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BackgroundViscoelastic hemostatic assays, such as rotational thromboelastometry (ROTEM) or thromboelastography, enable prompt diagnosis and accelerate targeted treatment. However, the complex interpretation of the results remains challenging. Visual Clot—a situation awareness-based visualization technology—was developed to assist clinicians in interpreting viscoelastic tests. ObjectiveFollowing a previous high-fidelity simulation study, we analyzed users’ perceptions of the technology, to identify its strengths and limitations from clinicians’ perspectives. MethodsThis is a mixed qualitative-quantitative study consisting of interviews and a survey. After solving coagulation scenarios using Visual Clot in high-fidelity simulations, we interviewed anesthesia personnel about the perceived advantages and disadvantages of the new tool. We used a template approach to identify dominant themes in interview responses. From these themes, we defined 5 statements, which were then rated on Likert scales in a questionnaire. ResultsWe interviewed 77 participants and 23 completed the survey. We identified 9 frequently mentioned topics by analyzing the interview responses. The most common themes were “positive design features,” “intuitive and easy to learn,” and “lack of a quantitative component.” In the survey, 21 respondents agreed that Visual Clot is easy to learn and 16 respondents stated that a combination of Visual Clot and ROTEM would help them manage complex hemostatic situations. ConclusionsA group of anesthesia care providers found Visual Clot well-designed, intuitive, and easy to learn. Participants highlighted its usefulness in emergencies, especially for clinicians inexperienced in coagulation management. However, the lack of quantitative information is an area for improvement.

Abstract Patient monitoring is the foundation of intensive care medicine. High workload and information overload can impair situation awareness of staff, thus leading to loss of important information about patients’ conditions. To facilitate mental processing of patient monitoring data, we developed the Visual-Patient-avatar Intensive Care Unit (ICU), a virtual patient model animated from vital signs and patient installation data. It incorporates user-centred design principles to foster situation awareness. This study investigated the avatar’s effects on information transfer measured by performance, diagnostic confidence and perceived workload. This computer-based study compared Visual-Patient-avatar ICU and conventional monitor modality for the first time. We recruited 25 nurses and 25 physicians from five centres. The participants completed an equal number of scenarios in both modalities. Information transfer, as the primary outcome, was defined as correctly assessing vital signs and installations. Secondary outcomes included diagnostic confidence and perceived workload. For analysis, we used mixed models and matched odds ratios. Comparing 250 within-subject cases revealed that Visual-Patient-avatar ICU led to a higher rate of correctly assessed vital signs and installations [rate ratio (RR) 1.25; 95% CI 1.19–1.31; P

BackgroundGuidelines recommend using viscoelastic coagulation tests to guide coagulation management, but interpreting the results remains challenging. Visual Clot, a 3D animated blood clot, facilitates interpretation through a user-centered and situation awareness–oriented design. ObjectiveThis study aims to compare the effects of Visual Clot versus conventional viscoelastic test results (rotational thrombelastometry [ROTEM] temograms) on the coagulation management performance of anesthesia teams in critical bleeding situations. MethodsWe conducted a prospective, randomized, high-fidelity simulation study in which anesthesia teams (consisting of a senior anesthesiologist, a resident anesthesiologist, and an anesthesia nurse) managed perioperative bleeding scenarios. Teams had either Visual Clot or ROTEM temograms available to perform targeted coagulation management. We analyzed the 15-minute simulations with post hoc video analysis. The primary outcome was correct targeted coagulation therapy. Secondary outcomes were time to targeted coagulation therapy, confidence, and workload. In addition, we have conducted a qualitative survey on user acceptance of Visual Clot. We used Poisson regression, Cox regression, and mixed logistic regression models, adjusted for various potential confounders, to analyze the data. ResultsWe analyzed 59 simulations. Teams using Visual Clot were more likely to deliver the overall targeted coagulation therapy correctly (rate ratio 1.56, 95% CI 1.00-2.47; P=.05) and administer the first targeted coagulation product faster (hazard ratio 2.58, 95% CI 1.37-4.85; P=.003). In addition, participants showed higher decision confidence with Visual Clot (odds ratio 3.60, 95% CI 1.49-8.71; P=.005). We found no difference in workload (coefficient –0.03, 95% CI –3.08 to 2.88; P=.99). ConclusionsUsing Visual Clot led to a more accurate and faster-targeted coagulation therapy than using ROTEM temograms. We suggest that relevant viscoelastic test manufacturers consider augmenting their complex result presentation with intuitive, easy-to-understand visualization to ease users’ burden from unnecessary cognitive load and enhance patient care.

Visual Patient Avatar ICU is an innovative approach to patient monitoring, enhancing the user’s situation awareness in intensive care settings. It dynamically displays the patient’s current vital signs using changes in color, shape, and animation. The technology can also indicate patient-inserted devices, such as arterial lines, central lines, and urinary catheters, along with their insertion locations. We conducted an international, multi-center study using a sequential qualitative-quantitative design to evaluate users’ perception of Visual Patient Avatar ICU among physicians and nurses. Twenty-five nurses and twenty-five physicians from the ICU participated in the structured interviews. Forty of them completed the online survey. Overall, ICU professionals expressed a positive outlook on Visual Patient Avatar ICU. They described Visual Patient Avatar ICU as a simple and intuitive tool that improved information retention and facilitated problem identification. However, a subset of participants expressed concerns about potential information overload and a sense of incompleteness due to missing exact numerical values. These findings provide valuable insights into user perceptions of Visual Patient Avatar ICU and encourage further technology development before clinical implementation.

Patient monitoring is crucial in critical care medicine. Perceiving and interpreting multiple vital signs requires a high workload that can lead to decreased situation awareness and consequently inattentional blindness, defined as impaired perception of unexpectedly changing data. To facilitate information transfer, we developed and validated the Visual-Patient avatar. Generated by numerical data, the animation displays the status of vital signs and patient installations according to a user-centered design to improve situation awareness. As a surrogate parameter for information transfer in patient monitoring, we recorded visual attention using eye-tracking data. In this computer-based study, we compared the correlation of visually perceived and correctly interpreted vital signs between a Visual-Patient-avatar ICU and conventional patient monitoring. A total of 50 recruited study participants (25 nurses, 25 physicians) from five European study centers completed five randomized scenarios in both modalities. Using a stationary eye tracker as the primary endpoint, we recorded how long different areas of interest of the two monitoring modalities were viewed. In addition, we tested for a possible association between the length of time an area of interest was viewed and the correctness of the corresponding question. With the conventional monitor, participants looked at the installation site the longest (median 2.13–2.51 s). With the Visual-Patient-avatar ICU, gaze distribution was balanced; no area of interest was viewed for particularly long. For both modalities, the longer an area was viewed, the more likely the associated question was answered incorrectly (OR 0.97, 95% CI 0.95–0.99, p = 0.008). The Visual-Patient-avatar ICU facilitates and improves information transfer through its visualizations, especially with written information. The longer an area of interest was viewed, the more likely the associated question was answered incorrectly.

Blood gas analysis plays a central role in modern medicine. Advances in technology have expanded the range of available parameters and increased the complexity of their interpretation. By applying user-centered design principles, it is possible to reduce the cognitive load associated with interpreting blood gas analysis. In this international, multicenter study, we explored anesthesiologists’ perspectives on Visual Blood, a novel visualization technique for presenting blood gas analysis results. We conducted interviews with participants following two computer-based simulation studies, the first utilizing virtual reality (VR) (50 participants) and the second without VR (70 participants). Employing the template approach, we identified key themes in the interview responses and formulated six statements, which were rated using Likert scales from 1 (strongly disagree) to 5 (strongly agree) in an online questionnaire. The most frequently mentioned theme was the positive usability features of Visual Blood. The online survey revealed that participants found Visual Blood to be an intuitive method for interpreting blood gas analysis (median 4, interquartile range (IQR) 4-4, p < 0.001). Participants noted that minimal training was required to effectively learn how to interpret Visual Blood (median 4, IQR 4-4, p < 0.001). However, adjustments are necessary to reduce visual overload (median 4, IQR 2-4, p < 0.001). Overall, Visual Blood received a favorable response. The strengths and weaknesses derived from these data will help optimize future versions of Visual Blood to improve the presentation of blood gas analysis results.

Abstract Background Measures of the sonorheometry based Quantra® viscoelastic hemostatic analyzer (HemoSonics, LCC, Charlottesville, VA, USA) were compared with corresponding results of the ROTEM® sigma device (Instrumentation Laboratory, Bedford, MA, USA). Methods In thirty-eight patients scheduled for elective cardiac surgery between December 2018 and October 2019, blood samples were taken after induction of anesthesia (sample 1) and after heparin neutralization (sample 2) and measured on Quantra (QPlus® Cartridge) and ROTEM sigma (ROTEM® sigma complete + hep Cartridge). Clot times and clot stiffness values were recorded. Clot stiffness values of ROTEM amplitudes (A in mm) were converted to shear modulus (G) in hectoPascal (hPa): G (hPa) = (5 x A)/(100-A). Additionally, time-to-results was recorded. Spearman rank test correlation and Bland Altman analysis were performed. Results Clot stiffness parameters of the Quantra correlated strongly with corresponding measurements of the ROTEM with r = 0.93 and 0.94 for EXTEM A10 vs CS and r = 0.94 and 0.96 for FIBTEM A10 vs FCS for sample 1 and 2, respectively. Quantra clot time correlated strongly with ROTEM INTEM CT with r = 0.71 for sample 1 and r = 0.75 for sample 2. However, Bland Altman analysis showed no agreement in all compared assays of both methods. The median time to delivery of first and complete results was significantly shorter for Quantra (412 and 658 s) compared to ROTEM sigma (839 and 1290 s). Conclusions The Quantra showed a strong correlation with the ROTEM sigma for determining clot times and clot stiffness and the parameters assess similar aspects of clot development. However, these parameters are not directly interchangeable and implicate that separate cut-off values need to be established for users of the Quantra device. Word count: 278. Trial registration The study was retrospectively registered with ClinicalTrials.gov (ID: NCT04210830 ) at December 20th 2019.

BackgroundPatient safety during anesthesia is crucially dependent on the monitoring of vital signs. However, the values obtained must also be perceived and correctly classified by the attending care providers. To facilitate these processes, we developed Visual-Patient-avatar, an animated virtual model of the monitored patient, which innovatively presents numerical and waveform data following user-centered design principles. After a high-fidelity simulation study, we analyzed the participants’ perceptions of 3 different monitor modalities, including this newly introduced technique. ObjectiveThe aim of this study was to collect and evaluate participants’ opinions and experiences regarding 3 different monitor modalities, which are Visual-Patient-avatar, Split Screen (avatar and Conventional monitor alongside each other), and Conventional monitor after using them during simulated critical anesthetic events. MethodsThis study was a researcher-initiated, single-center, semiquantitative study. We asked 92 care providers right after finishing 3 simulated emergency scenarios about their positive and negative opinions concerning the different monitor modalities. We processed the field notes obtained and derived the main categories and corresponding subthemes following qualitative research methods. ResultsWe gained a total of 307 statements. Through a context-based analysis, we identified the 3 main categories of “Visual-Patient-avatar,” “Split Screen,” and “Conventional monitor” and divided them into 11 positive and negative subthemes. We achieved substantial interrater reliability in assigning the statements to 1 of the topics. Most of the statements concerned the design and usability features of the avatar or the Split Screen mode. ConclusionsThis study semiquantitatively reviewed the clinical applicability of the Visual-Patient-avatar technique in a high-fidelity simulation study and revealed the strengths and limitations of the avatar only and Split Screen modality. In addition to valuable suggestions for improving the design, the requirement for training prior to clinical implementation was emphasized. The responses to the Split Screen suggest that this symbiotic modality generates better situation awareness in combination with numerical data and accurate curves. As a subsequent development step, a real-life introduction study is planned, where we will test the avatar in Split Screen mode under actual clinical conditions.

Interpreting blood gas analysis results can be challenging for the clinician, especially in stressful situations under time pressure. To foster fast and correct interpretation of blood gas results, we developed Visual Blood. This computer-based, multicentre, noninferiority study compared Visual Blood and conventional arterial blood gas (ABG) printouts. We presented six scenarios to anaesthesiologists, once with Visual Blood and once with the conventional ABG printout. The primary outcome was ABG parameter perception. The secondary outcomes included correct clinical diagnoses, perceived diagnostic confidence, and perceived workload. To analyse the results, we used mixed models and matched odds ratios. Analysing 300 within-subject cases, we showed noninferiority of Visual Blood compared to ABG printouts concerning the rate of correctly perceived ABG parameters (rate ratio, 0.96; 95% CI, 0.92–1.00; p = 0.06). Additionally, the study revealed two times higher odds of making the correct clinical diagnosis using Visual Blood (OR, 2.16; 95% CI, 1.42–3.29; p < 0.001) than using ABG printouts. There was no or, respectively, weak evidence for a difference in diagnostic confidence (OR, 0.84; 95% CI, 0.58–1.21; p = 0.34) and perceived workload (Coefficient, 2.44; 95% CI, −0.09–4.98; p = 0.06). This study showed that participants did not perceive the ABG parameters better, but using Visual Blood resulted in more correct clinical diagnoses than using conventional ABG printouts. This suggests that Visual Blood allows for a higher level of situation awareness beyond individual parameters’ perception. However, the study also highlighted the limitations of today’s virtual reality headsets and Visual Blood.

Viscoelastic point-of-care haemostatic resuscitation methods, such as ROTEM or TEG, are crucial in deciding on time-efficient personalised coagulation interventions. International transfusion guidelines emphasise increased patient safety and reduced treatment costs. We analysed care providers’ perceptions of ROTEM to identify perceived strengths and areas for improvement. We conducted a single-centre, mixed qualitative–quantitative study consisting of interviews followed by an online survey. Using a template approach, we first identified themes in the responses given by care providers about ROTEM. Later, the participants rated six statements based on the identified themes on five-point Likert scales in an online questionnaire. Seventy-seven participants were interviewed, and 52 completed the online survey. By analysing user perceptions, we identified ten themes. The most common positive theme was “high accuracy”. The most common negative theme was “need for training”. In the online survey, 94% of participants agreed that monitoring the real-time ROTEM temograms helps to initiate targeted treatment more quickly and 81% agreed that recurrent ROTEM training would be beneficial. Anaesthesia care providers found ROTEM to be accurate and quickly available to support decision-making in dynamic and complex haemostatic situations. However, clinicians identified that interpreting ROTEM is a complex and cognitively demanding task that requires significant training needs.

Introduction More than 300 million surgical procedures are performed each year. Acute kidney injury (AKI) is a common complication after major surgery and is associated with adverse short-term and long-term outcomes. However, there is a large variation in the incidence of reported AKI rates. The establishment of an accurate epidemiology of surgery-associated AKI is important for healthcare policy, quality initiatives, clinical trials, as well as for improving guidelines. The objective of the Epidemiology of Surgery-associated Acute Kidney Injury (EPIS-AKI) trial is to prospectively evaluate the epidemiology of AKI after major surgery using the latest Kidney Disease: Improving Global Outcomes (KDIGO) consensus definition of AKI.Methods and analysis EPIS-AKI is an international prospective, observational, multicentre cohort study including 10 000 patients undergoing major surgery who are subsequently admitted to the ICU or a similar high dependency unit. The primary endpoint is the incidence of AKI within 72 hours after surgery according to the KDIGO criteria. Secondary endpoints include use of renal replacement therapy (RRT), mortality during ICU and hospital stay, length of ICU and hospital stay and major adverse kidney events (combined endpoint consisting of persistent renal dysfunction, RRT and mortality) at day 90. Further, we will evaluate preoperative and intraoperative risk factors affecting the incidence of postoperative AKI. In an add-on analysis, we will assess urinary biomarkers for early detection of AKI.Ethics and dissemination EPIS-AKI has been approved by the leading Ethics Committee of the Medical Council North Rhine-Westphalia, of the Westphalian Wilhelms-University Münster and the corresponding Ethics Committee at each participating site. Results will be disseminated widely and published in peer-reviewed journals, presented at conferences and used to design further AKI-related trials.Trial registration number NCT04165369.

As the interpretation of viscoelastic coagulation test results remains challenging, we created Visual Clot, an animated blood clot aiming to facilitate raw rotational thromboelastometry (ROTEM) parameters. This study investigated anesthesia personnel’s cognitive processing in managing simulated bleeding scenarios using eye-tracking technology. This multicenter, international, computer-based study across five large, central European hospitals included 35 participants with minimal to no prior experience interpreting viscoelastic test results. Using eye-tracking technology and an iPad tagged with quick response codes, we defined the time to treatment decision and the time on screen surface in seconds of correctly solved scenarios as our outcomes. The median time to treatment decision was 52 s for Visual Clot and 205 s for ROTEM (p < 0.0001). The probability of solving the scenario correctly was more than 8 times higher when using Visual Clot than when using ROTEM (Hazard ratio [HR] 8.54, 95% CI from 6.5 to 11.21; p < 0.0001). Out of 194 correctly answered scenarios of participants with the eye-tracker, 154 (79.4%) were solved with Visual Clot and 40 (20.6%) with ROTEM. Participants spent on average 30 s less looking at the screen surface with Visual Clot compared to ROTEM (Coefficient −30.74 s, 95% CI from −39.27 to −22.27; p < 0.0001). For a comparison of the two modalities in terms of information transfer, we calculated the percentage of time on the screen surface of the overall time to treatment decision, which with Visual Clot was 14 percentage points shorter than with ROTEM (Coefficient −14.55, 95% CI from −20.05 to −9.12; p < 0.0001). Visual Clot seems to improve perception and detection of coagulopathies and leads to earlier initiation of the appropriate treatment. In a high-pressure working environment such as the operating and the resuscitation room, correct and timely decisions regarding bleeding management may have a relevant impact on patients’ outcomes.