The development of the adult deterioration detection system (ADDS) chart

The Adult Deterioration Detection System (ADDS) observation chart described in this short report was developed as part of a research project carried out at The University of Queensland for Queensland Health and the Australian Commission on Safety and Quality in Health Care (ACSQHC). The aim of the project was to investigate the design and use of observation charts in recognising and managing patient deterioration, including the design and evaluation of a new adult observation chart that incorporated human factors principles

Paper-based patient chart design information sheet

The purpose of this document is to help those involved in creating paper-based patient charts improve the human factors aspects of the design of their charts. It is based on the outcomes of a research project (“Human Factors Research Regarding Observation Charts”) carried out at the University of Queensland for the Australian Commission on Safety and Quality in Health Care, the Queensland Health Patient Safety and Quality Improvement Service and the Clinical Skills Development Service. Copies of the reports associated with this project are available online from the Commission’s website (www.safetyandquality.gov.au). As part of this project, we systematically reviewed 25 existing patient observation charts and developed a new chart (the “ADDS chart”) designed to identify patient deterioration, which was then evaluated in behavioural experiments. In this document, we will use some of the issues arising from this process to illustrate human factors design considerations for paper-based patient charts in general

Detecting abnormal vital signs on six observation charts: An experimental comparison

Paper-based observation charts are the principal means of monitoring changes to patients’ vital signs. There is considerable variation in the design of observation charts and a lack of empirical research on the performance of different designs. This report describes the results of a study carried out as part of a project funded by the Australian Commission for Safety and Quality in Health Care and Queensland Health to investigate the design and use of observation charts in recognising and managing patient deterioration, including the design and evaluation of a new adult observation chart that incorporated human factors principles. The first phase of this project involved using a procedure known as heuristic analysis to review 25 observation charts from Australia and New Zealand. 1,189 usability problems, which could lead to errors in recording data and identifying patient deterioration, were identified in the charts. The results from the heuristic analysis were used to design a new chart (the Adult Deterioration Detection System [ADDS] chart) based on human factors principles and current best practice. The study described in this report involved an empirical comparison of six charts (two versions of the ADDS chart, two existing charts rated as “well designed” in the heuristic analysis, one existing chart rated as being of “average design”, and one existing chart rated as “poorly designed”). Novices (individuals who were unfamiliar with using patient charts) and health professionals (doctors and nurses) were recruited as participants. Each chart design was shown to each participant four times displaying different physiological data with one abnormal vital sign (e.g. a high systolic blood pressure), and four times displaying different normal physiological data. After memorising the normal ranges for each vital sign, participants had to classify the physiological data on the charts as “normal” or “abnormal”. Error rates (the proportion of trials where participants made an incorrect normal/abnormal judgement) and response time (the time to read the chart and make the judgement) were measured. Results indicated that chart design had a statistically significant effect on both error rates and response time, with the charts identified as having better design tending to yield fewer errors and shorter decision times. Specifically, the two versions of the ADDS chart outperformed all the existing charts on both metrics, where the other charts yielded between 2.5 and 3.3 times as many errors as the ADDS chart. There was no significant difference between novices and health professionals in error rates for any chart, but the health professionals were significantly faster than novices at making their decisions for the charts rated as “average” and “poor”. There was no significant difference between doctors and nurses on either of the two performance measures for any of the charts. These data indicate that differences in the design of observation charts have a profound impact on chart users’ decisions regarding patients’ vital signs as well as the time it takes to make such decisions. Based on the current data, it appears that the ADDS chart is significantly better at signalling patient deterioration than other currently available charts

An Online Survey of Health Professionals’ Opinions Regarding Observation Charts

The current study was the second stage of a project funded by the Australian Commission for Quality and Safety in Health Care and Queensland Health to investigate the design and use of observation charts in recognising and managing patient deterioration, including the design and evaluation of a new adult observation chart that incorporated human factors principles. Improving the recognition and management of patients who deteriorate whilst in hospital is a frequently cited goal for patient safety. Changes in physiological observations or ‘vital signs’ commonly precede serious adverse medical events. Paper-based observation charts are the chief means of recording and monitoring changes to patients’ vital signs. One approach to improve the recognition and management of deteriorating patients is to improve the design of paper-based observation charts (note that the management of patient deterioration can potentially be affected by chart design if, for example, action plans are included on the chart). There is considerable variation in the design of observation charts in current use in Australia and a lack of empirical research on the performance of observation charts in general. The aim of the current study was to gauge the opinions of the population who actually use observation charts. We recruited a large sample of health professionals (N = 333) to answer general questions about the design of observation charts and specific questions about nine observation charts. The participants reported using observation charts daily, but only a minority reported having received any formal training in the use of such charts. In our previously-reported heuristic analysis of observation charts (1), we found that the majority of charts included a large number of abbreviations. In this survey, participants were asked to nominate which term they first thought of when seeing a particular abbreviation. Most abbreviations were overwhelmingly assigned the same meaning. However, some abbreviations had groups of participants nominating different terms for the same abbreviation. Participants were also asked to nominate their preferred terms for nine vital signs that commonly appear on observation charts. For some vital signs, there was a high level of agreement as to which term was easiest to understand; however, for other vital signs, there was no clearly preferred term. Participants were also asked about their chart design preferences both in terms of (a) recording observations and (b) detecting deterioration. In both instances, participants preferred the option to “Plot the value on a graph with graded colouring, where the colours correspond to a scoring system or graded responses for abnormality”. Participants’ preference was in line with what a human factors approach would recommend (i.e. charts with a colour-coded track and trigger system). In the final sections of the survey, participants were first asked to respond to 13 statements regarding the design of their own institution’s current observation chart, and then to respond to the same 13 statements for one of nine randomly-assigned observation charts. The nine observation charts included the new Adult Deterioration Detection System (ADDS) chart and eight charts of “good”, “average”, or “poor” design quality from the heuristic analysis. Participants’ mean aggregated rating across the 13 items for their institution’s current observation chart was close to the scale’s mid-point, 3 = neutral. For the assigned charts, there was a statistically significant effect of chart type on the aggregated rating. The a priori “poor” quality charts were each rated as having a significantly poorer design compared with each of the other charts (collectively, the a priori “average” and “good” quality charts). There was partial support for our hypothesis that health professionals would rate the “good” charts as having better design, compared to the “average” and “poor” charts. In conclusion, the online survey served two main purposes. First, it collected quantitative data on health professionals’ general preferences regarding aspects of the design of observation charts. This information informed the design of the ADDS chart and could also be used by other chart designers to produce more user-friendly hospital charts. Second, the online survey enabled health professionals to rate the design of the new ADDS chart as well as eight existing charts of varying quality. Overall, health professionals agreed with our human factors-based rating with regards to the “poor” quality charts. However, the health professionals did not differentiate between the “average” and “good” quality charts in their ratings

Thin-film design of amorphous hafnium oxide nanocomposites enabling strong interfacial resistive switching uniformity

A design concept of phase-separated amorphous nanocomposite thin films is presented that realizes interfacial resistive switching (RS) in hafnium oxide-based devices. The films are formed by incorporating an average of 7% Ba into hafnium oxide during pulsed laser deposition at temperatures ≤400°C. The added Ba prevents the films from crystallizing and leads to ∼20-nm-thin films consisting of an amorphous HfOx host matrix interspersed with ∼2-nm-wide, ∼5-to-10-nm-pitch Ba-rich amorphous nanocolumns penetrating approximately two-thirds through the films. This restricts the RS to an interfacial Schottky-like energy barrier whose magnitude is tuned by ionic migration under an applied electric field. Resulting devices achieve stable cycle-to-cycle, device-to-device, and sample-to-sample reproducibility with a measured switching endurance of ≥104 cycles for a memory window ≥10 at switching voltages of ±2 V. Each device can be set to multiple intermediate resistance states, which enables synaptic spike-timing-dependent plasticity. The presented concept unlocks additional design variables for RS devices

Ferroelectric orthorhombic ZrO2 thin films achieved through nanosecond laser annealing

A new approach for the stabilization of the ferroelectric orthorhombic ZrO2 films is demonstrated through nanosecond laser annealing (NLA) of as-deposited Si/SiOx/W(14 nm)/ZrO2(8 nm)/W(22 nm), grown by ion beam sputtering at low temperatures. The NLA process optimization is guided by COMSOL multiphysics simulations. The films annealed under the optimized conditions reveal the presence of the orthorhombic phase, as confirmed by X-ray diffraction, electron backscatter diffraction, and transmission electron microscopy. Macroscopic polarization-electric field hysteresis loops show ferroelectric behavior, with saturation polarization of 12.8 mu C cm(-2), remnant polarization of 12.7 mu C cm(-2) and coercive field of 1.2 MV cm(-1). The films exhibit a wake-up effect that is attributed to the migration of point defects, such as oxygen vacancies, and/or a transition from nonferroelectric (monoclinic and tetragonal phase) to the ferroelectric orthorhombic phase. The capacitors demonstrate a stable polarization with an endurance of 6.0 x 10(5) cycles, demonstrating the potential of the NLA process for the fabrication of ferroelectric memory devices with high polarization, low coercive field, and high cycling stability.A.P.S.C. and M.C.I. contributed equally to this work. This work was supported by the Portuguese Foundation for Science and Technology (FCT) in the framework of the Strategic Funding Contract UIDB/04650/2020. This work has received funding from the European Union's Horizon 2020 research and innovation program under grant agreement No 958174 (M-ERA-NET3/0003/2021-NanOx4EStor). M. C. I. and C. G. acknowledge the financial support by a grant of the Ministry of Research, Innovation and Digitization, CNCS/CCCDI - UEFISCDI, project number COFUND-M-ERANET-3-NanOx4Estor, within PNCDI III and POC 332/390008/29.12.2020-SMIS 109522. The authors acknowledge the CERIC-ERIC Consortium for access to experimental facilities and financial support under proposals 20202037, 20202038, and 20192055. The authors would also like to thank Jose Santos for technical support in the Thin Film Laboratory at CF-UM-UP. J.L.M-D. thanks the ERC grant, EU-H2020-ERC-ADG #882929, EROS. And the Royal Academy of Engineering, grant CIET1819_24. MOH thanks the Herchel Smith foundation of Cambridge for a research fellowship. This work made use of the University of Cambridge Wolfson Electron Microscopy Suite

Ferroelectricity and negative piezoelectric coefficient in orthorhombic phase pure ZrO2 thin films

A new approach for epitaxial stabilisation of ferroelectric orthorhombic (o-) ZrO2 films with negative piezoelectric coefficient in ∼ 8nm thick films grown by ion-beam sputtering is demonstrated. Films on (011)-Nb:SrTiO3 gave the oriented o-phase, as confirmed by transmission electron microscopy and electron backscatter diffraction mapping, grazing incidence x-ray diffraction and Raman spectroscopy. Scanning probe microscopy techniques and macroscopic polarization-electric field hysteresis loops show ferroelectric behavior, with saturation polarization of ∼14.3 µC/cm2, remnant polarization of ∼9.3 µC/cm2 and coercive field ∼1.2 MV/cm. In contrast to the o-films grown on (011)-Nb:SrTiO3, films grown on (001)-Nb:SrTiO3 showed mixed monoclinic (m-) and o-phases causing an inferior remnant polarization of ∼4.8 µC/cm2, over 50% lower than the one observed for the film grown on (011)-Nb:SrTiO3. Density functional theory (DFT) calculations of the SrTiO3/ZrO2 interfaces support the experimental findings of a stable polar o-phase for growth on (011) Nb:SrTiO3, and they also explain the negative piezoelectric coefficient.This work was supported by: (i) the Portuguese Foundation for Science and Technology (FCT) in the framework of the Strategic Funding Contract UIDB/04650/2020 and (ii) Project NECL - NORTE-01-0145-FEDER-022096 and Project UID/NAN/50024/2019. This work has received funding from the European Union's Horizon 2020 research and innovation programme under grant agreement No 958174 (M-ERA-NET3/0003/2021 - NanOx4EStor). This work was also developed within the scope of the project CICECO-Aveiro Institute of Materials, UIDB/50011/2020 & UIDP/50011/2020, financed by national funds through the Portuguese Foundation for Science and Technology/MCTES. It is also funded by national funds (OE), through FCT – Fundação para a Ciência e a Tecnologia, I.P., in the scope of the framework contract foreseen in the numbers 4, 5 and 6 of the article 23, of the Decree-Law 57/2016, of August 29, changed by Law 57/2017, of July 19.The calculations were carried out at the OBLIVION Supercomputer (based at the High Performance Computing Center - University of Évora) funded by the ENGAGE SKA Research Infrastructure (reference POCI-01-0145-FEDER-022217 - COMPETE 2020 and the Foundation for Science and Technology, Portugal) and by the BigData@UE project (reference ALT20-03-0246-FEDER-000033 - FEDER and the Alentejo 2020 Regional Operational Program). Oblivion resources were accessed through the advanced computing projects CPCA/A2/5649/2020 and CPCA/A2/4628/2020, funded by FCT I.P. The authors gratefully acknowledge the HPC RIVR consortium (www.hpc-rivr.si) and EuroHPC JU (eurohpc-ju.europa.eu) for funding this research by providing computing resources of the HPC system Vega at the Institute of Information Science (www.izum.si)The calculations were carried out at the OBLIVION Supercomputer (based at the High Performance Computing Center - University of Évora) funded by the ENGAGE SKA Research Infrastructure (reference POCI-01-0145-FEDER-022217 - COMPETE 2020 and the Foundation for Science and Technology, Portugal) and by the BigData@UE project (reference ALT20-03-0246-FEDER-000033 - FEDER and the Alentejo 2020 Regional Operational Program). Oblivion resources were accessed through the advanced computing projects CPCA/A2/5649/2020 and CPCA/A2/4628/2020, funded by FCT I.P. The authors gratefully acknowledge the HPC RIVR consortium (www.hpc-rivr.si) and EuroHPC JU (eurohpc-ju.europa.eu) for funding this research by providing computing resources of the HPC system Vega at the Institute of Information Science (www.izum.si