Available for download on the Downloads page.

This release has been years in the making, with work beginning on the External Fetal Monitoring (EFM, cardiotocography) simulator in 2020, but then being placed on the backburner due to the pandemic and to make way for cross-platform porting… it’s finally complete and stable!

External Fetal Monitoring (EFM, Cardiotocography)

New features with the External Fetal Monitor include simulation of:

• Fetal heart rate (FHR)
• Fetal heart rate variability (baseline variability)
• Uterine contractions via “toco”: set the frequency and the duration
• Fetal heart rhythms (interval variability) including:
  • Baseline (minimal variability)
  • Accelerations
  • Early Decelerations
  • Late Decelerations
  • Variable Decelerations

All on the background of the standard cardiotocography strip! Just set the variables and let Infirmary’s patient modeling do the rest to create your simulation or educational materials (e.g. rhythm strips).

Additional features include:

• Multiple “strip speeds” available on the EFM’s menu to fast-forward the simulation: 1:1, 1:10, 1:25 speeds are available.
• Temporal smoothing implemented for obstetric rhythms: when you make changes to the “patient”, Infirmary smoothly transitions the changes into the future waveform drawings.

Device Audio (and Alarm improvements)

Improvements have also been made to the Cardiac Monitor, the Defibrillator, and the Intra-Aortic Balloon Pump simulators as well, mainly including audio enhancements!

• Monitoring “beep” implemented for the Cardiac Monitor and the Defibrillator (sometimes called “anesthesia monitoring”)
  • Beeps a traditional tone on each heart beat, used to audibly keep track of heart rate and/or pulse oximetry in a busy environment
  • Can set to ECG mode: beeps on each QRS complex
  • Or can set to SpO2 mode: beeps on each SpO2 waveform and the tone changes depending on the SpO2 reading
  • Device alarms still sound in addition to the monitoring beep
• Audio alarm for Intra-Aortic Balloon Pump’s augmentation alarm
  • A unique tone unmistakable among the cacophony of potential critical care alarms
• Visual alarm improvement for Intra-Aortic Balloon Pump’s augmentation alarm

Screenshots

Available for download on the Downloads page.

In this minor release, a few subtle but important changes and fixes were implemented:

QRS/QT Morphology

• QRS interval and QTc interval is now adjustable under “Cardiac Profile”
• As you would expect, on all ECG tracings on all simulation devices, the QRS and ST segments are now drawn to those set intervals
• Allows for advanced simulation of narrow or wide complex morphologies, or abnormally elongated or shortened QTc pathology

Temporal Smoothing

• Changes made to vital signs, etc. (to the underlying digital patient model) are now applied synchronously with the cardiac and respiratory cycles
• Changing cardiac vital signs or rhythms no longer creates artifact or “ectopic”-appearing beats on ECG waveforms
• Changing respiratory vital signs or rhythms no longer creates artifact as well

Bugfixes

Some minor bugfixes were made to the Simulator interface for improved user experience. A bugfix was made to the Scenario Editor that fixed a feature-breaking bug. Specific details are in commit notes and issues logs.

Available for download on the Downloads page.

Multiple major improvements in this release, starting off with both visual and audio alarms in the Cardiac Monitor simulator. Many healthcare personnel are already overly familiar with alarms, so this probably does not need explaining… but I will:

Alarms (Visual and Audio!)

• Alarm limits able to be enabled, high/low values set, and alarm priority (low, moderate, high) are all adjustable in the Scenario Editor, as well as a default set of alarms (appropriate for adult patients) being enabled by default. Future plans exist for adjusting alarm limits in the simulator, as well as including default limits for other age groups, but this is not currently implemented.
• Alarms are present for all hemodynamic parameters (vital signs and advanced hemodynamics)

When alarms are active and set, if a physiologic parameter falls outside of an enabled alarm limit:

• The number visually flashes in the cardiac monitor. The numbers flash at different speeds based on priority- low priority is slow flashing, high priority is fast flashing.
• An audio alarm is sounded, and the audio alarm is selected based on alarm priority. Low priority alarms have a slow low-frequency beep and longer intermediary pause, high priority alarms have more rapid high-frequency beeping with slower pause.

Note: Audio is played cross-platform using libraries provided by the LibVLC project, a subset of the VLC Media Player. These libraries are bundled into the Windows and MacOS versions of Infirmary Integrated, but require installation of VLC and its libraries on Linux platforms. If the LibVLC libraries are missing, Infirmary Integrated will simply run without audio.

Options/Settings

• Alarms (includes both visual and audio) can be enabled and disabled in the Cardiac Monitor simulator via a newly-created menu option.
• Audio can be enabled or disabled in the main Infirmary Integrated simulator window via a newly-created menu option. This option will be used to silence all audio from all simulated devices, as audio is integrated into other devices in future versions.
• All changes localized into supported languages

Scenario Editor

This release brings back the Infirmary Integrated Scenario Editor as a cross-platform standalone tool used for creating simulation files that can be saved, shared, and then loaded into Infirmary Integrated and run in a stepwise manner. Simulation files created with the Scenario Editor can have multiple “steps” each with their own simulated patient’s parameters and vital signs. Steps can “progress” in different ways, depending on which progression is selected in the scenario player (which is part of Infirmary Integrated’s simulator). An example case for using simulation files created with the Scenario Editor would be for an educator to simulate a patient in a stable state, progressing to a deteriorating state, then depending on a student’s actions or response, could progress to an improved state or a declined state of hemodynamic parameters- all simulated with Infirmary Integrated.

While the Scenario Editor existed before in older releases of Infirmary Integrated, the following new features are part of this major release:

• Cross-platform functionality (runs on Windows, Linux, and MacOS) for both the Simulator and the Scenario Editor.
• Installer packages for Windows, Linux, and MacOS now include the Scenario Editor
• Improved major re-design of the Scenario Editor for ease of use and improved workflow
• Miscellaneous minor quality-of-life improvements and small features added

Additionally, some of the new features in the Scenario Editor blend into the Simulator when loading simulation files, including:

• The ability to choose which devices automatically open when loading a simulation file (e.g. cardiac monitor, 12 lead ECG, etc.)

Stability and Testing

There were also tons of behind-the-scenes improvements made to the entire program suite, including a large effort of modernizing the code that powers Infirmary Integrated. Many advancements in the C# programming language and the frameworks that Infirmary Integrated are built on are now utilized thoroughly. The language and frameworks have had significant changes over the last 5 years, improving overall performance and stability of Infirmary Integrated!

Lastly, immense amounts of testing went into this release, ensuring that all features work as intended! Although all computer programs have “bugs” in them, large amounts of testing went into this release to ensure that all major bugs are fixed and that Infirmary Integration is “production-ready”. This is the main reason why the project went from version 2.0 to 2.2: by the time version 2.1’s updates were tested as being stable, half of the updates for version 2.2 were already being added!

Bugfixes

Some major bugfixes and issues resolved in this release are:

• #139: Fixed atrial flutter drawing problems (out of phase synchronicity between A/V; A:V ratio)
• Fixed pacemaker spikes from blocking atrial flutter and fibrillation on isoelectric line drawing
• #143: Fixed “Reset Parameters” from unlinking patient model from device simulators (also disabled this button if auto-apply changes are enabled)
• #140, #137