Pod View. To return to the Pod View, click the X in the upper right hand corner of the patient window. The Status Indicator will show a green circle when HeRO is working normally. Depending upon your installation, the Bed Name, Patient Information, and Admist, Discharge, and Transfer may be automatically updated. When you scroll back in the history, you may click on the timeline and the HeRO Score will show the Score at that time. After a few minutes, the system will revert to the current time.
HeRO Pod View The HeRO Pod View displays multiple beds in a single view. For most installations, this is the default view. If the NICU has multiple pods/bays, the tabs at the top of the screen can be used to view beds in other pods. In this picture, the following are highlighted: HeRO status indicator which will normally be green. The current hourly HeRO Score. The HeRO 5-day trend. The Bed Name and Patient Information.
HeRO Viewing Stations HeRO Viewing Stations will be placed at designated locations in the NICU. Each station will have dedicated beds to display, but other beds can be viewed by selecting the tabs at the top of the screen.
Other conditions affecting the HeRO Score Expected "benign" causes of increased HeRO Scores: Tachyarrhythmia (SVT) Surgery/Anesthesia ROP exam or intervention (due to anticholinergic medications, laser or Avastin therapy) Steroids (eg. Dexamethasone) will decrease the HeRO Score (by decreasing inflammation and causing more normal heart rate patterns) Other common NICU drugs, ie. caffeine, have not been shown to impact upon the HeRO Score
The HeRO Score acutely spiked from about 1 to progressively higher scores over a 4-day period. At the time indicated by the yellow line, the HeRO Score was 4.25 and the patient had clinical signs of sepsis which yielded a positive blood culture. Acute increases in the HeRO Score in the days prior to clinical deterioration represent opportunities for earlier diagnosis and treatment, leading to better outcomes. Reference: HeRO monitoring to reduce mortality in NICU patients.
With this patient, the time of clinical diagnosis of NEC is indicated by the yellow vertical line, at which time the HeRO Score was greater than 5. Fourteen hours prior to the NEC diagnosis, the HeRO Score had risen to 2.36, reflecting fewer accelerations and transient decelerations.
Starting at the left, 5 days ago, the HeRO Score had risen from a baseline of 1 to 2 for several days, eventually reaching a peak greater than 5. At the time indicated by the yellow vertical line, the HeRO Score was 4.85 after a continuous rise for 24 hours. In the bottom part of the figure, the heart rate trace would not present as concerning to the unaided eye. The infant was diagnosed with Klebsiella septicemia (positive blood and urine cultures).
The same infant now 6 days later and 24 hours prior to diagnosis. This infant now demonstrates a lack of variability with large decelerations and few or no accelerations. This is significantly different than 6 days earlier. 1 Cardiovascular oscillations at the bedside: early diagnosis of neonatal sepsis using heart rate characteristics monitoring
What is normal heart rate variability? At the time of the heart rate trend and histogram shown below, a healthy infant exhibits a normal heart rate pattern, showing a balance of accelerations and decelerations from the median heart rate. 1 Cardiovascular oscillations at the bedside: early diagnosis of neonatal sepsis using heart rate characteristics monitoring
What is HeRO?HeRO is a non-invasive, continuous risk assessment for infection that has been proven to correlate with clinical symptoms and laboratory values for all infants in the NICU.The goal of HeRO is to allow for an earlier physical assessment of a declining infant.The largest randomized controlled trial in neonatal medicine demonstrated a 22% reduction in all-cause mortality for infants born at <1500 grams and 26% for infants born at <1000g.A publication history now exceeding 75 articles has shown:Improvements in neurodevelopmental outcomes,Decreased length of stay among infected survivors, andCost-effective monitoring for reduced mortality. 1 Abnormal Heart Rate Characteristics Preceding Neonatal Sepsis and Sepsis-Like Illness 2 Mortality Reduction by Heart Rate Characteristic Monitoring in Very Low Birth Weight Neonates: A Randomized Trial
Early in the course of infection, the Autonomic Nervous System causes changes in the variability of the heart rate. HeRO detects and quantifies these changes producing a HeRO Score between 0 and 7. HeRO responds to heart rate variability. A heart rate increase without a change in variability will not impact the HeRO Score. 1 Heart Rate Characteristics: Physiomarkers for Detection of Late-Onset Neonatal Sepsis.