Online training improves medical students' ability to recognise when a person is dying: The ORaClES randomised controlled trial.

BACKGROUND: Recognising dying is a key clinical skill for doctors, yet there is little training. AIM: To assess the effectiveness of an online training resource designed to enhance medical students' ability to recognise dying. DESIGN: Online multicentre double-blind randomised controlled trial (NCT03360812). The training resource for the intervention group was developed from a group of expert palliative care doctors' weightings of various signs/symptoms to recognise dying. The control group received no training. SETTING/PARTICIPANTS: Participants were senior UK medical students. They reviewed 92 patient summaries and provided a probability of death within 72 hours (0% certain survival - 100% certain death) pre, post, and 2 weeks after the training. Primary outcome: (1) Mean Absolute Difference (MAD) score between participants' and the experts' scores, immediately post intervention. Secondary outcomes: (2) weight attributed to each factor, (3) learning effect and (4) level of expertise (Cochran-Weiss-Shanteau (CWS)). RESULTS: Out of 168 participants, 135 completed the trial (80%); 66 received the intervention (49%). After using the training resource, the intervention group had better agreement with the experts in their survival estimates (δMAD = -3.43, 95% CI -0.11 to -0.34, p = <0.001) and weighting of clinical factors. There was no learning effect of the MAD scores at the 2-week time point (δMAD = 1.50, 95% CI -0.87 to 3.86, p = 0.21). At the 2-week time point, the intervention group was statistically more expert in their decision-making versus controls (intervention CWS = 146.04 (SD 140.21), control CWS = 110.75 (SD 104.05); p = 0.01). CONCLUSION: The online training resource proved effective in altering the decision-making of medical students to agree more with expert decision-making.

A randomised controlled trial to test the effectiveness of decision training on assessors' ability to determine optimal fitness-to-drive recommendations for older or disabled drivers.

BACKGROUND: Driving licensing jurisdictions require detailed assessments of fitness-to-drive from occupational therapy driver assessors (OTDAs). We developed decision training based on the recommendations of expert OTDAs, to enhance novices' capacity to make optimal fitness-to-drive decisions. The aim of this research was to determine effectiveness of training on novice occupational therapists' ability to make fitness-to-drive decisions. METHODS: A double blind, parallel, randomised controlled trial was conducted to test the effectiveness of decision training on novices' fitness-to-drive recommendations. Both groups made recommendations on a series of 64 case scenarios with the intervention group receiving training after reviewing two thirds of the cases; the control group, at this same point, just received a message of encouragement to continue. Participants were occupational therapy students on UK and Australian pre-registration programmes who individually took part online, following the website instructions. The main outcome of training was the reduction in mean difference between novice and expert recommendations on the cases. RESULTS: Two hundred eighty-nine novices were randomised into intervention; 166 completed the trial (70 in intervention; 96 in control). No statistical differences in scores were found pre-training. Post training, the control group showed no significant change in recommendations compared to the experts (t(96) = -.69; p = .5), whereas the intervention group exhibited a significant change (t(69) = 6.89; p < 0.001). For the intervention group, the mean difference compared with the experts' recommendations reduced with 95% CI from -.13 to .09. Effect size calculated at the post-training demonstrated a moderate effect (d = .69, r = .32). CONCLUSIONS: Novices who received the decision training were able to change their recommendations whereas those who did not receive training did not. Those receiving training became more able to identify drivers who were not fit-to-drive, as measured against experts' decisions on the same cases. This research demonstrated that novice occupational therapists can be trained to make decisions more aligned to those of expert OTDAs. The decision training and cases have been launched as a free training resource at www.fitnesstodrive.com . This can be used by novice driver assessors to increase their skill to identify drivers who are, and are not fit-to-drive, potentially increasing international workforce capacity in this growing field of practice.

Integrated Telehealth and Telecare for Monitoring Frail Elderly with Chronic Disease.

Objective: To investigate the potential of an integrated care system that acquires vital clinical signs and habits data to support independent living for elderly people with chronic disease. Materials and Methods: We developed an IEEE 11073 standards-based telemonitoring platform for monitoring vital signs and activity data of elderly living alone in their home. The platform has important features for monitoring the elderly: unobtrusive, simple, elderly-friendly, plug and play interoperable, and self-integration of sensors. Thirty-six (36) patients in a primary care practice in the United Kingdom (mean [standard deviation] age, 82 [10] years) with congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD) were provided with clinical sensors to measure the vital signs for their disease (blood pressure [BP] and weight for CHF, and oxygen saturation for COPD) and one passive infrared (PIR) motion sensor and/or a chair/bed sensor were installed in a patient's home to obtain their activity data. The patients were asked to take one measurement each day of their vital signs in the morning before breakfast. All data were automatically transmitted wirelessly to the remote server and displayed on a clinical portal for clinicians to monitor each patient. An alert algorithm detected outliers in the data and indicated alerts on the portal. Patient data have been analyzed retrospectively following hospital admission, emergency room visit or death, to determine whether the data could predict the event. Results: Data of patients who were monitored for a long period and had interventions were analyzed to identify useful parameters and develop algorithms to define alert rules. Twenty of the 36 participants had a clinical referral during the time of monitoring; 16 of them received some type of intervention. The most common reason for intervention was due to low oxygen levels for patients with COPD and high BP levels for CHF. Activity data were found to contain information on the well-being of patients, in particular for those with COPD. During exacerbation the activity level from PIR sensors increased slightly, and there was a decrease in bed occupancy. One subject with CHF who felt unwell spent most of the day in the bedroom. Conclusions: Our results suggest that integrated care monitoring technologies have a potential for providing improved care and can have positive impact on well-being of the elderly by enabling timely intervention. Long-term BP and pulse oximetry data could indicate exacerbation and lead to effective intervention; physical activity data provided important information on the well-being of patients. However, there remains a need for better understanding of long-term variations in vital signs and activity data to establish intervention protocols for improved disease management.

Designing effective visualizations of habits data to aid clinical decision making.

BACKGROUND: Changes in daily habits can provide important information regarding the overall health status of an individual. This research aimed to determine how meaningful information may be extracted from limited sensor data and transformed to provide clear visualization for the clinicians who must use and interact with the data and make judgments on the condition of patients. We ascertained that a number of insightful features related to habits and physical condition could be determined from usage and motion sensor data. METHODS: Our approach to the design of the visualization follows User Centered Design, specifically, defining requirements, designing corresponding visualizations and finally evaluating results. This cycle was iterated three times. RESULTS: The User Centered Design method was successfully employed to converge to a design that met the main objective of this study. The resulting visualizations of relevant features that were extracted from the sensor data were considered highly effective and intuitive to the clinicians and were considered suitable for monitoring the behavior patterns of patients. CONCLUSIONS: We observed important differences in the approach and attitude of the researchers and clinicians. Whereas the researchers would prefer to have as many features and information as possible in each visualization, the clinicians would prefer clarity and simplicity, often each visualization having only a single feature, with several visualizations per page. In addition, concepts considered intuitive to the researchers were not always to the clinicians.

Monitoring activities of daily living of the elderly and the potential for its use in telecare and telehealth: a review.

OBJECTIVE: This review was designed to determine whether telemonitoring activities of daily living (ADL) of elderly people can improve quality of life and be beneficial to their healthcare. MATERIALS AND METHODS: Electronic databases were searched for studies that monitored ADL of elderly people and preferably measured some clinical outcomes such as ability to predict key events that require intervention and for studies that assessed perception of elderly people of such telemonitoring systems. The articles were reviewed and assessed independently by two reviewers. RESULTS: One hundred seventy-five unique studies were found. Sixty-seven of these were identified for potential inclusion, and 25 studies were finally included. Study characteristics, parameters monitored, outcomes, and problems encountered were summarized and discussed. The main focus was on the potential benefits of ADL monitoring on the care of elderly people. CONCLUSIONS: Although most studies reported on technical improvements in methods for detecting changes in ADL, few, if any, determined the benefits to the patient of telemonitoring for changes in ADL or correlation with any physiological changes. We propose sensor and system characteristics for improved user acceptance and deployment in a large-scale care plan. We present areas requiring further investigation.

Protocol for the ORaClES study: an online randomised controlled trial to improve clinical estimates of survival using a training resource for medical students.

INTRODUCTION: Clinicians often struggle to recognise when palliative care patients are imminently dying (last 72 hours of life). A previous study identified the factors that expert palliative care doctors (with demonstrated prognostic skills) had used, to form a judgement about which patients were imminently dying. This protocol describes a study to evaluate whether an online training resource showing how experts weighted the importance of various symptoms and signs can teach medical students to formulate survival estimates for palliative care patients that are more similar to the experts' estimates. METHODS AND ANALYSIS: This online double-blind randomised controlled trial will recruit at least 128 students in the penultimate or final year of medical school in the UK. Participants are asked to review three series of vignettes describing patients referred to palliative care and provide an estimate about the probability (0%-100%) that each patient will die within 72 hours. After the first series, students randomised to the intervention arm are given access to an online training resource. All participants are asked to complete a second series of vignettes. After 2 weeks, all participants are asked to complete a third series. The primary outcome will be the probability of death estimates (0%-100%) provided by students in the intervention and control arms for the second series of vignettes. Secondary outcomes include the maintenance effect at 2-week follow-up, weighting of individual symptoms and signs, and level of expertise (discrimination and consistency). ETHICS AND DISSEMINATION: Approval has been obtained from the UCL Research Ethics Committee (8675/002) and local approvals will be obtained as appropriate. Results will be published in peer-reviewed journals using an open access format and presented at academic conferences. We will also publicise our findings on the Marie Curie website. TRIAL REGISTRATION NUMBER: NCT03360812; Pre-results.

Interoperable End-to-End Remote Patient Monitoring Platform Based on IEEE 11073 PHD and ZigBee Health Care Profile.

This paper describes the implementation of an end-to-end remote monitoring platform based on the IEEE 11073 standards for personal health devices (PHD). It provides an overview of the concepts and approaches and describes how the standard has been optimized for small devices with limited resources of processor, memory, and power that use short-range wireless technology. It explains aspects of IEEE 11073, including the domain information model, state model, and nomenclature, and how these support its plug-and-play architecture. It shows how these aspects underpin a much larger ecosystem of interoperable devices and systems that include IHE PCD-01, HL7, and BlueTooth LE medical devices, and the relationship to the Continua Guidelines, advocating the adoption of data standards and nomenclature to support semantic interoperability between health and ambient assisted living in future platforms. The paper further describes the adaptions that have been made in order to implement the standard on the ZigBee Health Care Profile and the experiences of implementing an end-to-end platform that has been deployed to frail elderly patients with chronic disease(s) and patients with diabetes.

Enhanced referral prioritisation for acute adult dietetic services: A randomised control trial to test a web-based decision training tool.

BACKGROUND & AIMS: Dietitians in acute adult services need to prioritise dietetic referrals in order to manage their daily workload and ensure effective treatment of patients. Newly qualified dietitians do not usually receive specific training on prioritisation and could be helped with an evidence-based, effective, decision-training tool that is based on the practice of experienced dietitians. We developed an internationally available web-based decision-training tool designed to improve novice dietitians' ability to make dietetic prioritisation decisions. The training tool comprised of a pre-training task, a post-training task and training materials. The aim of this study was to test the effectiveness of the training tool on novices' ability for dietetic prioritisation. METHODS: Pre-registration dietitians and recent graduates (one-year) from across the UK were invited to participate in this randomised controlled trial (RCT). Each participant made prioritisation decisions on a set of dietetic referral scenarios: 53 scenarios at pre-training and 27 at post-training. After pre-training the intervention group was presented with the training materials, whereas the control group was told to carry on with the post-training task. Participants did not know which group they had been randomly allocated to. We calculated i) level of agreement between decisions made by each novice and experts' consensus using Pearson correlation, intra-class correlation (ICC(2,1)); ii) intra-rater consistency using ICC(1,1) and iii) intra-group consistency using ICC (2,1). We compared group means at pre-training and post-training; estimated effect size using the degree of change from pre- to post-training, and 2-factor mixed ANOVA to assess overall effect of the training across the groups and time-points. RESULTS: 151 participants (69 in control and 82 in intervention) completed the trial. The groups did not differ in demographic characteristics. Both Pearson and ICC(2,1) correlations increased with training intervention; a moderate effect of training was found for both metrics, d = 0.69 (r = 0.32) for the former and d = 0.54 (r = 0.26) for the latter. Intra-rater consistency improved with training but with a small effect size, d = 0.32 (r = 0.16). The intra-group consistency also improved with training: ICC = 0.48 pre-training to 0.61 post-training. CONCLUSIONS: The training tool was found to be effective in improving the novice dietitian's ability to prioritise referrals in the acute adult setting. The training tool is freely available at www.dietitianreferral.org for use by all student or early career dietitians internationally.

Effects of an acute bout of dynamic stretching on biomechanical properties of the gastrocnemius muscle determined by shear wave elastography.

AIMS: The aim of this study was to examine the acute effects of dynamic stretching (DS) exercise on passive ankle range of motion (RoM), resting localized muscle stiffness, as measured by shear wave speed (SWS) of medial gastrocnemius muscle, fascicle strain, and thickness. METHODS/RESULTS: Twenty-three participants performed a DS protocol. Before and after stretching, SWS was measured in the belly of the resting medial gastrocnemius muscle (MGM) using shear wave elastography. DS produced small improvements in maximum dorsiflexion (+1.5° ±1.5; mean difference ±90% confidence limits) and maximum plantarflexion (+2.3° ±1.8), a small decrease in fascicle strain (-2.6% ±4.4) and a small increase in SWS at neutral resting angle (+11.4% ±1.5). There was also a small increase in muscle thickness (+4.1mm ±2.0). CONCLUSIONS: Through the use of elastography, this is the first study to suggest that DS increases muscle stiffness, decreases fascicle strain and increases muscle thickness as a result of improved RoM. These results can be beneficial to coaches, exercise and clinical scientists when choosing DS as a muscle conditioning or rehabilitation intervention.

Dynamic Threshold Analysis of Daily Oxygen Saturation for Improved Management of COPD Patients.

This study presents a novel dynamic threshold algorithm that is applied to daily self-measured SpO2 data for management of chronic obstructive pulmonary disease (COPD) patients in remote patient monitoring to improve accuracy of detection of exacerbation. Conventional approaches based on a fixed threshold applied to a single SpO 2 reading to detect deterioration in patient condition are known to have poor accuracy and result in high false alarm rates. This study develops and evaluates use of a dynamic threshold algorithm to reduce false alarm rates. Daily data from four COPD patients with a record of clinical interventions during the period were selected for analysis. We model the SpO2 time-series data as a combination of a trend and a stochastic component (residual). We estimate the long-term trend using a locally weighed least-squares (low-pass) filter over a long-term processing window. Results show that the time evolution of the long-term trend indicated exacerbation with improved accuracy compared to a fixed threshold in our study population. Deterioration in the condition of a patient also resulted in an increase in the standard deviation of the residual (σres ), from 2% or less when the patient is in a healthy condition to 4% or more when condition deteriorates. Statistical analysis of the residuals showed they had a normal distribution when the condition of the patient was stable but had a long tail on the lower side during deterioration.

Analysis of daily oxygen saturation for detecting deterioration in the condition of COPD patients.

This study presents a novel threshold algorithm that is applied to daily self-measured SpO(2) data for management of COPD patients in remote patient monitoring to improve accuracy of detection of exacerbation. Conventional approaches based on a fixed threshold applied to a single SpO(2) reading result in high false alarm rates. We model the SpO(2) time series data as a combination of a trend and a stochastic component (residual) and use the standard deviation of residuals to identify exacerbations. Deterioration in the condition of a patient results in an increase in the standard deviation of the residual (σ(res)), from 2% or less when the patient is in a healthy condition to 4% or more when the condition deteriorates. We present results from retrospective analysis of SpO(2) data measured in patients with COPD as part of a long term project to monitor frail elderly, and compare results from the new approach with those from the conventional approach.