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Objective: Out-of-hours discharge from ICU to the ward is associated with increased in-hospital mortality and ICU readmission. Little is known about why this occurs. We map the discharge process and describe the consequences of out-of-hours discharge to inform practice changes to reduce the impact of discharge at night. Design: This study was part of the REFLECT mixed methods study. We defined out-of-hours discharge as 16:00 - 07:59h. We undertook 20 in-depth case record reviews where in-hospital death after ICU discharge had been judged ‘probably avoidable’ in previous retrospective structured judgement reviews, and 20 where patients survived. We conducted semi-structured interviews with 55 patients, family members and staff with experience of ICU discharge processes. These, along with a stakeholder focus group, informed ICU discharge process mapping using the Human Factors-based Functional Analysis Resonance Method (FRAM). Setting: Three UK NHS hospitals, chosen to represent different hospital settings. Subjects: Patients discharged from ICU, their families and staff involved in their care. Interventions: None. Measurements and Main Results: Out-of-hours discharge was common. Patients and staff described out-of-hours discharge as unsafe due to a reduction in staffing and skill mix at night. Patients discharged out-of-hours were commonly discharged prematurely, had inadequate handover, were physiologically unstable and did not have deterioration recognised or escalated appropriately. We identified five interdependent functions key to facilitating timely ICU discharge: multi-disciplinary team decision for discharge; patient prepared for discharge; bed meeting; bed manager allocation of beds; and ward bed made available. Conclusion: We identified significant limitations in out-of-hours care provision following overnight discharged from ICU. Transfer to the ward before 16:00 should be facilitated where possible. Our work highlights changes to help make day time discharge more likely. Where discharge after 16:00 is unavoidable, support systems should be implemented to ensure the safety of patients discharged from ICU at night.

Background and AimsThough adequate nutrition following critical illness is fundamental to rehabilitation, it is poorly provided. To inform interventions to improve nutrition support for patients discharged from an intensive care unit (ICU), we aimed to document remediable problems in nutrition management on general hospital wards, and the context for these problems.MethodsThis work forms part of a larger mixed methods study: REcovery FoLlowing intensivE Care Treatment (REFLECT). From three NHS hospitals, chosen to represent different hospital settings, we conducted in-depth reviews of 20 cases where in-hospital death after ICU discharge was judged ‘probably avoidable’ and 20 cases where patients survived to hospital discharge. We interviewed 55 patients, family members and staff about their experiences of post-ICU ward care. From these primary data we extracted information related to nutrition provision to develop a process map of how enteral feeding is delivered to patients on hospital wards after ICU discharge.ResultsProblems with nutrition delivery were common (81 problems in 20/40 cases), mostly (70/81) in patients whose death was judged “probably avoidable”. Common issues included failure to monitor nutritional intake, delays in dietician/nutritional support referrals, removal of enteral feeding tubes before oral intake was established, and poor management of enteral nutrition delivery. Staff identified workload related to the high care needs of post-ICU patients as contributing to these problems in nutrition delivery. The process map of enteral feeding delivery demonstrated that local policy for tube placement confirmation risked prolonged system-related delays to administering naso-gastric feed, significantly affecting the volume of feed delivered to patients.ConclusionsUsing a novel mixed methods approach, we identified problems throughout the process of delivering nutritional support, which had profound consequences for post-ICU patients. We demonstrated the importance of multi-professional collaboration in delivering enteral nutrition. Improving collaborative working processes within the ward system may ensure timely confirmation of correct nasogastric tube placement, and support safe feeding. Addressing the common problems in post-ICU nutritional support we identified may support improved nutritional delivery and potentially enhance recovery from critical illness.Study registrationISRCTN:14658054

Editorial.

Aims: To explore registered nurses' experiences of patient safety in intensive care during COVID-19.Design: A qualitative interview study informed by constructivism. Method: Semi- structured interviews were conducted and audio- recorded with 19 registered nurses who worked in intensive care during COVID-19 between May and July 2021. Interviews were transcribed verbatim and thematically analysed utilizing framework. Results: Two key themes were identified. ‘On a war footing’—an unprecedented situation which describes the situation nurses faced, and the actions are taken to prepare for the safe delivery of care. ‘Doing the best we can’—Safe Delivery of Care which describes the ramifications of the actions taken on short- and long-term patient safety including organization of care, missed and suboptimal care and communication. Both themes were embedded in the landscape of Staff Well-being and Peer Support. Conclusion: Nurses reported an increase in patient safety risks which they attributed to the dilution of skill mix and fragmentation of care. Nurses demonstrated an under-standing of the holistic and long-term impacts on patient safety and recovery from critical illness. Impact: This study explored the perceived impact of COVID-19 on patient safety in intensive care from a nursing perspective. Dilution of skill mix, where specialist critical care registered nurses were diluted with registered nurses with no critical care experience, and the fragmentation of care was perceived to lead to reduced quality of care and increased adverse events and risk of harm which were not consistently formally reported. Furthermore, nurses demonstrated a holistic and long-term appreciation of patient safety. These findings should be considered as part of future nursing work-force modelling and patient safety strategies by intensive care leaders and managers. No public or patient contribution to this study. The study aims and objectives were developed in collaboration with health care professionals.

Editorial.

BackgroundDespite the exponential growth of wearable technology, previous research indicates a lack of statistically significant evidence to support the hypothesis that implementation of wearable ambulatory vital sign monitoring systems impact early patient deterioration detection and clinical outcomes. This highlights the need for large, rigorous studies to address this gap. The objective of this feasibility trial is to assess the impact of an ambulatory monitoring system (AMS) on deterioration detection and clinical outcomes in hospitalised patients, compared to standard care. As a secondary objective we will assess the feasibility of conducting a full randomised controlled trial (RCT).MethodsBetween 120 and 240 patients will be recruited and randomised equally to either an AMS or standard care group. Wearable devices will include a pulse oximeter (monitoring pulse rate and oxygen saturation), a chest patch (monitoring heart rate, respiratory rate and temperature) and a wireless blood pressure cuff (monitoring systolic and diastolic blood pressure). Both groups will wear the devices during their ward length of stay, however only data and alerts from the AMS group will be visible to clinical staff.DiscussionRecruitment of participants is expected to start in January 2022, with an anticipated completion date of December 2022. This feasibility RCT will test the early impact of our AMS implementation in a non-intensive care ward and provide data to support the design and deployment of a full RCT which will provide much-needed evidence of the impact of AMS on early deterioration detection and clinical outcomes.

Background To investigate the impact of physical activity interventions, including early mobilisation, on delirium outcomes in critically ill patients. Methods Electronic database literature searches were conducted, and studies were selected based on pre-specified eligibility criteria. Cochrane Risk of Bias-2 and Risk Of Bias In Non-randomised Studies-of Interventions quality assessment tools were utilised. Grading of Recommendations, Assessment, Development and Evaluations was used to assess levels of evidence for delirium outcomes. The study was prospectively registered on PROSPERO (CRD42020210872). Results Twelve studies were included; ten randomised controlled trials one observational case-matched study and one before-after quality improvement study. Only five of the included randomised controlled trial studies were judged to be at low risk of bias, with all others, including both non-randomised controlled trials deemed to be at high or moderate risk. The pooled relative risk for incidence was 0.85 (0.62–1.17) which was not statistically significant in favour of physical activity interventions. Narrative synthesis for effect on duration of delirium found favour towards physical activity interventions reducing delirium duration with median differences ranging from 0 to 2 days in three comparative studies. Studies comparing varying intervention intensities showed positive outcomes in favour of greater intensity. Overall levels of evidence were low quality. Conclusions Currently there is insufficient evidence to recommend physical activity as a stand-alone intervention to reduce delirium in Intensive Care Units. Physical activity intervention intensity may impact on delirium outcomes, but a lack of high-quality studies limits the current evidence base.

Purpose We performed a systematic review and meta-analysis to investigate the long-term outcomes of patients who develop new-onset atrial fibrillation (NOAF) during an intensive care unit (ICU) admission. Methods We searched the MEDLINE and EMBASE databases from 2000 to 2022. We included studies of adults based in general ICUs that evaluated long-term outcomes (at least 30 days after hospital discharge) of NOAF. We excluded studies involving patients with a history of atrial fibrillation (AF). We performed risk of bias assessment of the included studies based on a modified Newcastle Ottawa score (NOS). We extracted summary data for long-term outcomes. Where the outcome was reported in three or more studies we pooled effect sizes. Results We screened 2206 studies and included 15 studies reporting data from 561,797 patients. Pooled analysis of 4 studies using a random effects model revealed an association between NOAF acquired in an ICU and 90-day mortality (including ICU and hospital mortality) (RR 1.53, 95% CI 1.12–2.08). We also found an association between NOAF and 1-year mortality from 7 studies (RR 1.79, 95% CI 1.65–1.96), which remained when analysing 1-year mortality in hospital survivors (RR 1.72 (95% CI 1.49–1.98). Conclusions In patients who develop NOAF in an ICU, both 90-day and 1-year mortality are increased in comparison to those who do not develop NOAF. Current evidence suggests an increased risk of thromboembolic events after hospital discharge in patients who develop NOAF in an ICU.

Aims To understand current experiences of vital signs monitoring of patients and clinical staff on a surgical ward, and views on the introduction of wearable ambulatory monitoring into the general ward environment. Design Qualitative study. Methods Semi-structured interviews using topic guides were conducted with 15 patients and 15 nurses on a surgical ward between July 2018 and August 2019. The concept of ambulatory wearable devices for clinical monitoring was introduced at the end of the interview. Results Three interconnected themes were identified. Vital sign data as evidence for escalation, examined nurses' use of data to support escalation of care and the implications for patients perceived to be deteriorating who have not reached the threshold for escalation. The second theme, Trustworthiness of vital sign data, described nurses’ practice of using manual measurements to recheck or confirm automated vital signs readings when concerned. The final theme, finding a balance between continuous and intermittent monitoring, both patients and nurses agreed that although continuous monitoring may improve safety and reassurance, these needed to be balanced with multiple limitations. Factors to be considered included noise pollution, comfort, and impact on patient mobility and independence. Introduction of the concept of ambulatory wearable devices was viewed positively by both groups as offering solutions to some of the issues identified with traditional monitoring. However, most agreed that this would not be suitable for all patients and should not replace direct nurse/patient contact. Conclusion Both patients and staff identified the benefits of continuous monitoring to improve patient safety but, due to limitations, use should be carefully considered and patient-centred. Impact Feedback from nurses and patients suggests there is scope for ambulatory monitoring systems to be integrated into the hospital environment; however, both groups emphasized these should not add more noise to the ward nor replace direct nursing contact.

Background Commercially available wearable (ambulatory) pulse oximeters have been recommended as a method for managing patients at risk of physiological deterioration, such as active patients with COVID-19 disease receiving care in hospital isolation rooms; however, their reliability in usual hospital settings is not known. Objective We report the performance of wearable pulse oximeters in a simulated clinical setting when challenged by motion and low levels of arterial blood oxygen saturation (SaO2). Methods The performance of 1 wrist-worn (Wavelet) and 3 finger-worn (CheckMe O2+, AP-20, and WristOx2 3150) wearable, wireless transmission–mode pulse oximeters was evaluated. For this, 7 motion tasks were performed: at rest, sit-to-stand, tapping, rubbing, drinking, turning pages, and using a tablet. Hypoxia exposure followed, in which inspired gases were adjusted to achieve decreasing SaO2 levels at 100%, 95%, 90%, 87%, 85%, 83%, and 80%. Peripheral oxygen saturation (SpO2) estimates were compared with simultaneous SaO2 samples to calculate the root-mean-square error (RMSE). The area under the receiver operating characteristic curve was used to analyze the detection of hypoxemia (ie, SaO2 Results SpO2 estimates matching 215 SaO2 samples in both study phases, from 33 participants, were analyzed. Tapping, rubbing, turning pages, and using a tablet degraded SpO2 estimation (RMSE>4% for at least 1 device). All finger-worn pulse oximeters detected hypoxemia, with an overall sensitivity of ≥0.87 and specificity of ≥0.80, comparable to that of the Philips MX450 pulse oximeter. Conclusions The SpO2 accuracy of wearable finger-worn pulse oximeters was within that required by the International Organization for Standardization guidelines. Performance was degraded by motion, but all pulse oximeters could detect hypoxemia. Our findings support the use of wearable, wireless transmission–mode pulse oximeters to detect the onset of clinical deterioration in hospital settings. Trial Registration ISRCTN Registry 61535692; http://www.isrctn.com/ISRCTN61535692 International Registered Report Identifier (IRRID) RR2-10.1136/bmjopen-2019-034404

Background As survivorship following critical illness improves, there is greater focus on maximizing recovery. As well as physical effects, critical illness often results in cognitive impairments such as delirium, anxiety, or disorientation. In other populations, such as delirium, non-pharmacological approaches to manage these conditions are preferred, including re-orientation and ensuring personal care needs are met. Cognitive rehabilitation is also well documented for patients with neuropsychological deficits. Treatments include memory aids, compensation strategies, and functional execution. In other hospital populations, games and activities have been utilized to optimize patient engagement, stimulation, and aid recovery, but it is considered an emerging therapy in intensive care. Aims This service evaluation aimed to gather multidisciplinary team members' perceptions of the use of games based therapy (GBT) in critical care, including patient engagement and acceptability in clinical practice. Study design A UK-based single-centre qualitative service evaluation. Methods Purposive sampling was used to identify interviewees within an adult intensive care who had experience of using a recently implemented GBT intervention. Qualitative data were collected through semi-structured interviews, which were recorded and transcribed verbatim. Data were analysed using thematic analysis. Results Eight staff members across the multidisciplinary team were interviewed. One overarching theme of humanizing health care was identified, with three sub-themes of enhancing recovery, non-physical components of care, and bespoke tailoring. In addition, further recommendations for development of the service were summarized. Conclusion GBT was well received by staff in clinical practice. It was described as a supportive adjunct to traditional care and rehabilitation, enhancing staff-patient relationships. While it was recognized it may not suit all patients, GBT has the potential to enhance cognitive and physical recovery.

The challenges presented by the Coronavirus disease 2019 (COVID-19) pandemic to the National Health Service (NHS) in the United Kingdom (UK) led to a rapid adaptation of infection disease protocols in-hospital. In this paper we report on the optimisation of our wearable ambulatory monitoring system (AMS) to monitor COVID-19 patients on isolation wards. A wearable chest patch (VitalPatch®, VitalConnect, United States of America, USA) and finger-worn pulse oximeter (WristOx2® 3150, Nonin, USA) were used to estimate and transmit continuous Heart Rate (HR), Respiratory Rate (RR), and peripheral blood Oxygen Saturation (SpO2) data from ambulatory patients on these isolation wards to nurse bays remote from these patients, with a view to minimising the risk of infection for nursing staff. Our virtual High-Dependency Unit (vHDU) system used a secure web-based architecture and protocols (HTTPS and encrypted WebSockets) to transmit the vital-sign data in real time from wireless Android tablet devices, operating as patient data collection devices by the bedside in the isolation rooms, into the clinician dashboard interface available remotely via any modern web-browser. Fault-tolerant software strategies were used to reconnect the wearables automatically, avoiding the need for nurses to enter the isolation ward to re-set the patient monitoring equipment. The remote dashboard also displayed the vital-sign observations recorded by the nurses, using a separate electronic observation system, allowing them to review both sources of vital-sign data in one integrated chart. System usage was found to follow the trend of the number of local COVID-19 infections during the first wave of the pandemic in the UK (March to June 2020), with almost half of the patients on the isolation ward monitored with wearables during the peak of hospital admissions in the local area. Patients were monitored for a median of 31.5 [8.8, 75.4] hours, representing 88.1 [62.5, 94.5]% of the median time they were registered in the system. This indicates the system was being used in the isolation ward during this period. An updated version of the system has now also been used throughout the second and third waves of the pandemic in the UK.

Background "Failure to Rescue" includes failing to prevent avoidable patient deterioration and death. Despite its use, delays in care escalation still affect patient outcomes. Aims and objective The aim of this qualitative service evaluation was to map the barriers and facilitators to the escalation of care in the acute ward setting and identify those that are modifiable. Design A total of 55 hours of qualitative observations were completed to capture care escalation events. These were conducted at two hospital sites in one National Health Service trust. Methods Observations were iterative, with research team meetings being used to discuss the data and future methods. Field notes were analysed thematically by two researchers, extracting data on barriers and facilitators to escalation of care. Results Clinical nursing staff challenged the sensitivity and specificity of Early Warning Scores, describing tool failings in certain clinical scenarios. Staff did not escalate based on the alerting Early Warning Scores alone but used other clinical factors, such as bleeding, which are not necessarily captured in the scoring systems. Staff frequently did not re-escalate low-level scores. Patient and non-patient factors identified as posing barriers to escalation were complex care needs, patient outlier status, and involvement of multiple care teams. Factors negatively affecting the chain of communication during escalation were team tension, staffing levels, and inadequate handover. Conclusion This service evaluation identified barriers and facilitators to the escalation of care in the acute ward setting. Unlike other studies, we found that re-escalation or tracking of deterioration was problematic. Patients identified as being at a higher risk of escalation failure included complex patients, outliers, and patients with multiple care teams. Relevance to clinical practice This service evaluation demonstrates continuing health care communication barriers. Patient groups (complex patients and outliers) risk process failures during escalation. This can be applied in clinical practice by staff anticipating problems in these patients, documenting clear escalation pathways.

Background: Timely recognition of the deteriorating inpatient remains challenging. Ambulatory monitoring systems (AMS) may augment current monitoring practices. However, there are many challenges to implementation in the hospital environment, and evidence describing the clinical impact of AMS on deterioration detection and patient outcome remains unclear. Objective: To assess the impact of vital signs monitoring on detection of deterioration and related clinical outcomes in hospitalised patients using ambulatory monitoring systems, in comparison with standard care.Methods: A systematic search was conducted in August 2020 using MEDLINE, Embase, CINAHL, Cochrane Database of Systematic Reviews, CENTRAL and Health Technology Assessment databases, as well as grey literature. Studies comparing the use of AMS against standard care for deterioration detection and related clinical outcomes in hospitalised patients were included. Deterioration related outcomes (primary) included unplanned intensive care admissions, rapid response team or cardiac arrest activation, total and major complications rate. Other clinical outcomes (secondary) included in-hospital mortality and hospital length of stay. Exploratory outcomes included alerting system parameters and clinical trial registry information. Results: Of 8706 citations, 10 studies with different designs met the inclusion criteria, of which 7 were included in the meta-analyses. Overall study quality was moderate. The meta-analysis indicated that the AMS, when compared with standard care, was associated with a reduction in intensive care transfers (risk ratio, RR, 0.87; 95% confidence interval, CI, 0.66 to 1.15), rapid response or cardiac arrest team activation (RR, 0.84; 95% CI 0.69 to 1.01), total (RR, 0.77; 95% CI 0.44 to 1.32) and major (RR, 0.55; 95% CI 0.24 to 1.30) complications prevalence. There was also association with reduced mortality (RR, 0.48; 95% CI 0.18 to 1.29) and hospital length of stay (mean difference, MD, -0.09; 95% CI -0.43 to 0.44). However, none were statistically significant.Conclusion: This systematic review indicates that implementation of AMS may have a positive impact on early deterioration detection and associated clinical outcomes, but differing design/quality of available studies and diversity of outcomes measures limits a definite conclusion. Our narrative findings suggested that alarms should be adjusted to minimise false alerts and promote rapid clinical action in response to deterioration.PROSPERO Registration number: CRD42020188633

BACKGROUND Commercially available wearable (ambulatory) pulse oximeters have been recommended as a method for managing patients at risk of physiological deterioration, such as active patients with COVID-19 disease receiving care in hospital isolation rooms; however, their reliability in usual hospital settings is not known. OBJECTIVE We report the performance of wearable pulse oximeters in a simulated clinical setting when challenged by motion and low levels of arterial blood oxygen saturation (SaO2). METHODS The performance of 1 wrist-worn (Wavelet) and 3 finger-worn (CheckMe O2+, AP-20, and WristOx2 3150) wearable, wireless transmission–mode pulse oximeters was evaluated. For this, 7 motion tasks were performed: at rest, sit-to-stand, tapping, rubbing, drinking, turning pages, and using a tablet. Hypoxia exposure followed, in which inspired gases were adjusted to achieve decreasing SaO2 levels at 100%, 95%, 90%, 87%, 85%, 83%, and 80%. Peripheral oxygen saturation (SpO2) estimates were compared with simultaneous SaO2 samples to calculate the root-mean-square error (RMSE). The area under the receiver operating characteristic curve was used to analyze the detection of hypoxemia (ie, SaO2 RESULTS SpO2 estimates matching 215 SaO2 samples in both study phases, from 33 participants, were analyzed. Tapping, rubbing, turning pages, and using a tablet degraded SpO2 estimation (RMSE>4% for at least 1 device). All finger-worn pulse oximeters detected hypoxemia, with an overall sensitivity of ≥0.87 and specificity of ≥0.80, comparable to that of the Philips MX450 pulse oximeter. CONCLUSIONS The SpO2 accuracy of wearable finger-worn pulse oximeters was within that required by the International Organization for Standardization guidelines. Performance was degraded by motion, but all pulse oximeters could detect hypoxemia. Our findings support the use of wearable, wireless transmission–mode pulse oximeters to detect the onset of clinical deterioration in hospital settings. CLINICALTRIAL ISRCTN Registry 61535692; http://www.isrctn.com/ISRCTN61535692 INTERNATIONAL REGISTERED REPORT RR2-10.1136/bmjopen-2019-034404

BACKGROUND The standard of care in general wards includes periodic manual measurements, with the data entered into track-and-trigger charts, either on paper or electronically. Wearable devices may support health care staff, improve patient safety, and promote early deterioration detection in the interval between periodic measurements. However, regulatory standards for ambulatory cardiac monitors estimating heart rate (HR) and respiratory rate (RR) do not specify performance criteria during patient movement or clinical conditions in which the patient’s oxygen saturation varies. Therefore, further validation is required before clinical implementation and deployment of any wearable system that provides continuous vital sign measurements. OBJECTIVE The objective of this study is to determine the agreement between a chest-worn patch (VitalPatch) and a gold standard reference device for HR and RR measurements during movement and gradual desaturation (modeling a hypoxic episode) in a controlled environment. METHODS After the VitalPatch and gold standard devices (Philips MX450) were applied, participants performed different movements in seven consecutive stages: at rest, sit-to-stand, tapping, rubbing, drinking, turning pages, and using a tablet. Hypoxia was then induced, and the participants’ oxygen saturation gradually reduced to 80% in a controlled environment. The primary outcome measure was accuracy, defined as the mean absolute error (MAE) of the VitalPatch estimates when compared with HR and RR gold standards (3-lead electrocardiography and capnography, respectively). We defined these as clinically acceptable if the rates were within 5 beats per minute for HR and 3 respirations per minute (rpm) for RR. RESULTS Complete data sets were acquired for 29 participants. In the movement phase, the HR estimates were within prespecified limits for all movements. For RR, estimates were also within the acceptable range, with the exception of the sit-to-stand and turning page movements, showing an MAE of 3.05 (95% CI 2.48-3.58) rpm and 3.45 (95% CI 2.71-4.11) rpm, respectively. For the hypoxia phase, both HR and RR estimates were within limits, with an overall MAE of 0.72 (95% CI 0.66-0.78) beats per minute and 1.89 (95% CI 1.75-2.03) rpm, respectively. There were no significant differences in the accuracy of HR and RR estimations between normoxia (≥90%), mild (89.9%-85%), and severe hypoxia ( CONCLUSIONS The VitalPatch was highly accurate throughout both the movement and hypoxia phases of the study, except for RR estimation during the two types of movements. This study demonstrated that VitalPatch can be safely tested in clinical environments to support earlier detection of cardiorespiratory deterioration. CLINICALTRIAL ISRCTN Registry ISRCTN61535692; https://www.isrctn.com/ISRCTN61535692

ObjectivesLate recognition of physiological deterioration is a frequent problem in hospital wards. We assessed whether ambulatory (wearable) physiological monitoring combined with a system that continuously merges physiological variables into a single “risk” score (VSI), changed care and outcome in patients after major surgery.DesignPre- and post-interventional study.SettingA single centre tertiary referral university hospital upper-gastrointestinal service.ParticipantsPatients who underwent major upper-gastrointestinal surgery.InterventionsPhase-I (pre-intervention phase): Patients received continuous wearable monitoring and standard care, but the VSI score was not available for clinical use. Phase-II (post-intervention phase): Patients received continuous wearable monitoring. In addition to standard care the VSI score was displayed for use in clinical practice.Measurements and Main Results200 participants were monitored in phase-I. 207 participants were monitored in phase-II. Participants were monitored (median, interquartile range, IQR) for 30.2% (13.8-49.2) of available time in phase-I and 58.2% (33.1-75.2) of available time in phase-II.Clinical staff recorded observations more frequently in the 36 hours prior to a major adverse event (death, cardiac arrest or unplanned admission to intensive care) for phase-II participants (median, IQR, time between observations of 1.00, 0.50-2.08 hours) than phase-I participants (1.50, 0.75-2.50 hours, pp=0.129). 6/200 participants died before hospital discharge in phase-I, 1/207 participants died in hospital in phase-II. 20 (10.0%) patients in phase-I and 26 (12.6%) patients in phase-II had an unplanned admission to intensive care. Ward length-of-stay was unaltered (8.91, 6.71-14.02 days in phase-I, vs. 8.97, 5.99-13.85 days in phase-II, p=0.327).ConclusionThe combination of the integrated monitoring system with ambulatory monitoring in high-risk post-surgical patients improved recognition and management of deteriorating patients without increasing the observation rate in those patients who did not deteriorate.

Background Timely recognition of patient deterioration remains challenging. Ambulatory monitoring systems (AMSs) may provide support to current monitoring practices; however, they need to be thoroughly tested before implementation in the clinical environment for early detection of deterioration. Objective The objective of this study was to assess the wearability of a selection of commercially available AMSs to inform a future prospective study of ambulatory vital sign monitors in an acute hospital ward. Methods Five pulse oximeters (4 with finger probes and 1 wrist-worn only, collecting pulse rates and oxygen saturation) and 2 chest patches (collecting heart rates and respiratory rates) were selected to be part of this study: The 2 chest-worn patches were VitalPatch (VitalConnect) and Peerbridge Cor (Peerbridge); the 4 wrist-worn devices with finger probe were Nonin WristOx2 3150 (Nonin), Checkme O2+ (Viatom Technology), PC-68B, and AP-20 (both from Creative Medical); and the 1 solely wrist-worn device was Wavelet (Wavelet Health). Adult participants wore each device for up to 72 hours while performing usual “activities of daily living” and were asked to score the perceived exertion and perception of pain or discomfort by using the Borg CR-10 scale; thoughts and feelings caused by the AMS using the Comfort Rating Scale (CRS); and to provide general free text feedback. Median and IQRs were reported and nonparametric tests were used to assess differences between the devices’ CRS scores. Results Quantitative scores and feedback were collected in 70 completed questionnaires from 20 healthy volunteers, with each device tested approximately 10 times. The Wavelet seemed to be the most wearable device (P Conclusions Our results suggest that adult participants prefer to wear wrist-worn pulse oximeters without a probe compressing the fingertip and they prefer to wear a smaller chest patch. A compromise between wearability, reliability, and accuracy should be made for successful and practical integration of AMSs within the hospital environment.

ObjectiveTo investigate the short-term mortality effect of discharge from an intensive care unit (ICU) with a tracheostomy in place in comparison to delaying discharge until after tracheostomy removal.DesignA propensity score matched cohort study using data from the TracMan study.SettingSeventy-two UK ICUs taking part in the TracMan study, a randomised controlled trial comparing early tracheostomy (within 4 days of critical care admission) with deferred tracheostomy (after 10 days if still indicated).Participants622 patients who underwent a tracheostomy while in the TracMan study between November 2004 and November 2008. 144 patients left ICU with a tracheostomy. 999 days of observation from 294 patients were included in the control pool.InterventionsWe matched patients discharged with a tracheostomy in place 1:1 with patients who remained in an ICU until either their tracheostomy was removed or they died with the tracheostomy in place. Propensity models were developed according to discharge destination, accounting for likely confounding factors.Primary outcome measureThe primary outcome was 30-day mortality from the matching day. For the ‘discharged with a tracheostomy’ group, this was death within 30 days after the discharge day. For the ‘remained in ICU’ group, this was death within 30 days after the matched day.Results22 (15.3%) patients who left ICU with a tracheostomy died within 30 days compared with 26 (18.1%) who remained in ICU (relative risk 0.98, 95% CI 0.43 to 2.23).ConclusionKeeping patients on an ICU to provide tracheostomy care was not found to affect mortality. Tracheostomy presence may indicate a higher risk of mortality due to underlying diseases and conditions rather than posing a risk in itself.The TracMan trial was registered on the ISRCTN database (ISRCTN28588190).

BACKGROUND Timely recognition of patient deterioration remains challenging. Ambulatory monitoring systems (AMSs) may provide support to current monitoring practices; however, they need to be thoroughly tested before implementation in the clinical environment for early detection of deterioration. OBJECTIVE The objective of this study was to assess the wearability of a selection of commercially available AMSs to inform a future prospective study of ambulatory vital sign monitors in an acute hospital ward. METHODS Five pulse oximeters (4 with finger probes and 1 wrist-worn only, collecting pulse rates and oxygen saturation) and 2 chest patches (collecting heart rates and respiratory rates) were selected to be part of this study: The 2 chest-worn patches were VitalPatch (VitalConnect) and Peerbridge Cor (Peerbridge); the 4 wrist-worn devices with finger probe were Nonin WristOx2 3150 (Nonin), Checkme O2+ (Viatom Technology), PC-68B, and AP-20 (both from Creative Medical); and the 1 solely wrist-worn device was Wavelet (Wavelet Health). Adult participants wore each device for up to 72 hours while performing usual “activities of daily living” and were asked to score the perceived exertion and perception of pain or discomfort by using the Borg CR-10 scale; thoughts and feelings caused by the AMS using the Comfort Rating Scale (CRS); and to provide general free text feedback. Median and IQRs were reported and nonparametric tests were used to assess differences between the devices’ CRS scores. RESULTS Quantitative scores and feedback were collected in 70 completed questionnaires from 20 healthy volunteers, with each device tested approximately 10 times. The Wavelet seemed to be the most wearable device (PP=.04) with a median (IQR) score of 3.00 (1.00). General pain and discomfort scores and total percentage of time worn are also reflective of this. CONCLUSIONS Our results suggest that adult participants prefer to wear wrist-worn pulse oximeters without a probe compressing the fingertip and they prefer to wear a smaller chest patch. A compromise between wearability, reliability, and accuracy should be made for successful and practical integration of AMSs within the hospital environment.

Background Patients discharged to the ward from an intensive care unit (ICU) commonly experience a reduction in mobility but few mobility interventions. Barriers and facilitators for mobilisation on acute wards after discharge from an ICU were explored. Design and methods A human factors analysis was undertaken using the Functional Resonance Analysis Method (FRAM) as part of the Recovery Following Intensive Care Treatment (REFLECT) study. A FRAM focus group was formed from members of the ICU and ward multidisciplinary teams from two hospitals, with experience of working in six hospitals. They identified factors influencing mobilisation and the interdependency of these factors. Results Patients requiring discharge assessments or on Enhanced Recovery After Surgery (ERAS) pathways compete for priority with post-ICU patients with more urgent rehabilitation needs. Patients unable to stand and step to a chair or requiring mobilisation equipment were deemed particularly susceptible to missing mobilisation interventions. The ability to mobilise was perceived to be highly influenced by multidisciplinary staffing levels and skill mix. These factors are interdependent in facilitating or inhibiting mobilisation. Conclusions This human factors analysis of post-ICU mobilisation highlighted several influencing factors and demonstrated their interdependency. Future interventions should focus on mitigating competing priorities to ensure regular mobilisation, target patients unable to stand and step to a chair on discharge from ICU and create robust processes to ensure suitable equipment availability. Trial registration number ISRCTN14658054

IntroductionAutomated continuous ambulatory monitoring may provide an alternative to intermittent manual vital signs monitoring. This has the potential to improve frequency of measurements, timely escalation of care and patient safety. However, a major barrier to the implementation of these wearable devices in the ward environment is their uncertain reliability, efficiency and data fidelity. The purpose of this study is to test performance of selected devices in a simulated clinical setting including during movement and low levels of peripheral oxygen saturation.Methods and analysisThis is a single centre, prospective, controlled, cross-sectional, diagnostic accuracy study to determine the specificity and sensitivity of currently available ambulatory vital signs monitoring equipment in the detection of hypoxia and the effect of movement on data acquisition. We will recruit up to 45 healthy volunteers who will attend a single study visit; starting with a movement phase and followed by the hypoxia exposure phase where we will gradually decrease saturation levels down to 80%. We will simultaneously test one chest patch, one wrist worn only and three wrist worn with finger probe devices against ‘clinical standard ‘and ‘gold standard’ references. We will measure peripheral oxygen saturations, pulse rate, heart rate and respiratory rate continuously and arterial blood gases intermittently throughout the study.Ethics and disseminationThis study has received ethical approval by the East of Scotland Research Ethics Service REC 2 (19/ES/0008). The results will be broadly distributed through conference presentations and peer-reviewed publications.Trial registration numberISRCTN61535692registered on 10/06/2019.

Aims To identify the practical challenges encountered when using wearable monitors for patients discharged from the intensive care unit. Background Patients discharged from intensive care units are a high-risk group that might benefit from continuing observation using ‘wearable’ monitors to enable faster identification of physiological deterioration and facilitate timely clinical action. This area of technological innovation is of key interest to nurses who manage this group of patients. Design A prospective observational study. Methods An observational study conducted in 2013–2014 used wearable monitors to record continuous observations for patients discharged from an intensive care unit to develop a predictive model of patients likely to deteriorate. Screening data for study eligibility and case report form data to assess monitor tolerance and comfort were collected daily and analysed using Microsoft Access. Results/findings Patients (n = 2704) were discharged from an intensive care unit during the study, 208 consented to wearing the monitor. Of the 192 included in analysis, 130 (67·7%) removed the monitor before the trial finished. Reasons cited for removal included ‘discomfort and irritation’ 61 (31·8%) and ‘feeling too unwell’ 8 (4·2%). Five hundred seventeen patients were screened following adaption of the wearable monitor. Despite design changes, 56 (10·8%) patients were unable to wear monitors for reasons related to their anatomy or condition. Of 124 patients, 65 patients (52·4%) who were approached refused participation. Conclusion Work is needed to understand wireless monitor comfort and design for acutely unwell patients. Product design needs to develop further, so patients are catered for in flexibility of monitor placement and improved comfort for long-term wear.

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.

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.

IntroductionA substantial number of patients discharged from intensive care units (ICUs) subsequently die without leaving hospital. It is unclear how many of these deaths are preventable. Ward-based management following discharge from ICU is an area that patients and healthcare staff are concerned about. The primary aim of REFLECT (Recovery Following Intensive Care Treatment) is to develop an intervention plan to reduce in-hospital mortality rates in patients who have been discharged from ICU.Methods and analysisREFLECT is a multicentre mixed-methods exploratory study examining ward care delivery to adult patients discharged from ICU. The study will be made up of four substudies. Medical notes of patients who were discharged from ICU and subsequently died will be examined using a retrospective case records review (RCRR) technique. Patients and their relatives will be interviewed about their post-ICU care, including relatives of patients who died in hospital following ICU discharge. Staff involved in the care of patients post-ICU discharge will be interviewed about the care of this patient group. The medical records of patients who survived their post-ICU stay will also be reviewed using the RCRR technique. The analyses of the substudies will be both descriptive and use a modified grounded theory approach to identify emerging themes. The evidence generated in these four substudies will form the basis of the intervention development, which will take place through stakeholder and clinical expert meetings.Ethics and disseminationEthical approval has been obtained through the Wales Research and Ethics Committee 4 (17/WA/0107). We aim to disseminate the findings through international conferences, international peer-reviewed journals and social media.Trial registration numberISRCTN14658054.