Managing Complexity: Black Older Adults With Multimorbidity.

BACKGROUND AND OBJECTIVES: Black older adults have higher rates of multimorbidity and receive less effective multimorbidity support than their white counterparts. Yet little is known about the experiences of Black older adults with multimorbidity that may be at the heart of those disparities and which are central to interventions and improving care for this population. In this study, we aimed to conceptualize the multimorbidity management (MM) experience for Black older adults. RESEARCH DESIGN AND METHODS: As part of a larger study on Black older adults' multimorbidity and physician empathy, we conducted in-depth qualitative interviews with 30 Black older adults living in a large midwestern city in the United States aged 65 years and older with self-reported multimorbidity. We used grounded theory analysis to distill findings into a core conceptual category as well as component domains and dimensions. RESULTS: "Managing complexity" emerged as the core category to describe MM in our sample. Managing complexity included domains of "social context," "daily logistics," "care time," and "care roles." DISCUSSION AND IMPLICATIONS: We discuss how managing complexity is distinct from patient complexity and how it is related to cumulative inequality and precarity. Study findings have potential implications for intervention around provider education and empathy as well as for enabling agency of Black older adults with MM.

Adopting human factors in early phase and experimental medicine research: A nested pilot study observing controlled human infection with SARS-CoV-2.

AIMS: The influence of human factors on safety in healthcare settings is well established, with targeted interventions reducing risk and enhancing team performance. In experimental and early phase clinical research participant safety is paramount and safeguarded by guidelines, protocolized care and staff training; however, the real-world interaction and implementation of these risk-mitigating measures has never been subjected to formal system-based assessment. METHODS: Independent structured observations, systematic review of study documents, and interviews and focus groups were used to collate data on three key tasks undertaken in a clinical research facility (CRF) during a SARS CoV-2 controlled human infection model (CHIM) study. The Systems Engineering Initiative for Patient Safety (SEIPS) was employed to analyse and categorize findings, and develop recommendations for safety interventions. RESULTS: High levels of team functioning and a clear focus on participant safety were evident throughout the study. Despite this, latent risks in both study-specific and CRF work systems were identified in all four SEIPS domains (people, environment, tasks and tools). Fourteen actionable recommendations were generated collaboratively. These included inter-organization and inter-study standardization, optimized checklists for safety critical tasks, and use of simulation for team training and exploration of work systems. CONCLUSIONS: This pioneering application of human factors techniques to analyse work systems during the conduct of research in a CRF revealed risks unidentified by routine review and appraisal, and despite international guideline adherence. SEIPS may aid categorization of system problems and the formulation of recommendations that reduce risk and mitigate potential harm applicable across a trials portfolio.

Reporting guideline for the early-stage clinical evaluation of decision support systems driven by artificial intelligence: DECIDE-AI.

A growing number of artificial intelligence (AI)-based clinical decision support systems are showing promising performance in preclinical, in silico evaluation, but few have yet demonstrated real benefit to patient care. Early-stage clinical evaluation is important to assess an AI system's actual clinical performance at small scale, ensure its safety, evaluate the human factors surrounding its use and pave the way to further large-scale trials. However, the reporting of these early studies remains inadequate. The present statement provides a multi-stakeholder, consensus-based reporting guideline for the Developmental and Exploratory Clinical Investigations of DEcision support systems driven by Artificial Intelligence (DECIDE-AI). We conducted a two-round, modified Delphi process to collect and analyze expert opinion on the reporting of early clinical evaluation of AI systems. Experts were recruited from 20 pre-defined stakeholder categories. The final composition and wording of the guideline was determined at a virtual consensus meeting. The checklist and the Explanation & Elaboration (E&E) sections were refined based on feedback from a qualitative evaluation process. In total, 123 experts participated in the first round of Delphi, 138 in the second round, 16 in the consensus meeting and 16 in the qualitative evaluation. The DECIDE-AI reporting guideline comprises 17 AI-specific reporting items (made of 28 subitems) and ten generic reporting items, with an E&E paragraph provided for each. Through consultation and consensus with a range of stakeholders, we developed a guideline comprising key items that should be reported in early-stage clinical studies of AI-based decision support systems in healthcare. By providing an actionable checklist of minimal reporting items, the DECIDE-AI guideline will facilitate the appraisal of these studies and replicability of their findings.

Patient Harm and Institutional Avoidability of Out-of-Hours Discharge From Intensive Care: An Analysis Using Mixed Methods.

OBJECTIVES: 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 REcovery FoLlowing intensive CarE Treatment mixed methods study. We defined out-of-hours discharge as 16:00 to 07:59 hours. We undertook 20 in-depth case record reviews where in-hospital death after ICU discharge had been judged "probably avoidable" in previous retrospective structured judgment reviews, and 20 where patients survived. We conducted semistructured 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. SETTING: Three U.K. National Health Service 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 recognized or escalated appropriately. We identified five interdependent function keys to facilitating timely ICU discharge: multidisciplinary team decision for discharge, patient prepared for discharge, bed meeting, bed manager allocation of beds, and ward bed made available. CONCLUSIONS: We identified significant limitations in out-of-hours care provision following overnight discharge 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.

Systematic review of applied usability metrics within usability evaluation methods for hospital electronic healthcare record systems: Metrics and Evaluation Methods for eHealth Systems.

BACKGROUND AND OBJECTIVES: Electronic healthcare records have become central to patient care. Evaluation of new systems include a variety of usability evaluation methods or usability metrics (often referred to interchangeably as usability components or usability attributes). This study reviews the breadth of usability evaluation methods, metrics, and associated measurement techniques that have been reported to assess systems designed for hospital staff to assess inpatient clinical condition. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology, we searched Medline, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, and Open Grey from 1986 to 2019. For included studies, we recorded usability evaluation methods or usability metrics as appropriate, and any measurement techniques applied to illustrate these. We classified and described all usability evaluation methods, usability metrics, and measurement techniques. Study quality was evaluated using a modified Downs and Black checklist. RESULTS: The search identified 1336 studies. After abstract screening, 130 full texts were reviewed. In the 51 included studies 11 distinct usability evaluation methods were identified. Within these usability evaluation methods, seven usability metrics were reported. The most common metrics were ISO9241-11 and Nielsen's components. An additional "usefulness" metric was reported in almost 40% of included studies. We identified 70 measurement techniques used to evaluate systems. Overall study quality was reflected in a mean modified Downs and Black checklist score of 6.8/10 (range 1-9) 33% studies classified as "high-quality" (scoring eight or higher), 51% studies "moderate-quality" (scoring 6-7), and the remaining 16% (scoring below five) were "low-quality." CONCLUSION: There is little consistency within the field of electronic health record systems evaluation. This review highlights the variability within usability methods, metrics, and reporting. Standardized processes may improve evaluation and comparison electronic health record systems and improve their development and implementation.

Development and evaluation of an electronic hospital referral system: a human factors approach.

Coordinating care across hospitals has been identified as a patient safety risk as referrals are often paper-based and poorly documented. Electronic referral systems have the potential to improve the situation but can fail to gain uptake. We applied a human factors/ergonomics (HFE) approach to place analysis of local workflow and user engagement central to the development of a new regional electronic referral system. The intervention was evaluated with a before-and-after study. Referral quality improved, referrals containing sufficient clinical information for continuation of care increased from 36.9% to 83.5% and completeness of referral information significantly improved. There was a 35.7% reduction in the number of calls to the on-call specialist, and the mean period between admission and surgery for expedited transfers was reduced. Applying HFE informed design with use-based evidence; the system maintains sustained uptake three years after implementation. Reliable recording of information translates to better patient safety during inter-hospital transitions. Practitioners summary: This study developed, implemented and evaluated a clinical referral system using a human factors approach. Process analysis and usability studies were used to inform the application requirements and design. Region-wide implementation in hospitals resulted in the improved quality and completeness of clinical referral information and efficiencies in the referral process.

Protocol for a mixed-methods exploratory investigation of care following intensive care discharge: the REFLECT study.

INTRODUCTION: A 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 ANALYSIS: REFLECT 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 DISSEMINATION: Ethical 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 NUMBER: ISRCTN14658054.

Retrospective Attention in Short-Term Memory Has a Lasting Effect on Long-Term Memory Across Age.

OBJECTIVES: Declines in both short- and long-term memory are typical of healthy aging. Recent findings suggest that retrodictive attentional cues ("retro-cues") that indicate the location of to-be-probed items in short-term memory (STM) have a lasting impact on long-term memory (LTM) performance in young adults. Whether older adults can also use retro-cues to facilitate both STM and LTM is unknown. METHOD: Young and older adults performed a visual STM task in which spatially informative retro-cues or noninformative neutral-cues were presented during STM maintenance of real-world objects. We tested participants' memory at both STM and LTM delays for objects that were previously cued with retrodictive or neutral-cues during STM order to measure the lasting impact of retrospective attention on LTM. RESULTS: Older adults showed reduced STM and LTM capacity compared to young adults. However, they showed similar magnitude retro-cue memory benefits as young adults at both STM and LTM delays. DISCUSSION: To the best of our knowledge, this is the first study to investigate whether retro-cues in STM facilitate the encoding of objects into LTM such that they are more likely to be subsequently retrieved by older adults. Our results support the idea that retrospective attention can be an effective means by which older adults can improve their STM and LTM performance, even in the context of reduced memory capacity.

Improving emergency surgical care for patients with right iliac fossa pain at a regional scale: A quality improvement study using the Supported Champions implementation strategy.

INTRODUCTION: Methods to improve clinical systems safety suffer from significant difficulties in implementation and scaling up. We used an upscaling implementation strategy entitled Supported Champions in a quality and safety improvement programme for emergency surgery at regional level, focusing on patients with right iliac fossa pain. METHODS: A before-after study was conducted across four acute NHS Trusts: A 6 month intervention phase was preceded and followed by 3 months of data collection. An established Human Factors intervention was led at each Trust by a small group of staff selected as Champions. Champions received training in teamwork and systems improvement and were supported by Human Factors experts. The primary improvement aim was to expedite surgery for patients with sepsis, using Royal College of Surgeons emergency surgery guidelines as the measure. Additional outcomes studied included length of inpatient stay and 30-day readmission rates. RESULTS: Breaches of RCS urgency guidelines decreased markedly from 13.7% of operated patients pre-intervention to 3.5% post-intervention (p = 0.000). Mean time from booking to incision decreased in three of the four sites, whilst median length of stay increased in 3 of 4. Overall 30-day readmission rate remained stable (7.84% pre-intervention versus 7.31% post-intervention, p = 0.959). DISCUSSION: The Supported Champions model allowed all surgical teams to reduce delay for septic patients by more than 50%, using distinct Quality Improvement strategies to address local issues. Improvement was implemented in 4 diverse settings with a quarter of the level of expert input previously used in a single hospital.

Usability evaluation methods employed to assess information visualisations of electronically stored patient data for clinical use: a protocol for a systematic review.

BACKGROUND: The use of electronic records in healthcare is increasing. To avoid errors, it is essential that the data displays used by these systems are usable: efficient, effective and satisfying. A wide variety of display techniques are used to present clinical data, but the best methods to assess the usability of these techniques have not been determined. This systematic review will answer the question: What methods are employed to assess the usability of electronic visualisations of patient data for clinical use? The results of this systematic review will then be used to inform best assessment and design practice. METHODS: MEDLINE, EMBASE, CINAHL, OpenGrey, and the Cochrane Database of Systematic Reviews will be searched for original studies related to the usability of electronic information visualisations of patient data for clinical use. Reference lists of eligible studies and relevant reviews will be explored to identify further eligible studies. DISCUSSION: This systematic review will identify methods used to assess the usability of electronic information visualisations of patient data for clinical use. We will summarise the similarities and differences between the methods found. Our results will inform best practice when developing new user interfaces to display electronic patient data for clinical use. TRIAL REGISTRATION: PROSPERO CRD42016041604.

Combining Systems and Teamwork Approaches to Enhance the Effectiveness of Safety Improvement Interventions in Surgery: The Safer Delivery of Surgical Services (S3) Program.

IMPORTANCE: Patient safety improvement interventions usually address either work systems or team culture. We do not know which is more effective, or whether combining approaches is beneficial. OBJECTIVE: To compare improvement in surgical team performance after interventions addressing teamwork culture, work systems, or both. DESIGN: Suite of 5 identical controlled before-after intervention studies, with preplanned analysis of pooled data for indirect comparisons of strategies. SETTING: Operating theatres in 5 UK hospitals performing elective orthopedic, plastic, or vascular surgery PARTICIPANTS:: All operating theatres staff, including surgeons, nurses, anaesthetists, and others INTERVENTIONS:: 4-month safety improvement interventions, using teamwork training (TT), systems redesign and standardization (SOP), Lean quality improvement, SOP + TT combination, or Lean + TT combination. MAIN OUTCOMES AND MEASURES: Team technical and nontechnical performance and World Health Organization (WHO) checklist compliance, measured for 3 months before and after intervention using validated scales. Pooled data analysis of before-after change in active and control groups, comparing combined versus single and systems versus teamwork interventions, using 2-way ANOVA. RESULTS: We studied 453 operations, (255 intervention, 198 control). TT improved nontechnical skills and WHO compliance (P < 0.001), but not technical performance; systems interventions (Lean & SOP, 2 & 3) improved nontechnical skills and technical performance (P < 0.001) but improved WHO compliance less. Combined interventions (4 & 5) improved all performance measures except WHO time-out attempts, whereas single approaches (1 & 2 & 3) improved WHO compliance less (P < 0.001) and failed to improve technical performance. CONCLUSIONS & RELEVANCE: Safety interventions combining teamwork training and systems rationalization are more effective than those adopting either approach alone. This has important implications for safety improvement strategies in hospitals.

Intentional Rounding: a staff-led quality improvement intervention in the prevention of patient falls.

AIMS AND OBJECTIVES: This study designed and evaluated the use of a specific implementation strategy to deliver a nursing staff-led Intentional Rounding intervention to reduce inpatient falls. BACKGROUND: Patient falls are a common cause of harm during hospital treatment. Intentional Rounding has been proposed as a potential strategy for prevention, but has not received much objective evaluation. Previous work has suggested that logical interventions to improve patient care require an integrated implementation strategy, using teamwork training and systems improvement training, to instigate positive change and improvement. METHODS: Customised Intentional Rounding was implemented and evaluated as part of a staff-led quality improvement intervention to reduce falls on a neuroscience ward. Intentional Rounding was instigated using a prespecified implementation strategy, which comprised of: (1) engagement and communication activities, (2) teamwork and systems improvement training, (3) support and coaching and (4) iterative Plan-Do-Check-Act cycles. Process (compliance with hourly visiting to patients by staff) and outcome (incidence of falls) measures were recorded pre- and postintervention. Falls measured on the active ward were compared with incidence of falls in 50 wards across the rest of the same Trust. RESULTS: There was a 50% reduction in patient falls on the active ward vs. a minimal increase across the rest of the Trust (3·48%). Customised Intentional Rounding, designed by staff specifically for the context, appeared to be effective in reducing patient falls. CONCLUSIONS: Improvement programmes based on integrating teamwork training and staff-led systems redesign, together with a preplanned implementation strategy, can deliver effective change and improvement. RELEVANCE TO CLINICAL PRACTICE: This study demonstrates, through the implementation of a specific strategy, an effective improvement intervention to reduce patient falls. It provides insight into the effective design and practical implementation of integrated improvement programmes to reduce risk to patients at the frontline.

Lean Participative Process Improvement: Outcomes and Obstacles in Trauma Orthopaedics.

OBJECTIVES: To examine the effectiveness of a "systems" approach using Lean methodology to improve surgical care, as part of a programme of studies investigating possible synergy between improvement approaches. SETTING: A controlled before-after study using the orthopaedic trauma theatre of a UK Trust hospital as the active site and an elective orthopaedic theatre in the same Trust as control. PARTICIPANTS: All staff involved in surgical procedures in both theatres. INTERVENTIONS: A one-day "lean" training course delivered by an experienced specialist team was followed by support and assistance in developing a 6 month improvement project. Clinical staff selected the subjects for improvement and designed the improvements. OUTCOME MEASURES: We compared technical and non-technical team performance in theatre using WHO checklist compliance evaluation, "glitch count" and Oxford NOTECHS II in a sample of directly observed operations, and patient outcome (length of stay, complications and readmissions) for all patients. We collected observational data for 3 months and clinical data for 6 months before and after the intervention period. We compared changes in measures using 2-way analysis of variance. RESULTS: We studied 576 cases before and 465 after intervention, observing the operation in 38 and 41 cases respectively. We found no significant changes in team performance or patient outcome measures. The intervention theatre staff focused their efforts on improving first patient arrival time, which improved by 20 minutes after intervention. CONCLUSIONS: This version of "lean" system improvement did not improve measured safety processes or outcomes. The study highlighted an important tension between promoting staff ownership and providing direction, which needs to be managed in "lean" projects. Space and time for staff to conduct improvement activities are important for success.

Validation of the Lung Subtyping Panel in Multiple Fresh-Frozen and Formalin-Fixed, Paraffin-Embedded Lung Tumor Gene Expression Data Sets.

Context .- A histologic classification of lung cancer subtypes is essential in guiding therapeutic management. Objective .- To complement morphology-based classification of lung tumors, a previously developed lung subtyping panel (LSP) of 57 genes was tested using multiple public fresh-frozen gene-expression data sets and a prospectively collected set of formalin-fixed, paraffin-embedded lung tumor samples. Design .- The LSP gene-expression signature was evaluated in multiple lung cancer gene-expression data sets totaling 2177 patients collected from 4 platforms: Illumina RNAseq (San Diego, California), Agilent (Santa Clara, California) and Affymetrix (Santa Clara) microarrays, and quantitative reverse transcription-polymerase chain reaction. Gene centroids were calculated for each of 3 genomic-defined subtypes: adenocarcinoma, squamous cell carcinoma, and neuroendocrine, the latter of which encompassed both small cell carcinoma and carcinoid. Classification by LSP into 3 subtypes was evaluated in both fresh-frozen and formalin-fixed, paraffin-embedded tumor samples, and agreement with the original morphology-based diagnosis was determined. Results .- The LSP-based classifications demonstrated overall agreement with the original clinical diagnosis ranging from 78% (251 of 322) to 91% (492 of 538 and 869 of 951) in the fresh-frozen public data sets and 84% (65 of 77) in the formalin-fixed, paraffin-embedded data set. The LSP performance was independent of tissue-preservation method and gene-expression platform. Secondary, blinded pathology review of formalin-fixed, paraffin-embedded samples demonstrated concordance of 82% (63 of 77) with the original morphology diagnosis. Conclusions .- The LSP gene-expression signature is a reproducible and objective method for classifying lung tumors and demonstrates good concordance with morphology-based classification across multiple data sets. The LSP panel can supplement morphologic assessment of lung cancers, particularly when classification by standard methods is challenging.

The Safer Delivery of Surgical Services Program (S3): Explaining Its Differential Effectiveness and Exploring Implications for Improving Quality in Complex Systems.

OBJECTIVE: To analyze the challenges encountered during surgical quality improvement interventions, and explain the relative success of different intervention strategies. SUMMARY BACKGROUND DATA: Understanding why and how interventions work is vital for developing improvement science. The S3 Program of studies tested whether combining interventions addressing culture and system was more likely to result in improvement than either approach alone. Quantitative results supported this theory. This qualitative study investigates why this happened, what aspects of the interventions and their implementation most affected improvement, and the implications for similar programs. METHODS: Semistructured interviews were conducted with hospital staff (23) and research team members (11) involved in S3 studies. Analysis was based on the constant comparative method, with coding conducted concurrently with data collection. Themes were identified and developed in relation to the program theory behind S3. RESULTS: The superior performance of combined intervention over single intervention arms appeared related to greater awareness and ability to act, supporting the S3 hypothesis. However, we also noted unforeseen differences in implementation that seemed to amplify this difference. The greater ambition and more sophisticated approach in combined intervention arms resulted in requests for more intensive expert support, which seemed crucial in their success. The contextual challenges encountered have potential implications for the replicability and sustainability of the approach. CONCLUSIONS: Our findings support the S3 hypothesis, triangulating with quantitative results and providing an explanatory account of the causal relationship between interventions and outcomes. They also highlight the importance of implementation strategies, and of factors outside the control of program designers.

Quality Improvement in Surgery Combining Lean Improvement Methods with Teamwork Training: A Controlled Before-After Study.

BACKGROUND: To investigate the effectiveness of combining teamwork training and lean process improvement, two distinct approaches to improving surgical safety. We conducted a controlled interrupted time series study in a specialist UK Orthopaedic hospital incorporating a plastic surgery team (which received the intervention) and an Orthopaedic theatre team acting as a control. STUDY DESIGN: We used a 3 month intervention with 3 months data collection period before and after it. A combined teamwork training and lean process improvement intervention was delivered by an experienced specialist team. Before and after the intervention we evaluated team non-technical skills using NOTECHS II, technical performance using the glitch rate and WHO checklist compliance using a simple 3 point scale. We recorded complication rate, readmission rate and length of hospital stay data for 6 months before and after the intervention. RESULTS: In the active group, but not the control group, full compliance with WHO Time Out (T/O) increased from 14 to 71% (p = 0.032), Sign Out attempt rate (S/O) increased from 0% to 50% (p<0.001) and Oxford NOTECHS II scores increased after the intervention (P = 0.058). Glitch rate decreased in the active group and increased in the control group (p = 0.001). Complications and length of stay appeared to rise in the control group and fall in the active group. CONCLUSIONS: Combining teamwork training and systems improvement enhanced both technical and non-technical operating team process measures, and were associated with a trend to better safety outcome measures in a controlled study comparison. We suggest that approaches which address both system and culture dimensions of safety may prove valuable in reducing risks to patients.

SEND: a system for electronic notification and documentation of vital sign observations.

BACKGROUND: Recognising the limitations of a paper-based approach to documenting vital sign observations and responding to national clinical guidelines, we have explored the use of an electronic solution that could improve the quality and safety of patient care. We have developed a system for recording vital sign observations at the bedside, automatically calculating an Early Warning Score, and saving data such that it is accessible to all relevant clinicians within a hospital trust. We have studied current clinical practice of using paper observation charts, and attempted to streamline the process. We describe our user-focussed design process, and present the key design decisions prior to describing the system in greater detail. RESULTS: The system has been deployed in three pilot clinical areas over a period of 9 months. During this time, vital sign observations were recorded electronically using our system. Analysis of the number of observations recorded (21,316 observations) and the number of active users (111 users) confirmed that the system is being used for routine clinical observations. Feedback from clinical end-users was collected to assess user acceptance of the system. This resulted in a System Usability Scale score of 77.8, indicating high user acceptability. CONCLUSIONS: Our system has been successfully piloted, and is in the process of full implementation throughout adult inpatient clinical areas in the Oxford University Hospitals. Whilst our results demonstrate qualitative acceptance of the system, its quantitative effect on clinical care is yet to be evaluated.