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Greenhalgh T, Darbyshire JL, Lee C, Ladds E, Ceolta-Smith J. What is quality in long covid care? Lessons from a national quality improvement collaborative and multi-site ethnography. BMC Med 2024; 22:159. [PMID: 38616276 PMCID: PMC11017565 DOI: 10.1186/s12916-024-03371-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 03/26/2024] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Long covid (post covid-19 condition) is a complex condition with diverse manifestations, uncertain prognosis and wide variation in current approaches to management. There have been calls for formal quality standards to reduce a so-called "postcode lottery" of care. The original aim of this study-to examine the nature of quality in long covid care and reduce unwarranted variation in services-evolved to focus on examining the reasons why standardizing care was so challenging in this condition. METHODS In 2021-2023, we ran a quality improvement collaborative across 10 UK sites. The dataset reported here was mostly but not entirely qualitative. It included data on the origins and current context of each clinic, interviews with staff and patients, and ethnographic observations at 13 clinics (50 consultations) and 45 multidisciplinary team (MDT) meetings (244 patient cases). Data collection and analysis were informed by relevant lenses from clinical care (e.g. evidence-based guidelines), improvement science (e.g. quality improvement cycles) and philosophy of knowledge. RESULTS Participating clinics made progress towards standardizing assessment and management in some topics; some variation remained but this could usually be explained. Clinics had different histories and path dependencies, occupied a different place in their healthcare ecosystem and served a varied caseload including a high proportion of patients with comorbidities. A key mechanism for achieving high-quality long covid care was when local MDTs deliberated on unusual, complex or challenging cases for which evidence-based guidelines provided no easy answers. In such cases, collective learning occurred through idiographic (case-based) reasoning, in which practitioners build lessons from the particular to the general. This contrasts with the nomothetic reasoning implicit in evidence-based guidelines, in which reasoning is assumed to go from the general (e.g. findings of clinical trials) to the particular (management of individual patients). CONCLUSION Not all variation in long covid services is unwarranted. Largely because long covid's manifestations are so varied and comorbidities common, generic "evidence-based" standards require much individual adaptation. In this complex condition, quality improvement resources may be productively spent supporting MDTs to optimise their case-based learning through interdisciplinary discussion. Quality assessment of a long covid service should include review of a sample of individual cases to assess how guidelines have been interpreted and personalized to meet patients' unique needs. STUDY REGISTRATION NCT05057260, ISRCTN15022307.
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Affiliation(s)
- Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Rd, Oxford, OX2 6GG, UK.
| | - Julie L Darbyshire
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Rd, Oxford, OX2 6GG, UK
| | - Cassie Lee
- Imperial College Healthcare NHS Trust, London, UK
| | - Emma Ladds
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Rd, Oxford, OX2 6GG, UK
| | - Jenny Ceolta-Smith
- LOCOMOTION Patient Advisory Group and Lived Experience Representative, London, UK
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Lee C, Greenwood DC, Master H, Balasundaram K, Williams P, Scott JT, Wood C, Cooper R, Darbyshire JL, Gonzalez AE, Davies HE, Osborne T, Corrado J, Iftekhar N, Rogers N, Delaney B, Greenhalgh T, Sivan M. Prevalence of orthostatic intolerance in long covid clinic patients and healthy volunteers: A multicenter study. J Med Virol 2024; 96:e29486. [PMID: 38456315 DOI: 10.1002/jmv.29486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/29/2024] [Accepted: 02/13/2024] [Indexed: 03/09/2024]
Abstract
Orthostatic intolerance (OI), including postural orthostatic tachycardia syndrome (PoTS) and orthostatic hypotension (OH), are often reported in long covid, but published studies are small with inconsistent results. We sought to estimate the prevalence of objective OI in patients attending long covid clinics and healthy volunteers and associations with OI symptoms and comorbidities. Participants with a diagnosis of long covid were recruited from eight UK long covid clinics, and healthy volunteers from general population. All undertook standardized National Aeronautics and Space Administration Lean Test (NLT). Participants' history of typical OI symptoms (e.g., dizziness, palpitations) before and during the NLT were recorded. Two hundred seventy-seven long covid patients and 50 frequency-matched healthy volunteers were tested. Healthy volunteers had no history of OI symptoms or symptoms during NLT or PoTS, 10% had asymptomatic OH. One hundred thirty (47%) long covid patients had previous history of OI symptoms and 144 (52%) developed symptoms during the NLT. Forty-one (15%) had an abnormal NLT, 20 (7%) met criteria for PoTS, and 21 (8%) had OH. Of patients with an abnormal NLT, 45% had no prior symptoms of OI. Relaxing the diagnostic thresholds for PoTS from two consecutive abnormal readings to one abnormal reading during the NLT, resulted in 11% of long covid participants (an additional 4%) meeting criteria for PoTS, but not in healthy volunteers. More than half of long covid patients experienced OI symptoms during NLT and more than one in 10 patients met the criteria for either PoTS or OH, half of whom did not report previous typical OI symptoms. We therefore recommend all patients attending long covid clinics are offered an NLT and appropriate management commenced.
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Affiliation(s)
- Cassie Lee
- Imperial College Healthcare NHS Trust, London, UK
| | | | - Harsha Master
- Covid Assessment and Rehabilitation Service, Hertfordshire Community NHS Trust, Welwyn Garden City, UK
| | - Kumaran Balasundaram
- NIHR Leicester Biomedical Research Centre, Respiratory & Infection Theme, Glenfield Hospital, Leicester, UK
| | - Paul Williams
- Covid Assessment and Rehabilitation Service, Hertfordshire Community NHS Trust, Welwyn Garden City, UK
| | - Janet T Scott
- Development and Innovation Department, NHS Highlands, Inverness, UK
- MRC-University of Glasgow Centre for Virus Research, Glasgow, UK
| | - Conor Wood
- Birmingham Community Healthcare, Birmingham, UK
| | - Rowena Cooper
- Development and Innovation Department, NHS Highlands, Inverness, UK
| | - Julie L Darbyshire
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Helen E Davies
- Department of Respiratory Medicine, University Hospital of Wales, Cardiff, UK
| | - Thomas Osborne
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, UK
| | - Joanna Corrado
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, UK
| | - Nafi Iftekhar
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, UK
| | | | - Brendan Delaney
- Department of Surgery & Cancer, Imperial College, Faculty of Medicine, London, UK
| | - Trish Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Manoj Sivan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, UK
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Ladds E, Darbyshire JL, Bakerly ND, Falope Z, Tucker-Bell I. Cognitive dysfunction after covid-19. BMJ 2024; 384:e075387. [PMID: 38302141 DOI: 10.1136/bmj-2023-075387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Affiliation(s)
- Emma Ladds
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Julie L Darbyshire
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Nawar Diar Bakerly
- The Northern Care Alliance, Manchester Metropolitan University, University of Manchester
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McWilliams DJ, King EB, Nydahl P, Darbyshire JL, Gallie L, Barghouthy D, Bassford C, Gustafson OD. Mobilisation in the EveNing to prevent and TreAt deLirium (MENTAL): a mixed-methods, randomised controlled feasibility trial. EClinicalMedicine 2023; 62:102101. [PMID: 37533416 PMCID: PMC10393539 DOI: 10.1016/j.eclinm.2023.102101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 08/04/2023] Open
Abstract
Background Delirium is common in critically ill patients and associated with longer hospital stays, increased morbidity and higher healthcare costs. Non-pharmacological interventions have been advocated for delirium management, however there is little evidence evaluating feasibility and acceptability of physical interventions administered in the evening. The aim of this study was to conduct a feasibility trial of evening mobilisation to prevent and treat delirium in patients admitted to intensive care. Methods In this mixed-methods, randomised controlled feasibility trial we recruited participants from intensive care units at two university hospitals in the United Kingdom. Eligible participants who were able to respond to verbal stimulus (Richmond agitation and sedation scale ≥3) and expected to stay in intensive care for at least 24 h were randomly assigned (1:1) to receive usual care or usual care plus evening mobilisation. The evening mobilisation was delivered between 19:00 and 21:00, for up to seven consecutive evenings or ICU discharge, whichever was sooner. All outcome assessments were completed by a team member blinded to randomisation and group allocation. Primary objective was to assess feasibility and acceptability of evening mobilisation. Primary feasibility outcomes were recruitment, consent and retention rates, and intervention fidelity. Intervention acceptability was evaluated through semi-structured interviews of participants and staff. Secondary outcomes included prevalence in incidence and duration of delirium, measured using the Confusion Assessment Method for ICU. This trial is registered at ClinicalTrials.gov, NCT05401461. Findings Between July 16th, 2022, and October 31st, 2022, 58 eligible patients (29 usual care; 29 usual care plus evening mobilisation) were enrolled. We demonstrated the feasibility and acceptability of both the trial design and evening mobilisation intervention. Consent and retention rates over three months were 88% (58/66) and 90% (52/58) respectively, with qualitative analysis demonstrating good acceptability reported by both participants and staff. Secondary outcomes for the evening intervention group compared with the control group were: delirium incidence 5/26 (19%; 95% CI: 6-39%) vs 8/28 (29%; 95% CI: 13-49%) and mean delirium duration 2 days (SD 0.7) vs 4.25 days (SD 2.0). Interpretation Results of this trial will inform the development of a definitive full-scale randomised controlled trial investigating the effects of evening mobilisation to treat delirium and improve health-related outcomes. Funding None.
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Affiliation(s)
- David J. McWilliams
- Centre for Care Excellence, Coventry University and University Hospitals Coventry & Warwickshire NHS Trust, Coventry, United Kingdom
| | - Elizabeth B. King
- Oxford Allied Health Professions Research & Innovation Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Centre for Movement, Occupational and Rehabilitation Sciences (MOReS), Oxford Institute of Nursing, Midwifery and Allied Health Research (OxINMAHR), Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, United Kingdom
| | - Peter Nydahl
- Nursing Research, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Julie L. Darbyshire
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | | | - Dalia Barghouthy
- Critical Care, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, United Kingdom
| | - Christopher Bassford
- Critical Care, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, United Kingdom
| | - Owen D. Gustafson
- Oxford Allied Health Professions Research & Innovation Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Centre for Movement, Occupational and Rehabilitation Sciences (MOReS), Oxford Institute of Nursing, Midwifery and Allied Health Research (OxINMAHR), Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, United Kingdom
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Ghorayeb A, Darbyshire JL, Wronikowska MW, Watkinson PJ. Design and validation of a new Healthcare Systems Usability Scale (HSUS) for clinical decision support systems: a mixed-methods approach. BMJ Open 2023; 13:e065323. [PMID: 36717136 PMCID: PMC9887724 DOI: 10.1136/bmjopen-2022-065323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE To develop and validate a questionnaire to assess the usability of clinical decision support systems (CDSS) and to assist in the early identification of usability issues that may impact patient safety and quality of care. DESIGN Mixed research methods were used to develop and validate the questionnaire. The qualitative study involved scale item development, content and face validity. Pilot testing established construct validity using factor analysis and facilitated estimates for reliability and internal consistency using the Cronbach's alpha coefficient. SETTING Two hospitals within a single National Health Service Trust. PARTICIPANTS We recruited a panel of 7 experts in usability and questionnaire writing for health purposes to test content validity; 10 participants to assess face validity and 78 participants for the pilot testing. To be eligible for this last phase, participants needed to be health professionals with at least 3 months experience using the local hospital electronic patient record system. RESULTS Feedback from the face and content validity phases contributed to the development and improvement of scale items. The final Healthcare Systems Usability Scale (HSUS) proved quick to complete, easy to understand and was mostly worded by potential users. Exploratory analysis revealed four factors related to patient safety, task execution, alerts or recommendations accuracy, the effects of the system on workflow and ease of system use. These separate into four subscales: patient safety and decision effectiveness (seven items), workflow integration (six items), work effectiveness (five items) and user control (four items). These factors affect the quality of care and clinician's ability to make informed and timely decisions when using CDSS. The HSUS has a very good reliability with global Cronbach's alpha 0.914 and between 0.702 and 0.926 for the four subscales. CONCLUSION The HSUS is a valid and reliable tool for usability testing of CDSS and early identification of usability issues that may cause medical adverse events.
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Affiliation(s)
- Abir Ghorayeb
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Julie L Darbyshire
- Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Marta W Wronikowska
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Peter J Watkinson
- Kadoorie Centre for Critical Care Research and Education, Oxford University Hospitals NHS Trust, Oxford, UK
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Darbyshire JL, Duncan Young J. Variability of environmental sound levels: An observational study from a general adult intensive care unit in the UK. J Intensive Care Soc 2022; 23:389-397. [PMID: 36751355 PMCID: PMC9679913 DOI: 10.1177/17511437211022127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Intensive care units are significantly louder than WHO guidelines recommend. Patients are disturbed by activities around them and frequently report disrupted sleep. This can lead to slower recovery and long-term health problems. Environmental sound levels are usually reported as LAeq24, a single daily value that reflects mean sound levels over the previous 24-h period. This may not be the most appropriate measure for intensive care units (ICUs) and other similar areas. Humans experience sound in context, and disturbance will vary according to both the individual and acoustic features of the ambient sounds. Loudness is one of a number of measures that approximate the human perception of sound, taking into account tone, duration, and frequency, as well as volume. Typically sounds with higher frequencies, such as alarms, are perceived as louder and more disturbing. Methods Sound level data were collected from a single NHS Trust hospital general adult intensive care unit between October 2016 and May 2018. Summary data (mean sound levels (LAeq) and corresponding Zwicker calculated loudness values) were subsequently analysed by minute, hour, and day. Results The overall mean LAeq24 across the study duration was 47.4 dBA. This varied by microphone location. We identified a clear pattern to sound level fluctuations across the 24-h period. Weekends were significantly quieter than weekdays in statistical terms but this reduction of 0.2 dB is not detectable by human hearing. Peak loudness values over 90 dB were recorded every hour. Conclusions Perception of sound is sensitive to the environment and individual characteristics and sound levels in the ICU are location specific. This has implications for routine environmental monitoring practices. Peak loudness values are consistently between 90 and 100 dB. These may be driven by alarms and other sudden high-frequency sounds, leading to more disturbance than LAeq24 sound levels suggest. Addressing sounds with high loudness values may improve the ICU environment more than an overall reduction in the 24-h mean decibel value.
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Affiliation(s)
- Julie L Darbyshire
- Julie L Darbyshire, Nuffield
Department of Clinical Neurosciences, University of Oxford, Oxford UK.
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7
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Bedford JP, Garside T, Darbyshire JL, Betts TR, Young JD, Watkinson PJ. Risk factors for new-onset atrial fibrillation during critical illness: A Delphi study. J Intensive Care Soc 2022; 23:414-424. [PMID: 36751347 PMCID: PMC9679893 DOI: 10.1177/17511437211022132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background New-onset atrial fibrillation (NOAF) is common during critical illness and is associated with poor outcomes. Many risk factors for NOAF during critical illness have been identified, overlapping with risk factors for atrial fibrillation in patients in community settings. To develop interventions to prevent NOAF during critical illness, modifiable risk factors must be identified. These have not been studied in detail and it is not clear which variables warrant further study. Methods We undertook an international three-round Delphi process using an expert panel to identify important predictors of NOAF risk during critical illness. Results Of 22 experts invited, 12 agreed to participate. Participants were located in Europe, North America and South America and shared 110 publications on the subject of atrial fibrillation. All 12 completed the three Delphi rounds. Potentially modifiable risk factors identified include 15 intervention-related variables. Conclusions We present the results of the first Delphi process to identify important predictors of NOAF risk during critical illness. These results support further research into modifiable risk factors including optimal plasma electrolyte concentrations, rates of change of these electrolytes, fluid balance, choice of vasoactive medications and the use of preventative medications in high-risk patients. We also hope our findings will aid the development of predictive models for NOAF.
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Affiliation(s)
- Jonathan P Bedford
- Nuffield Department of Clinical Neurosciences, University of
Oxford, Oxford, UK,Jonathan P Bedford, Kadoorie Centre for
Critical Care Research and Education, Level 3, John Radcliffe Hospital, Headley
Way, Headington, Oxford OX3 9DU, UK.
| | - Tessa Garside
- Nuffield Department of Clinical Neurosciences, University of
Oxford, Oxford, UK
| | - Julie L Darbyshire
- Nuffield Department of Clinical Neurosciences, University of
Oxford, Oxford, UK
| | - Timothy R Betts
- Radcliffe Department of Medicine, University of Oxford, Oxford,
UK
| | - J Duncan Young
- Nuffield Department of Clinical Neurosciences, University of
Oxford, Oxford, UK
| | - Peter J Watkinson
- Nuffield Department of Clinical Neurosciences, University of
Oxford, Oxford, UK,NIHR Oxford Biomedical Research Centre, Oxford, UK
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Darbyshire JL, Greig PR, Hinton L, Young JD. Monitoring sound levels in the intensive care unit: A mixed-methods system development project to optimize design features for a new electronic interface in the healthcare environment. Int J Med Inform 2021; 153:104538. [PMID: 34343956 PMCID: PMC8417813 DOI: 10.1016/j.ijmedinf.2021.104538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 06/07/2021] [Accepted: 07/15/2021] [Indexed: 11/16/2022]
Abstract
Understanding the user experience is key to effective design. Agile design practices foster efficient systems development. Implementing technological change requires socio-cultural understanding of teams. User-testing data from multiple sources allows for better systems evaluation. A well-designed system requires little training or explanation to use.
Background Intensive care units (ICU) are busy round the clock and it is difficult to maintain low sound levels that support patient rest. To help ICU staff manage activities we developed a visual display that monitors and reports sound levels in real-time. This facilitates immediate feedback, encouraging proactive behavior change to limit disturbances. Methods Following the principles of user-centered design practices we created our ‘user persona’ to understand the needs and goals of potential users of the system. We then conducted iterative user testing with current members of the ICU team, primarily using the ‘think aloud’ method to refine the design and functionality of our novel system. Ethnography evaluated team use of the display. Results The final design was simple, clear, and efficient, and both functional and aesthetically pleasing for the key user demographic. We identified challenges in the implementation and adoption process that were separate from the ‘usability’ of the system itself. Conclusions Embedding the design process within the core user demographic ensured the final product delivered relevant information for key users, and that this information was intuitive to interpret. Initiating sustainable change is not straightforward. It requires recognition of cultural practices within teams, departments, professions, organizations, and strategies to maximize engagement.
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Affiliation(s)
- Julie L Darbyshire
- Nuffield Department of Clinical Neurosciences, Unhiniversity of Oxford, UK.
| | - Paul R Greig
- Nuffield Department of Clinical Neurosciences, Unhiniversity of Oxford, UK; Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Lisa Hinton
- Nuffield Department of Primary Health Care Sciences, University of Oxford, UK
| | - J Duncan Young
- Nuffield Department of Clinical Neurosciences, Unhiniversity of Oxford, UK
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Ede J, Vollam S, Darbyshire JL, Gibson O, Tarassenko L, Watkinson P. Non-contact vital sign monitoring of patients in an intensive care unit: A human factors analysis of staff expectations. Appl Ergon 2021; 90:103149. [PMID: 32866689 DOI: 10.1016/j.apergo.2020.103149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/12/2020] [Accepted: 05/06/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Infra-red and thermal imaging enable wireless systems to monitor patients' vital signs and absence of wires may improve patient experiences. No studies have explored staff perceptions of the concept of this specific type of technology in the adult population. Understanding existing working systems before introducing technology could improve adoption. METHODS We conducted semi-structured interviews with Intensive Care Unit (ICU) staff exploring perceptions of wireless patient monitoring. We used the Systems Engineering Initiative for Patient Safety (SEIPS) model to guide thematic analysis. RESULTS We identified usability themes relating to staff perceptions of current patient monitoring experiences, staff perceptions of patient/relative expectations of ICU care, troubleshooting, hierarchy of monitoring, and consensus of trust. CONCLUSION The concept of wireless monitoring has perceived benefits for patients and staff. The Systems Engineering Initiative for Patient Safety model guided a systems-based exploratory evaluation. Results highlight the social and environmental factors which may influence usability, adoption, or abandonment of wireless technology in the ICU.
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Dahella SS, Briggs JS, Coombes P, Farajidavar N, Meredith P, Bonnici T, Darbyshire JL, Watkinson PJ. Implementing a system for the real-time risk assessment of patients considered for intensive care. BMC Med Inform Decis Mak 2020; 20:161. [PMID: 32677936 PMCID: PMC7366315 DOI: 10.1186/s12911-020-01176-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 07/02/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Delay in identifying deterioration in hospitalised patients is associated with delayed admission to an intensive care unit (ICU) and poor outcomes. For the HAVEN project (HICF ref.: HICF-R9-524), we have developed a mathematical model that identifies deterioration in hospitalised patients in real time and facilitates the intervention of an ICU outreach team. This paper describes the system that has been designed to implement the model. We have used innovative technologies such as Portable Format for Analytics (PFA) and Open Services Gateway initiative (OSGi) to define the predictive statistical model and implement the system respectively for greater configurability, reliability, and availability. RESULTS The HAVEN system has been deployed as part of a research project in the Oxford University Hospitals NHS Foundation Trust. The system has so far processed > 164,000 vital signs observations and > 68,000 laboratory results for > 12,500 patients and the algorithm generated score is being evaluated to review patients who are under consideration for transfer to ICU. No clinical decisions are being made based on output from the system. The HAVEN score has been computed using a PFA model for all these patients. The intent is that this score will be displayed on a graphical user interface for clinician review and response. CONCLUSIONS The system uses a configurable PFA model to compute the HAVEN score which makes the system easily upgradable in terms of enhancing systems' predictive capability. Further system enhancements are planned to handle new data sources and additional management screens.
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Affiliation(s)
- Simarjot S Dahella
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Buckingham Building, Lion Terrace, Portsmouth, PO1 3HE, UK
| | - James S Briggs
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Buckingham Building, Lion Terrace, Portsmouth, PO1 3HE, UK.
| | - Paul Coombes
- IM&T, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
| | - Nazli Farajidavar
- Department of Engineering, Institute of Biomedical Engineering, University of Oxford, Old Road Campus Research Building, Oxford, OX3 7DQ, UK
| | - Paul Meredith
- Research & Innovation, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth, PO6 3LY, UK
| | - Timothy Bonnici
- Critical Care Department, University College London NHS Foundation Trust, 235 Euston Road, London, NW1 2BU, UK
| | - Julie L Darbyshire
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
| | - Peter J Watkinson
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
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Darbyshire JL, Borthwick M, Edmonds P, Vollam S, Hinton L, Young JD. Measuring sleep in the intensive care unit: Electroencephalogram, actigraphy, or questionnaire? J Intensive Care Soc 2020; 21:22-27. [PMID: 32284714 PMCID: PMC7137156 DOI: 10.1177/1751143718816910] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Studies consistently report deranged sleep in patients admitted to intensive care unit. Poor sleep has harmful physical and cognitive effects, and an evidence-based intervention to improve sleep is needed. It is, however, difficult to measure sleep in the intensive care unit. 'Gold standard' monitoring (polysomnography) is unsuitable for usual care. METHODS We collected concurrent sleep data from electroencephalograph recordings, activity monitoring, and nurse- and patient-completed Richards-Campbell Sleep Questionnaires (RCSQ). RESULTS Electroencephalograph data (n = 34) confirm poor sleep. Individual bouts last approximately 1 min and around 2 h of sleep overnight is common. Correlation between electroencephalograph, self-report, nurse-report, actigraphy and overall activity score is low (ρ = 0.123 (n = 24), 0.127 (n = 22), and 0.402 and - 0.201 (n = 13), respectively). Correlation between nurse and patient assessment is limited (ρ = 0.537 (n = 444)). CONCLUSIONS No current method of sleep monitoring seems suitable in the intensive care unit. However, to facilitate comparison across studies, the patient-completed RCSQ seems the most meaningful measure.
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Affiliation(s)
- Julie L Darbyshire
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Mark Borthwick
- Adult Intensive Care Unit, University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Sarah Vollam
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Lisa Hinton
- Nuffield Department of Primary Health Sciences, University of Oxford, Oxford, UK
| | - J Duncan Young
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Abstract
Excessive noise in hospitals adversely affects patients' sleep and recovery, causes stress and fatigue in staff and hampers communication. The World Health Organization suggests sound levels should be limited to 35 decibels. This is probably unachievable in intensive care units, but some reduction from current levels should be possible. A preliminary step would be to identify principal sources of noise. As part of a larger project investigating techniques to reduce environmental noise, we installed a microphone array system in one with four beds in an adult general intensive care unit. This continuously measured locations and sound pressure levels of noise sources. This report summarises results recorded over one year. Data were collected between 7 April 2017 and 16 April 2018 inclusive. Data for a whole day were available for 248 days. The sound location system revealed that the majority of loud sounds originated from extremely limited areas, very close to patients' ears. This proximity maximises the adverse effects of high environmental noise levels for patients. Some of this was likely to be appropriate communication between the patient, their caring staff and visitors. However, a significant proportion of loud sounds may originate from equipment alarms which are sited at the bedside. A redesign of the intensive care unit environment to move alarm sounds away from the bed-side might significantly reduce the environmental noise burden to patients.
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Affiliation(s)
- J L Darbyshire
- Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | | | - J Cheer
- Institute of Sound and Vibration Research, Southampton University, Southampton, UK
| | - F M Fazi
- Institute of Sound and Vibration Research, Southampton University, Southampton, UK
| | - J D Young
- Nuffield Department of Clinical Neurosciences, University of Oxford, UK
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Darbyshire JL, Hinton L, Young JD, Greig PR. Using the experience-based co-design method to design a teaching package. Med Educ 2018; 52:1198. [PMID: 30345676 PMCID: PMC6690073 DOI: 10.1111/medu.13720] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Abstract
OBJECTIVES To collate and appraise the use of subjective measures to assess sleep in the intensive care unit (ICU). DESIGN A systematic search and critical review of the published literature. DATA SOURCES Medline, Scopus, and Cumulative Index to Nursing and Allied Health Literature were searched using combinations of the key words "Sleep," "Critical Care," "Intensive Care," and "Sleep Disorders," and this was complemented by hand searching the most recent systematic reviews on related topics. STUDY ELIGIBILITY CRITERIA Papers were limited to non-gray English-language studies of the adult population, published in the last 10 years. OUTCOME MEASURES Primary outcomes were the number and categorization of quantitative studies reporting measures of sleep, the number of participants for each data collection method, and a synthesis of related material to appraise the use of survey tools commonly used for sleep measurement in the ICU. RESULTS Thirty-eight papers reported quantitative empirical data collection on sleep, 17 of which used a primary method of subjective assessment of sleep by the patient or nurse. Thirteen methods of subjective sleep assessment were identified. Many of these tools lacked validity and reliability testing. CONCLUSIONS Research using questionnaires to assess sleep is commonplace in light of practical barriers to polysomnography or other measures of sleep. A methodologically sound approach to tool development and testing is crucial to gather meaningful data, and this robust approach was lacking in many cases. Further research measuring sleep subjectively in ICU should use the Richards Campbell Sleep Questionnaire, and researchers should maintain a commitment to transparency in describing methods.
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Affiliation(s)
- Emma L Jeffs
- 1 Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Julie L Darbyshire
- 1 Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Darbyshire JL, Greig PR, Vollam S, Young JD, Hinton L. "I Can Remember Sort of Vivid People…but to Me They Were Plasticine." Delusions on the Intensive Care Unit: What Do Patients Think Is Going On? PLoS One 2016; 11:e0153775. [PMID: 27096605 PMCID: PMC4838295 DOI: 10.1371/journal.pone.0153775] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 04/04/2016] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Patients who develop intensive care unit (ICU) acquired delirium stay longer in the ICU, and hospital, and are at risk of long-term mental and physical health problems. Despite guidelines for patient assessment, risk limitation, and treatment in the ICU population, delirium and associated delusions remain a relatively common occurrence on the ICU. There is considerable information in the literature describing the incidence, suspected causes of, and discussion of the benefits and side-effects of the various treatments for delirium in the ICU. But peer-reviewed patient-focused research is almost non-existent. There is therefore a very limited understanding of the reality of delusions in the intensive care unit from the patient's point of view. METHOD A secondary analysis of the original interviews conducted by the University of Oxford Health Experiences Research Group was undertaken to explore themes relating specifically to sleep and delirium. RESULTS Patients describe a liminal existence on the ICU. On the threshold of consciousness their reality is uncertain and their sense of self is exposed. Lack of autonomy in an unfamiliar environment prompts patients to develop explanations and understandings for themselves with no foothold in fact. CONCLUSION Patients on the ICU are perhaps more disoriented than they appear and early psychological intervention in the form of repeated orientation whilst in the ICU might improve the patient experience and defend against development of side-effects.
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Affiliation(s)
- Julie L. Darbyshire
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Paul R. Greig
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Sarah Vollam
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - J. Duncan Young
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
- Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Lisa Hinton
- Department of Primary Care, University of Oxford, Oxford, United Kingdom
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Affiliation(s)
- Julie L Darbyshire
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Darbyshire JL, Young JD. An investigation of sound levels on intensive care units with reference to the WHO guidelines. Crit Care 2013; 17:R187. [PMID: 24005004 PMCID: PMC4056361 DOI: 10.1186/cc12870] [Citation(s) in RCA: 134] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 09/03/2013] [Indexed: 12/13/2022]
Abstract
Introduction Patients in intensive care units (ICUs) suffer from sleep deprivation arising from nursing interventions and ambient noise. This may exacerbate confusion and ICU-related delirium. The World Health Organization (WHO) suggests that average hospital sound levels should not exceed 35 dB with a maximum of 40 dB overnight. We monitored five ICUs to check compliance with these guidelines. Methods Sound levels were recorded in five adult ICUs in the UK. Two sound level monitors recorded concurrently for 24 hours at the ICU central stations and adjacent to patients. Sample values to determine levels generated by equipment and external noise were also recorded in an empty ICU side room. Results Average sound levels always exceeded 45 dBA and for 50% of the time exceeded between 52 and 59 dBA in individual ICUs. There was diurnal variation with values decreasing after evening handovers to an overnight average minimum of 51 dBA at 4 AM. Peaks above 85 dBA occurred at all sites, up to 16 times per hour overnight and more frequently during the day. WHO guidelines on sound levels could be only achieved in a side room by switching all equipment off. Conclusion All ICUs had sound levels greater than WHO recommendations, but the WHO recommended levels are so low they are not achievable in an ICU. Levels adjacent to patients are higher than those recorded at central stations. Unit-wide noise reduction programmes or mechanical means of isolating patients from ambient noise, such as earplugs, should be considered.
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Lawton J, Jenkins N, Darbyshire JL, Holman RR, Farmer AJ, Hallowell N. Challenges of maintaining research protocol fidelity in a clinical care setting: a qualitative study of the experiences and views of patients and staff participating in a randomized controlled trial. Trials 2011; 12:108. [PMID: 21542916 PMCID: PMC3104488 DOI: 10.1186/1745-6215-12-108] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Accepted: 05/04/2011] [Indexed: 01/04/2023] Open
Abstract
Background Trial research has predominantly focused on patient and staff understandings of trial concepts and/or motivations for taking part, rather than why treatment recommendations may or may not be followed during trial delivery. This study sought to understand why there was limited attainment of the glycaemic target (HbA1c ≤6.5%) among patients who participated in the Treating to Target in Type 2 Diabetes Trial (4-T). The objective was to inform interpretation of trial outcomes and provide recommendations for future trial delivery. Methods In-depth interviews were conducted with 45 patients and 21 health professionals recruited from 11 of 58 trial centres in the UK. Patients were broadly representative of those in the main trial in terms of treatment allocation, demographics and glycaemic control. Both physicians and research nurses were interviewed. Results Most patients were committed to taking insulin as recommended by 4-T staff. To avoid hypoglycaemia, patients occasionally altered or skipped insulin doses, normally in consultation with staff. Patients were usually unaware of the trial's glycaemic target. Positive staff feedback could lead patients to believe they had been 'successful' trial participants even when their HbA1c exceeded 6.5%. While some staff felt that the 4-T automated insulin dose adjustment algorithm had increased their confidence to prescribe larger insulin doses than in routine clinical practice, all described situations where they had not followed its recommendations. Staff regarded the application of a 'one size fits all' glycaemic target during the trial as contradicting routine clinical practice where they would tailor treatments to individuals. Staff also expressed concerns that 'tight' glycaemic control might impose an unacceptably high risk of hypoglycaemia, thus compromising trust and safety, especially amongst older patients. To address these concerns, staff tended to adapt the trial protocol to align it with their clinical practices and experiences. Conclusions To understand trial findings, foster attainment of endpoints, and promote protocol fidelity, it may be necessary to look beyond individual patient characteristics and experiences. Specifically, the context of trial delivery, the impact of staff involvement, and the difficulties staff may encounter in balancing competing 'clinical' and 'research' roles and responsibilities may need to be considered and addressed.
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Affiliation(s)
- Julia Lawton
- Centre for Population Health Sciences, University of Edinburgh, Medical School, Teviot Place, Edinburgh, EH8 9AG, UK.
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Abstract
BACKGROUND Evidence supporting the addition of specific insulin regimens to oral therapy in patients with type 2 diabetes mellitus is limited. METHODS In this 3-year open-label, multicenter trial, we evaluated 708 patients who had suboptimal glycated hemoglobin levels while taking metformin and sulfonylurea therapy. Patients were randomly assigned to receive biphasic insulin aspart twice daily, prandial insulin aspart three times daily, or basal insulin detemir once daily (twice if required). Sulfonylurea therapy was replaced by a second type of insulin if hyperglycemia became unacceptable during the first year of the study or subsequently if glycated hemoglobin levels were more than 6.5%. Outcome measures were glycated hemoglobin levels, the proportion of patients with a glycated hemoglobin level of 6.5% or less, the rate of hypoglycemia, and weight gain. RESULTS Median glycated hemoglobin levels were similar for patients receiving biphasic (7.1%), prandial (6.8%), and basal (6.9%) insulin-based regimens (P=0.28). However, fewer patients had a level of 6.5% or less in the biphasic group (31.9%) than in the prandial group (44.7%, P=0.006) or in the basal group (43.2%, P=0.03), with 67.7%, 73.6%, and 81.6%, respectively, taking a second type of insulin (P=0.002). [corrected] Median rates of hypoglycemia per patient per year were lowest in the basal group (1.7), higher in the biphasic group (3.0), and highest in the prandial group (5.7) (P<0.001 for the overall comparison). The mean weight gain was higher in the prandial group than in either the biphasic group or the basal group. Other adverse event rates were similar in the three groups. CONCLUSIONS Patients who added a basal or prandial insulin-based regimen to oral therapy had better glycated hemoglobin control than patients who added a biphasic insulin-based regimen. Fewer hypoglycemic episodes and less weight gain occurred in patients adding basal insulin. (Current Controlled Trials number, ISRCTN51125379.)
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Affiliation(s)
- Rury R Holman
- Diabetes Trials Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, United Kingdom.
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