Requirements for a Bespoke Intensive Care Unit Dashboard in Response to the COVID-19 Pandemic:Semistructured Interview Study

BACKGROUND: Intensive care units (ICUs) around the world are in high demand due to patients with COVID-19 requiring hospitalization. As researchers at the University of Bristol, we were approached to develop a bespoke data visualization dashboard to assist two local ICUs during the pandemic that will centralize disparate data sources in the ICU to help reduce the cognitive load on busy ICU staff in the ever-evolving pandemic. OBJECTIVE: The aim of this study was to conduct interviews with ICU staff in University Hospitals Bristol and Weston National Health Service Foundation Trust to elicit requirements for a bespoke dashboard to monitor the high volume of patients, particularly during the COVID-19 pandemic. METHODS: We conducted six semistructured interviews with clinical staff to obtain an overview of their requirements for the dashboard and to ensure its ultimate suitability for end users. Interview questions aimed to understand the job roles undertaken in the ICU, potential uses of the dashboard, specific issues associated with managing COVID-19 patients, key data of interest, and any concerns about the introduction of a dashboard into the ICU. RESULTS: From our interviews, we found the following design requirements: (1) a flexible dashboard, where the functionality can be updated quickly and effectively to respond to emerging information about the management of this new disease; (2) a mobile dashboard, which allows staff to move around on wards with a dashboard, thus potentially replacing paper forms to enable detailed and consistent data entry; (3) a customizable and intuitive dashboard, where individual users would be able to customize the appearance of the dashboard to suit their role; (4) real-time data and trend analysis via informative data visualizations that help busy ICU staff to understand a patient’s clinical trajectory; and (5) the ability to manage tasks and staff, tracking both staff and patient movements, handovers, and task monitoring to ensure the highest quality of care. CONCLUSIONS: The findings of this study confirm that digital solutions for ICU use would potentially reduce the cognitive load of ICU staff and reduce clinical errors at a time of notably high demand of intensive health care

Enhanced Recovery after Intensive Care (ERIC): study protocol for a German stepped wedge cluster randomised controlled trial to evaluate the effectiveness of a critical care telehealth program on process quality and functional outcome

Introduction: Survival after critical illness has noticeably improved over the last decades due to advances in critical care medicine. Besides, there is an increasing number of elderly patients with chronic diseases being treated in the intensive care unit (ICU). More than half of the survivors of critical illness suffer from medium-term or long-term cognitive, psychological and/or physical impairments after ICU discharge, which is recognised as post-intensive care syndrome (PICS). There are evidence-based and consensus-based quality indicators (QIs) in intensive care medicine, which have a positive influence on patients' long-term outcomes if adhered to. Methods and analysis: The protocol of a multicentre, pragmatic, stepped wedge cluster randomised controlled, quality improvement trial is presented. During 3 predefined steps, 12 academic hospitals in Berlin and Brandenburg, Germany, are randomly selected to move in a one-way crossover from the control to the intervention condition. After a multifactorial training programme on QIs and clinical outcomes for site personnel, ICUs will receive an adapted, interprofessional protocol for a complex telehealth intervention comprising of daily telemedical rounds at ICU. The targeted sample size is 1431 patients. The primary objective of this trial is to evaluate the effectiveness of the intervention on the adherence to eight QIs daily measured during the patient's ICU stay, compared with standard of care. Furthermore, the impact on long-term recovery such as PICS-related, patient-centred outcomes including health-related quality of life, mental health, clinical assessments of cognition and physical function, all-cause mortality and cost-effectiveness 3 and 6 months after ICU discharge will be evaluated. Ethics and dissemination: This protocol was approved by the ethics committee of the Charité-Universitätsmedizin, Berlin, Germany (EA1/006/18). The results will be published in a peer-reviewed scientific journal and presented at international conferences. Study findings will also be disseminated via the website (www.eric-projekt.net). Trial registration number: ClinicalTrials.gov Registry (NCT03671447)

Identifying Priorities in Intensive Care : a description of a system for collecting intensive care data, an analysis of the data collected, a critique of aspects of severity scoring systems used to compare intensive care outcome, identification of priorities in intensive care and proposals to improve outcome for intensive care patients.

MDThis thesis reviews the requirements for intensive care audit data and describes the development of ICARUS (Intensive Care Audit and Resource Utilisation System), a system to collect and analyse intensive care audit information. By the end of 1998 ICARUS contained information on over 45,000 intensive care admissions. A study was performed to determine the accuracy of the data collection and entry in ICARUS. The data in ICARUS was used to investigate some limitations of the APACHE II severity scoring system. The studies examined the effect of changes in physiological values and post-intensive care deaths, and the effect of casemix adjustment on mortality predicted by APACHE II. A hypothesis is presented that excess intensive care mortality in the United Kingdom may be concealed by intensive care mortality prediction models. A critical analysis of ICARUS data was undertaken to identify patient groups most likely to benefit from intensive care. This analysis revealed a high mortality in critically ill patients admitted from the wards to the intensive care unit. To help identify critically ill ward patients, the physiological values and procedures in the 24 hours before intensive care admission from the ward were recorded: examination of the results suggested that management of these patients could be improved. This led to the setting up of a patient at risk team (PART). Two studies report the effect of the PART on patients on the wards and on the patients admitted from the wards to the intensive care unit. Additional care for surgical patients on the wards is suggested as a way of improving the management of high-risk postoperative patients. The thesis concludes by discussing the benefits of the ICARUS system and speculating on the direction that should be taken for intensive care audit in the future

Family Views of End-of-Life Care in Acute and Community Hospitals

The Hospice friendly Hospitals Programme (HfH) commissioned this study to assess the quality of end-of-life care in acute and community hospitals from the perspectives of bereaved relatives. A major rationale for the study was to develop and test methodology to survey bereaved relatives' views of end-of-life care that covers the HfH Programme themes of Integrated Care, Communication, Patient Autonomy and Design & Dignity. Another driver was to inform the set-up of a Nationwide Audit of End-of-Life Care (McKeown et al., 2010).The overall aim of the study was to assess the quality of end-of-life care in two acute and two community hospitals from the perspectives of bereaved relatives. Study subobjectives were to conduct a literature review to ascertain important ethical and methodological issues; to describe a census of deaths across study sites; to field test a survey instrument aimed evaluating the impact of the Hospice friendly Hospitals (HfH) Programme; to collect data about HfH Programme themes; and to establish if there were any differences in the pattern of results between acute and community hospitals

A novel computerized test for detecting and monitoring visual attentional deficits and delirium in the ICU

Objectives: Delirium in the ICU is associated with poor outcomes but is under-detected. Here we evaluated performance of a novel, graded test for objectively detecting inattention in delirium, implemented on a custom-built computerized device (Edinburgh Delirium Test Box–ICU). Design: A pilot study was conducted, followed by a prospective case-control study. Setting: Royal Infirmary of Edinburgh General ICU. Patients: A pilot study was conducted in an opportunistic sample of 20 patients. This was followed by a validation study in 30 selected patients with and without delirium (median age, 63 yr; range, 23–84) who were assessed with the Edinburgh Delirium Test Box–ICU on up to 5 separate days. Presence of delirium was assessed using the Confusion Assessment Method for the ICU. Measurements and Main Results: The Edinburgh Delirium Test Box–ICU involves a behavioral assessment and a computerized test of attention, requiring patients to count slowly presented lights. Thirty patients were assessed a total of 79 times (n = 31, 23, 15, 8, and 2 for subsequent assessments; 38% delirious). Edinburgh Delirium Test Box–ICU scores (range, 0–11) were lower for patients with delirium than those without at the first (median, 0 vs 9.5), second (median, 3.5 vs 9), and third (median, 0 vs 10.5) assessments (all p < 0.001). An Edinburgh Delirium Test Box–ICU score less than or equal to 5 was 100% sensitive and 92% specific to delirium across assessments. Longitudinally, participants’ Edinburgh Delirium Test Box–ICU performance was associated with delirium status. Conclusions: These findings suggest that the Edinburgh Delirium Test Box–ICU has diagnostic utility in detecting ICU delirium in patients with Richmond Agitation and Sedation Scale Score greater than –3. The Edinburgh Delirium Test Box–ICU has potential additional value in longitudinally tracking attentional deficits because it provides a range of scores and is sensitive to change

Implementation of an evidence-based practice nursing handover tool in intensive care using the knowledge-to-action framework

Background Miscommunication during handover has been linked to adverse patient events and is an international patient safety priority. Despite the development of handover resources, s tandardised handover tools for nursing team leader s in intensive care are limited. Aims The study aim was to implement and evaluate an evidence- based electronic minimum dataset for nursing team leader shift -to-shift handover in the intensive care unit using the k nowledge- to-action framework. Methods This study was conducted in a 21- bed medical/surgical intensive care unit in Queensland, Australia. Senior registered nurses involved in team leader handover were recruited. Three phases of the knowledge- to-action framework (select, tailor and implement interventions, monitor knowledge use and evaluate outcomes ) guided the implementation and evaluation process. A post -implementation practice audit and survey were carried out to determine nursing team leader use and perceptions of the electronic minimum dataset three months after implementation. Results are presented using descriptive statistics ( median, IQR, frequency and percentage) . Results Overall (86%, n=49) , team leader s used the electronic minimum dataset for handover and communication regarding patient plan increased . K ey content items however were absent from handovers and additional documentation was required alongside the minimum dataset to conduct handover. Of the team leader s surveyed (n=35), those receiving handover perceived the electronic minimum dataset more Page 4 of 24 positive ly than team leader s giving handover (n=35) . Benefits to using the electronic minimum dataset included the pat ient content (48%), suitability for short -stay patients (16%), decreased time updating (12%) and print ing the tool (12%) . Almost half of the participants however, found the minimum dataset contained irrelevant information, reported difficulties navigating and locating relevant information and pertinent information was missing. Suggestions for improvement focused on modifications to the electronic handover interface. Linking evidence to action Prior to developing and implementing electronic handover tools , adequate infrastructure is required to support knowledge translation and ensure clinician and organisational needs are met

Role of the multidisciplinary team in the care of the tracheostomy patient

Barbara Bonvento,1 Sarah Wallace,1,2 James Lynch,1 Barry Coe,1 Brendan A McGrath1 1Acute Intensive Care Unit, University Hospital South Manchester, Manchester, 2Royal College of Speech and Language Therapists, London, UK Abstract: Tracheostomies are used to provide artificial airways for increasingly complex patients for a variety of indications. Patients and their families are dependent on knowledgeable multidisciplinary staff, including medical, nursing, respiratory physiotherapy and speech and language therapy staff, dieticians and psychologists, from a wide range of specialty backgrounds. There is increasing evidence that coordinated tracheostomy multidisciplinary teams can influence the safety and quality of care for patients and their families. This article reviews the roles of these team members and highlights the potential for improvements in care. Keywords: tracheotomy, physiotherapist, Speech & Language, Nursin

An investigation into the effects of commencing haemodialysis in the critically ill

<b>Introduction:</b> We have aimed to describe haemodynamic changes when haemodialysis is instituted in the critically ill. 3 hypotheses are tested: 1)The initial session is associated with cardiovascular instability, 2)The initial session is associated with more cardiovascular instability compared to subsequent sessions, and 3)Looking at unstable sessions alone, there will be a greater proportion of potentially harmful changes in the initial sessions compared to subsequent ones. <b>Methods:</b> Data was collected for 209 patients, identifying 1605 dialysis sessions. Analysis was performed on hourly records, classifying sessions as stable/unstable by a cutoff of >+/-20% change in baseline physiology (HR/MAP). Data from 3 hours prior, and 4 hours after dialysis was included, and average and minimum values derived. 3 time comparisons were made (pre-HD:during, during HD:post, pre-HD:post). Initial sessions were analysed separately from subsequent sessions to derive 2 groups. If a session was identified as being unstable, then the nature of instability was examined by recording whether changes crossed defined physiological ranges. The changes seen in unstable sessions could be described as to their effects: being harmful/potentially harmful, or beneficial/potentially beneficial. <b>Results:</b> Discarding incomplete data, 181 initial and 1382 subsequent sessions were analysed. A session was deemed to be stable if there was no significant change (>+/-20%) in the time-averaged or minimum MAP/HR across time comparisons. By this definition 85/181 initial sessions were unstable (47%, 95% CI SEM 39.8-54.2). Therefore Hypothesis 1 is accepted. This compares to 44% of subsequent sessions (95% CI 41.1-46.3). Comparing these proportions and their respective CI gives a 95% CI for the standard error of the difference of -4% to 10%. Therefore Hypothesis 2 is rejected. In initial sessions there were 92/1020 harmful changes. This gives a proportion of 9.0% (95% CI SEM 7.4-10.9). In the subsequent sessions there were 712/7248 harmful changes. This gives a proportion of 9.8% (95% CI SEM 9.1-10.5). Comparing the two unpaired proportions gives a difference of -0.08% with a 95% CI of the SE of the difference of -2.5 to +1.2. Hypothesis 3 is rejected. Fisher’s exact test gives a result of p=0.68, reinforcing the lack of significant variance. <b>Conclusions:</b> Our results reject the claims that using haemodialysis is an inherently unstable choice of therapy. Although proportionally more of the initial sessions are classed as unstable, the majority of MAP and HR changes are beneficial in nature