Effect of a Continuous Bedside Pressure Mapping System for Reducing Interface Pressures: A Randomized Clinical Trial.

Importance: Continuous bedside pressure mapping (CBPM) technology can assist in detecting skin areas with excessive interface pressure and inform efficient patient repositioning to prevent the development of pressure injuries (PI). Objective: To evaluate the efficacy of CBPM technology in reducing interface pressure and the incidence of PIs. Design, Setting, and Participants: This parallel, 2-group randomized clinical trial was performed at a tertiary acute care center. The study started to enroll participants in December 2014 and was completed in May 2018. Participants included adults partially or completely dependent for bed mobility. Statistical analysis was performed from September 2018 to December 2022. Intervention: Nursing staff using visual feedback from CBPM technology for 72 hours. Main Outcomes and Measures: Absolute number of sensing points with pressure readings greater than 40 mm Hg, mean interface pressure across all sensing points under a patient's body, proportion of participants who had pressure readings greater than 40 mm Hg, and pressure-related skin and soft tissue changes. Results: There were 678 patients recruited. After attrition, 260 allocated to the control group (151 [58.1%] male; mean [SD] age, 61.9 [18.5] years) and 247 in the intervention group (147 [59.5%] male; mean [SD] age, 63.6 [18.1] years) were included in analyses. The absolute number of sensing points with pressures greater than 40 mm Hg were 11 033 in the control group vs 9314 in the intervention group (P = .16). The mean (SD) interface pressure was 6.80 (1.63) mm Hg in the control group vs 6.62 (1.51) mm Hg in the intervention group (P = .18). The proportion of participants who had pressure readings greater than 40 mm Hg was 99.6% in both the control and intervention groups. Conclusions and Relevance: In this randomized clinical trial to evaluate the efficacy of CBPM technology in the reduction of interface pressure and the incidence of PIs in a tertiary acute care center, no statistically significant benefit was seen for any of the primary outcomes. These results suggest that longer duration of monitoring and adequately powered studies where CBPM feedback is integrated into a multifaceted intervention to prevent PI are needed. Trial Registration: ClinicalTrials.gov Identifier: NCT02325388.

Exploring data reduction strategies in the analysis of continuous pressure imaging technology.

BACKGROUND: Science is becoming increasingly data intensive as digital innovations bring new capacity for continuous data generation and storage. This progress also brings challenges, as many scientific initiatives are challenged by the shear volumes of data produced. Here we present a case study of a data intensive randomized clinical trial assessing the utility of continuous pressure imaging (CPI) for reducing pressure injuries. OBJECTIVE: To explore an approach to reducing the amount of CPI data required for analyses to a manageable size without loss of critical information using a nested subset of pressure data. METHODS: Data from four enrolled study participants excluded from the analytical phase of the study were used to develop an approach to data reduction. A two-step data strategy was used. First, raw data were sampled at different frequencies (5, 30, 60, 120, and 240 s) to identify optimal measurement frequency. Second, similarity between adjacent frames was evaluated using correlation coefficients to identify position changes of enrolled study participants. Data strategy performance was evaluated through visual inspection using heat maps and time series plots. RESULTS: A sampling frequency of every 60 s provided reasonable representation of changes in interface pressure over time. This approach translated to using only 1.7% of the collected data in analyses. In the second step it was found that 160 frames within 24 h represented the pressure states of study participants. In total, only 480 frames from the 72 h of collected data would be needed for analyses without loss of information. Only ~ 0.2% of the raw data collected would be required for assessment of the primary trial outcome. CONCLUSIONS: Data reduction is an important component of big data analytics. Our two-step strategy markedly reduced the amount of data required for analyses without loss of information. This data reduction strategy, if validated, could be used in other CPI and other settings where large amounts of both temporal and spatial data must be analysed.

Healthcare provider and patient/family perceptions of continuous pressure imaging technology for prevention of pressure injuries: A secondary analysis of patients enrolled in a randomized control trial.

INTRODUCTION: Despite the availability of various pressure injury (PI) prevention strategies (e.g., risk identification, use of pressure re-distribution surfaces, frequent repositioning), they persist as a significant issue for healthcare systems worldwide. Continuous pressure imaging (CPI) is a novel technology that could be integrated within a comprehensive approach to the prevention of PIs. We studied the perceptions of healthcare providers and patients/families to identify facilitators and barriers to the use of this technology. METHODS: Hospitalized patients/family members from a randomized controlled trial assessing the efficacy of CPI in preventing PIs completed a survey after 72 hours (or upon discharge from hospital) of CPI monitoring. They were asked questions about prior and current experience with CPI technology. For healthcare providers, perceptions on the use of the device and its impact on care were explored through a survey distributed by email or hard copies. RESULTS: A total of 125 healthcare providers and 525 patients/family members completed the surveys. Of the healthcare providers, 95% either agreed/strongly agreed that the CPI technology was easy to use and 65% stated that the device improved how they provided pressure relief for patients. Identified issues with the device were cost, the fitting of the mattress cover, and the fixation of the patients/families on the device. Over a quarter of the patient/family respondents agreed/strongly agreed that the device influenced how pressure relief was provided. This response was statistically associated with whether the monitor was turned on (intervention arm; 52.7%) or off (control arm; 4.2%). DISCUSSION AND CONCLUSION: CPI technology was positively perceived by healthcare providers. Most patients/families felt it influenced care when the CPI monitor was turned on. Concerns raised around cost and the ease of use of these devices by healthcare providers may affect the decisions of healthcare system administrators to adopt and implement this technology.

The use of drones for the delivery of diagnostic test kits and medical supplies to remote First Nations communities during Covid-19.

BACKGROUND: Health care inequity in remote and rural Indigenous communities often involves difficulty accessing health care services and supplies. Remotely Piloted Aircraft Systems, or drones, offer a potentially cost-effective method for reducing inequity by removing geographic barriers, increasing timeliness, and improving accessibility of supplies, equipment, and remote care. METHODS: We assessed the feasibility of drones for delivery of supplies, medical equipment, and medical treatment across multiple platforms, including drone fleet development and testing; payload system integration (custom fixed-mount, winch, and parachute); and medical delivery simulations (COVID-19 test kit delivery and return, delivery of personal protective equipment, and remote ultrasound delivery and testing). RESULTS: Drone operational development has led to a finalized, scalable fleet of small to large drones with functional standard operating procedures across a range of scenarios, and custom payload systems including a fixed-mount, winch-based and parachute-based system. Simulation scenarios were successful, with COVID-19 test swabs returned to the lab with no signal degradation and a remote ultrasound successfully delivered and remotely guided in the field. DISCUSSION/CONCLUSIONS: Drone-based medical delivery models offer an innovative approach to addressing longstanding issues of health care access and equity and are particularly relevant in the context of SARS-CoV-2.

Pioneering Remotely Piloted Aerial Systems (Drone) Delivery of a Remotely Telementored Ultrasound Capability for Self Diagnosis and Assessment of Vulnerable Populations-the Sky Is the Limit.

Remotely Piloted Aerial Systems (RPAS) are poised to revolutionize healthcare in out-of-hospital settings, either from necessity or practicality, especially for remote locations. RPAS have been successfully used for surveillance, search and rescue, delivery, and equipping drones with telemedical capabilities being considered. However, we know of no previous consideration of RPAS-delivered tele-ultrasound capabilities. Of all imaging technologies, ultrasound is the most portable and capable of providing real-time point-of-care information regarding anatomy, physiology, and procedural guidance. Moreover, remotely guided ultrasound including self-performed has been a backbone of medical care on the International Space Station since construction. The TeleMentored Ultrasound Supported Medical Interventions Group of the University of Calgary partnered with the Southern Alberta Institute of Technology to demonstrate RPAS delivery of a smartphone-supported tele-ultrasound system by the SwissDrones SDO50 RPAS. Upon receipt of the sanitized probe, a completely ultrasound-naïve volunteer was guided by a remote expert located 100 km away using online video conferencing (Zoom), to conduct a self-performed lung ultrasound examination. It proved feasible for the volunteer to examine their anterior chest, sides, and lower back bilaterally, correlating with standard recommended examinations in trauma/critical care, including the critical locations of a detailed COVID-19 lung diagnosis/surveillance examination. We contend that drone-delivered telemedicine including a tele-ultrasound capability could be leveraged to enhance point-of-care diagnostic accuracy in catastrophic emergencies, and allow diagnostic capabilities to be delivered to vulnerable populations in remote locations for whom transport is impractical or undesirable, speeding response times, or obviating the risk of disease transmission depending on the circumstances.

Development and initial implementation of electronic clinical decision supports for recognition and management of hospital-acquired acute kidney injury.

BACKGROUND: Acute kidney injury (AKI) is common in hospitalized patients and is associated with poor patient outcomes and high costs of care. The implementation of clinical decision support tools within electronic medical record (EMR) could improve AKI care and outcomes. While clinical decision support tools have the potential to enhance recognition and management of AKI, there is limited description in the literature of how these tools were developed and whether they meet end-user expectations. METHODS: We developed and evaluated the content, acceptability, and usability of electronic clinical decision support tools for AKI care. Multi-component tools were developed within a hospital EMR (Sunrise Clinical Manager™, Allscripts Healthcare Solutions Inc.) currently deployed in Calgary, Alberta, and included: AKI stage alerts, AKI adverse medication warnings, AKI clinical summary dashboard, and an AKI order set. The clinical decision support was developed for use by multiple healthcare providers at the time and point of care on general medical and surgical units. Functional and usability testing for the alerts and clinical summary dashboard was conducted via in-person evaluation sessions, interviews, and surveys of care providers. Formal user acceptance testing with clinical end-users, including physicians and nursing staff, was conducted to evaluate the AKI order set. RESULTS: Considerations for appropriate deployment of both non-disruptive and interruptive functions was important to gain acceptability by clinicians. Functional testing and usability surveys for the alerts and clinical summary dashboard indicated that the tools were operating as desired and 74% (17/23) of surveyed healthcare providers reported that these tools were easy to use and could be learned quickly. Over three-quarters of providers (18/23) reported that they would utilize the tools in their practice. Three-quarters of the participants (13/17) in user acceptance testing agreed that recommendations within the order set were useful. Overall, 88% (15/17) believed that the order set would improve the care and management of AKI patients. CONCLUSIONS: Development and testing of EMR-based decision support tools for AKI with clinicians led to high acceptance by clinical end-users. Subsequent implementation within clinical environments will require end-user education and engagement in system-level initiatives to use the tools to improve care.

Economic Evaluations of Strategies to Prevent Hospital-Acquired Pressure Injuries.

GENERAL PURPOSE: To provide information from a review of literature about economic evaluations of preventive strategies for pressure injuries (PIs). TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant should be better able to:1. Identify the purpose and methods used for this study.2. Compare costs and effectiveness related to preventative strategies for PIs. ABSTRACT: BACKGROUND: Pressure injuries (PIs) are a common and resource-intensive challenge for acute care hospitals worldwide. While a number of preventive strategies have the potential to reduce the cost of hospital-acquired PIs, it is unclear what approach is the most effective. OBJECTIVE: The authors performed a narrative review of the literature on economic evaluations of preventive strategies to survey current findings and identify important factors in economic assessments. DATA SOURCES: Ovid, MEDLINE, NHS Economic Evaluation Databases, and the Cochrane Database of Systematic ReviewsSELECTION CRITERIA: Potentially relevant original research articles and systematic reviews were considered. DATA EXTRACTION: Selection criteria included articles that were written in English, provided data on cost or economic evaluations of preventive strategies of PIs in acute care, and published between January 2004 and September 2015. Data were abstracted from the articles using a standardized approach to evaluate how the items on the Consolidated Health Economic Evaluation Reporting Standards checklist were addressed. DATA SYNTHESIS: The searches identified 192 references. Thirty-three original articles were chosen for full-text reviews. Nineteen of these articles provided clear descriptions of interventions, study methods, and outcomes considered. CONCLUSIONS: Limitations in the available literature prevent firm conclusions from being reached about the relative economic merits of the various approaches to the prevention of PIs. The authors' review revealed a need for additional high-quality studies that adhere to commonly used standards of both currently utilized and emerging ways to prevent hospital-acquired PIs.

A Mixed-methods Study to Assess Interrater Reliability and Nurse Perception of the Braden Scale in a Tertiary Acute Care Setting.

Research regarding the reliability of the Braden Scale and nurses' perspectives on the instrument for predicting pressure ulcer (PU) risk in acute care settings is limited. A mixed-methods study was conducted in a tertiary acute care facility to examine interrater reliability (IRR) of the Braden Scale and its subscales, and a qualitative survey using semi-structured interviews was conducted among nurses caring for patients in acute care units to gain nurse perspective regarding scale usability. Data were extracted from a previous retrospective, randomized, controlled trial involving adult patients with compromised mobility receiving care in a tertiary acute care hospital in Canada. One-way, intraclass correlation coefficients (ICCs) were calculated on item and total scores, and kappa statistics were used to determine reliability of categorizing patients on their risk. Interview results were categorized by common themes. Reliability was assessed on 64 patients, where nurses and research staff independently assessed enrolled participants at baseline and after 72 hours using the Braden Scale as it appeared on an electronic medical record. IRR for the total score was high (ICC = 0.807). The friction and shear item had the lowest reliability (ICC = 0.266). Reliability of categorizing patients' level of risk had moderate agreement (κ = 0.408). Three (3) major and 12 subthemes emerged from the 14 nurse interviews; nurses were aware of the scale's purpose but were uncertain of its effectiveness, some items were difficult to rate, and questions were raised as to whether using the scale enhanced patient care. Aspects identified by nurses to enhance usability included: 1) changes to the electronic version (incorporating the scale into daily assessment documents with readily available item descriptions), 2) additional training, and 3) easily available resource material to improve reliability and usability of scale. These findings need to be considered when using the Braden Scale in clinical practice. Further study of the value of the total Braden Scale and its subscales is warranted.

Efficacy of a pressure-sensing mattress cover system for reducing interface pressure: study protocol for a randomized controlled trial.

BACKGROUND: Interface pressure is a key risk factor in the development of pressure ulcers. Visual feedback of continuous interface pressure between the body and support surface could inform clinicians on repositioning strategies and play a key role in an overall strategy for the prevention and management of pressure ulcers. METHODS/DESIGN: A parallel two-group randomized controlled clinical trial will be conducted to study the effect of continuous pressure imaging on reducing interface pressure and on the incidence of pressure ulcers in vulnerable hospital patients. A total of 678 eligible consenting inpatients at risk of pressure ulcer development in a tertiary acute care institution will be randomly allocated to either having the ForeSite PT™ system with the liquid-crystal display monitor turned on to provide visual feedback to the clinicians while also collecting continuous interface pressure data (intervention group) or to having the ForeSite PT™ system with monitor turned off (that is, not providing visual feedback) but still collecting continuous interface pressure data (control group), in a ratio of 1:1. Continuous interface pressure data will be collected in both groups for 3 days (72 h). Data collection will continue until discharge for a subset of approximately 60 patients. The primary outcome will be the differences in the two groups' interface pressure analysis. Interface pressure readings will be collected through hourly samplings of continuous interface pressure recordings. Secondary outcomes will be the differences between the two groups in pressure-related skin and soft tissue changes in areas at risk of pressure ulcer (obtained at baseline within 24 h of admission) and on the third day of the trial or at discharge and perceptions of the intervention by patients and clinicians (obtained on the third day or at discharge). DISCUSSION: This will be the first randomized controlled trial to investigate the effect of visual feedback with continuous interface pressure of vulnerable hospital patients across different care settings, and the association between interface pressure and development of pressure-related skin and soft tissue changes. The results could provide important information to guide clinical practice in the prevention and management of pressure ulcers. TRIALS REGISTRATION: ClinicalTrials.gov NCT02325388 (date of registration: 24 December 2014).

Multidimensional evaluation of a radio frequency identification wi-fi location tracking system in an acute-care hospital setting.

Real-time locating systems (RTLS) have the potential to enhance healthcare systems through the live tracking of assets, patients and staff. This study evaluated a commercially available RTLS system deployed in a clinical setting, with three objectives: (1) assessment of the location accuracy of the technology in a clinical setting; (2) assessment of the value of asset tracking to staff; and (3) assessment of threshold monitoring applications developed for patient tracking and inventory control. Simulated daily activities were monitored by RTLS and compared with direct research team observations. Staff surveys and interviews concerning the system's effectiveness and accuracy were also conducted and analyzed. The study showed only modest location accuracy, and mixed reactions in staff interviews. These findings reveal that the technology needs to be refined further for better specific location accuracy before full-scale implementation can be recommended.

The efficacy of computer-enabled discharge communication interventions: a systematic review.

CONTEXT: Traditional manual/dictated discharge summaries are inaccurate, inconsistent and untimely. Computer-enabled discharge communications may improve information transfer by providing a standardised document that immediately links acute and community healthcare providers. OBJECTIVE: To conduct a systematic review evaluating the efficacy of computer-enabled discharge communication compared with traditional communication for patients discharged from acute care hospitals. DATA SOURCES: MEDLINE, EMBASE, Cochrane CENTRAL Register of Controlled Trials and MEDLINE In-Process. Keywords from three themes were combined: discharge communication, electronic/online/web-based and controlled interventional studies. STUDY SELECTION: Study types included: clinical trials, quasiexperimental studies with concurrent controls and controlled before--after studies. Interventions included: (1) automatic population of a discharge document by computer database(s); (2) transmission of discharge information via computer technology; or (3) computer technology providing a 'platform' for dynamic discharge communication. Controls included: no intervention or traditional manual/dictated discharge summaries. Primary outcomes included: mortality, readmission and adverse events/near misses. Secondary outcomes included: timeliness, accuracy, quality/completeness and physician/patient satisfaction. DATA EXTRACTION: Description of interventions and study outcomes were extracted by two independent reviewers. RESULTS: 12 unique studies were identified: eight randomised controlled trials and four quasi-experimental studies. Pooling/meta-analysis was not possible, given the heterogeneity of measures and outcomes reported. The primary outcomes of mortality and readmission were inconsistently reported. There was no significant difference in mortality, and one study reported reduced long-term readmission. Intervention groups experienced reductions in perceived medical errors/adverse events, and improvements in timeliness and physician/patient satisfaction. CONCLUSIONS: Computer-enabled discharge communications appear beneficial with respect to a number of important secondary outcomes. Primary outcomes of mortality and readmission are less commonly reported in this literature and require further study.

Patient satisfaction: evaluating the success of hospital ward redesign.

Patients who were moved from a traditional medical ward to a new state-of-the-art medical ward were surveyed regarding their perceptions of quality during their hospitalization. Respondents rated the environment of the state-of-the-art facility, as well as the overall quality of their hospital stay, more positively. However, fewer differences in perceptions of the quality of the broader hospital environment and little difference in the perceived quality of staff-patient interactions were found. Findings indicated that enhancing the facilities of the patient care environment improved patients' overall perceptions of the quality of their hospital stay.

Ototoxicity induced by gentamicin and furosemide.

OBJECTIVE: To present a case of ototoxicity induced by furosemide and once-daily gentamicin therapy. CASE SUMMARY: A 60-year-old white woman presented to the hospital with community-acquired pneumonia and urinary tract infection. The antibiotic regimen included gentamicin and, after 5 doses, the patient reported profound bilateral hearing loss. A Pure Tone Audiogram suggested moderate to moderately severe sensorineural hearing loss bilaterally. The only risk factors present included her age, elevated temperature, and the use of furosemide. DISCUSSION: Several risk factors may predispose a patient to developing aminoglycoside ototoxicity: the 1555 chromosomal mutation, preexisting disorders of hearing and balance, hypovolemia, bacteremia, liver and renal dysfunction, and the simultaneous administration of other ototoxic medications. The cumulative dose and duration of aminoglycoside therapy are more important than serum concentrations. Administration of an aminoglycoside followed by furosemide may increase the risk of ototoxicity. The aminoglycoside interacts with the cell membranes in the inner ear, increasing their permeability. This theoretically allows the loop diuretic to penetrate into the cells in higher concentrations, causing more severe damage. CONCLUSIONS: Auditory toxicity occurred after only 5 days of gentamicin therapy and 1 dose of furosemide. An aminoglycoside followed by furosemide may increase the risk for ototoxicity. Clinicians need to be aware of the synergistic potential of ototoxic medications.