How to co-design a prototype of a clinical practice tool: a framework with practical guidance and a case study.

Clinical tools for use in practice-such as medicine reconciliation charts, diagnosis support tools and track-and-trigger charts-are endemic in healthcare, but relatively little attention is given to how to optimise their design. User-centred design approaches and co-design principles offer potential for improving usability and acceptability of clinical tools, but limited practical guidance is currently available. We propose a framework (FRamework for co-dESign of Clinical practice tOols or 'FRESCO') offering practical guidance based on user-centred methods and co-design principles, organised in five steps: (1) establish a multidisciplinary advisory group; (2) develop initial drafts of the prototype; (3) conduct think-aloud usability evaluations; (4) test in clinical simulations; (5) generate a final prototype informed by workshops. We applied the framework in a case study to support co-design of a prototype track-and-trigger chart for detecting and responding to possible fetal deterioration during labour. This started with establishing an advisory group of 22 members with varied expertise. Two initial draft prototypes were developed-one based on a version produced by national bodies, and the other with similar content but designed using human factors principles. Think-aloud usability evaluations of these prototypes were conducted with 15 professionals, and the findings used to inform co-design of an improved draft prototype. This was tested with 52 maternity professionals from five maternity units through clinical simulations. Analysis of these simulations and six workshops were used to co-design the final prototype to the point of readiness for large-scale testing. By codifying existing methods and principles into a single framework, FRESCO supported mobilisation of the expertise and ingenuity of diverse stakeholders to co-design a prototype track-and-trigger chart in an area of pressing service need. Subject to further evaluation, the framework has potential for application beyond the area of clinical practice in which it was applied.

The effects of decreased body temperature on the onset, duration and action of medetomidine and its antagonist atipamezole in juvenile farmed estuarine crocodiles (Crocodylus porosus).

OBJECTIVE: To determine the efficacy of medetomidine for immobilisation of captive juvenile crocodiles over a range of temperatures, and its reversibility with atipamezole. STUDY DESIGN: Prospective experimental study. ANIMALS: Forty male estuarine crocodiles (body weight 2.0 to 4.8 kg). METHODS: Each crocodile was randomly assigned to one of four temperature groups: Group 1:32 °C; Group 2:27 °C; Group 3:22 °C; and Group 4:17 °C (n = 10 for each group). Medetomidine (0.5 mg kg(-1) ) was administered intramuscularly (IM) into the thoracic limb of all crocodiles. After 50 minutes, all animals from each group received 2.5 mg kg(-1) atipamezole IM in the opposite thoracic limb and time to recovery was documented. Heart and respiratory rates and the degree of immobilisation were monitored every 5 minutes until recovery, and behaviour monitored for 7 subsequent days. RESULTS: Onset of immobilisation occurred at 15 ± 10 minutes in Group 1, and at 30 ± 10 minutes in Groups 2 and 3. In Group 4, animals were not immobilised. Recovery following atipamezole was 10 ± 5 minutes at all temperatures. One-way analysis of variance (anova) demonstrated a significant difference in induction times between groups (p < 0.01) but not in recovery times following atipamezole administration (p < 0.25). Heart and respiratory rates decreased markedly following medetomidine administration and increased markedly following atipamezole reversal. CONCLUSIONS AND CLINICAL RELEVANCE: Medetomidine administered in the thoracic limb of juvenile captive estuarine crocodiles provides profound sedation or immobilisation at temperatures of 22 °C and above. Atipamezole administered in the contralateral thoracic limb results in consistent reversal of the effects of medetomidine and a return to normal behaviour within 15-20 minutes regardless of temperature. Even though immobilisation is not induced at 17 °C, profound reversible sedation does occur reliably and repeatably.

Preliminary studies of alfaxalone for intravenous immobilization of juvenile captive estuarine crocodiles (Crocodylus porosus) and Australian freshwater crocodiles (Crocodylus johnstoni) at optimal and selected sub-optimal thermal zones.

OBJECTIVES: To investigate the character of immobilization given by alfaxalone in juvenile crocodiles at optimal and at suboptimal temperatures. STUDY DESIGN: Prospective, randomized partial crossover study. ANIMALS: Twenty captive male estuarine (weight 0.6-2.5 kg) and five captive male freshwater crocodiles (weight 0.2-0.6 kg). METHODS: Crocodiles were acclimatized for 24 hours at one of the following environmental temperatures; 32 °C, 27 °C, 22 °C or 17 °C, then received 3 mg kg(-1) intravenous (IV) alfaxalone into the dorsal occipital venous sinus. Duration and quality of immobilization was assessed and heart rate (HR) measured. On a separate occasion each crocodile was immobilized at one other environmental temperature. RESULTS: Alfaxalone, 3 mg kg(-1) IV, produced immobilization for 55 (range 15-100 minutes in estuarine, and 20 (range 20-25) minutes in freshwater crocodiles at 32 °C. There was no significant difference overall in immobilization times between temperatures, other than that, in estuarine crocodiles, duration was shorter at 32 °C than 22 °C. The character of immobilization was unpredictable, with animals recovering without warning, or having extended recoveries requiring assisted ventilation. Assisted ventilation was necessary mainly at the lower temperatures. Median HR in all temperature treatments decreased within 5 minutes post-injection, but the change in HR over the duration of immobilization was affected by the temperature, with a progressively smaller range of fall as temperature decreased. At 17 °C, two estuarine crocodiles appeared to re-immobilize after initial recovery, became severely bradycardiac and required ventilation and re-warming. CONCLUSIONS AND CLINICAL RELEVANCE: Alfaxalone IV in small captive estuarine and freshwater crocodiles provides adequate induction of immobilization at various temperatures. However, the unpredictable results following induction mean it is unsuitable for field use and should be restricted to environments where intubation and ventilation are available, where animals can be warmed to optimal temperature, and where access to immersion in water can be restricted for 24 hours.

Training for managing impacted fetal head at caesarean birth: multimethod evaluation of a pilot.

BACKGROUND: Implementation of national multiprofessional training for managing the obstetric emergency of impacted fetal head (IFH) at caesarean birth has potential to improve quality and safety in maternity care, but is currently lacking in the UK. OBJECTIVES: To evaluate a training package for managing IFH at caesarean birth with multiprofessional maternity teams. METHODS: The training included an evidence-based lecture supported by an animated video showing management of IFH, followed by hands-on workshops and real-time simulations with use of a birth simulation trainer, augmented reality and management algorithms. Guided by the Kirkpatrick framework, we conducted a multimethod evaluation of the training with multiprofessional maternity teams. Participants rated post-training statements about relevance and helpfulness of the training and pre-training and post-training confidence in their knowledge and skills relating to IFH (7-point Likert scales, strongly disagree to strongly agree). An ethnographer recorded sociotechnical observations during the training. Participants provided feedback in post-training focus groups. RESULTS: Participants (N=57) included 21 midwives, 25 obstetricians, 7 anaesthetists and 4 other professionals from five maternity units. Over 95% of participants agreed that the training was relevant and helpful for their clinical practice and improving outcomes following IFH. Confidence in technical and non-technical skills relating to managing IFH was variable before the training (5%-92% agreement with the pre-training statements), but improved in nearly all participants after the training (71%-100% agreement with the post-training statements). Participants and ethnographers reported that the training helped to: (i) better understand the complexity of IFH, (ii) recognise the need for multiprofessional training and management and (iii) optimise communication with those in labour and their birth partners. CONCLUSIONS: The evaluated training package can improve self-reported knowledge, skills and confidence of multiprofessional teams involved in management of IFH at caesarean birth. A larger-scale evaluation is required to validate these findings and establish how best to scale and implement the training.

Preliminary studies of chemical immobilization of captive juvenile estuarine (Crocodylus porosus) and Australian freshwater (C. johnstoni) crocodiles with medetomidine and reversal with atipamezole.

OBJECTIVE: To establish a safe, reliable and reversible immobilization protocol for captive juvenile crocodiles. STUDY DESIGN: Prospective, randomized, clinical study. ANIMALS: Thirty male estuarine crocodiles (body mass 1-12.1 kg) and 10 male Australian freshwater crocodiles (body mass 4.1-12.8 kg). METHODS: An optimized dose of medetomidine (0.5 mg kg(-1)) was administered intramuscularly (IM) into the tail (Group 1; n = 5), pelvic limb (Group 2; n = 5) and thoracic limb (Groups 3 and 4; n = 5 in each group) of estuarine crocodiles weighing 3-12.1 kg. Their heart and respiratory rates and degree of immobilization were monitored every 15 minutes until recovery and daily thereafter for 3 subsequent days. In Group 4 (n = 5), medetomidine was antagonized with an optimized dose of atipamezole (2.5 mg kg(-1)) given IM into the thoracic limb and time to recovery recorded. The effects of increasing doses of medetomidine given IM in the thoracic limb (n = 4) and intravenously (n = 6) were determined in 1-2 kg estuarine crocodiles. Australian freshwater crocodiles (4.1-12.8 kg) were administered medetomidine IM into the thoracic limb in divided doses at 0.5 mg kg(-1) (n = 5) and 0.75 mg kg(-1) (n = 5) and similarly monitored. RESULTS: Immobilization was achieved only in the estuarine crocodiles >3 kg and when medetomidine was administered into the thoracic limb. Immobilization was achieved within 30 minutes and the duration of immobilization lasted approximately 90 minutes. Immobilization in estuarine crocodiles was readily reversed with atipamezole. A dose of 0.75 g kg(-1) was required to immobilize Australian freshwater crocodiles and the onset of immobilization was longer and the duration shorter than seen in the estuarine crocodiles. The heart and respiratory rates of all immobilized animals decreased significantly and arterial blood pressure became undetectable in the animals in which it was measured. CONCLUSIONS AND CLINICAL RELEVANCE: Medetomidine administered in the thoracic limb of captive estuarine and Australian freshwater crocodiles, ranging from 3 to 12.8 kg, provides a predictable onset and duration of immobilization sufficient for physical examination, sample collection, short minor procedures and translocation of the animals. Atipamezole administered in the thoracic limb results in complete reversal of the effects of medetomidine in the estuarine crocodile and a rapid return to normal behaviour.

Comparison of biochemical stress indicators in juvenile captive estuarine crocodiles (Crocodylus porosus) following physical restraint or chemical restraint by midazolam injection.

Using a prospective, randomized study design we demonstrate that midazolam sedation minimizes acidosis compared with physical restraint in captive juvenile estuarine crocodiles during handling or noninvasive procedures at preferred body temperature. A dose of midazolam (5.0 mg/kg) was administered intramuscularly into the forelimb of 20 male estuarine crocodiles weighing 2-3.5 kg. Their heart and respiratory rate and degree of sedation were monitored until recovery and then daily for 7 subsequent days. Blood samples were taken at 30, 60, 90, 180, and 360 min. We recorded lactate, partial pressure of carbon dioxide (CO2), hematocrit, glucose, and blood pH. A second group (1.9-2.6 kg) was physically restrained for 5 min and the same parameters recorded. Physically restrained animals demonstrated elevated heart rate, respiratory rate, glucose, lactate, and anion gap compared with the midazolam-treated group. Physically restrained animals had lower pH, bicarbonate, and partial pressure of CO2 compared with the midazolam-treated group. Behavior in the physically restrained group in the days following the study was disrupted, with reluctance to feed and bask, compared with midazolam-treated animals whose behavior was normal. We conclude that midazolam administered in the forelimb of captive estuarine crocodiles of 2-3.5 kg provides predictable onset and duration of sedation enabling physical examination, sample collection, and translocation of the animals with minimal disturbance to lactate, pH, and CO2. Behavior following recovery appears normal.