Perceived Workload Using Separate (Filtering Facepiece Respirator and Face Shield) and Powered Air-Purifying Respirator and Integrated Lightweight Protective Air-Purifying Respirator: Protocol for an International Multisite Human Factors Randomized Crossover Feasibility Study.

BACKGROUND: The design of personal protective equipment (PPE) may affect well-being and clinical work. PPE as an integrated item may improve usability and increase adherence by healthcare professionals. Human factors design and safety may reduce occupational-acquired diseases. As an integrated PPE, a lightweight protective air-purifying respirator (L-PAPR) could be used during health procedures where healthcare professionals are exposed to airborne pathogens. The human factors affecting the implementation of alternative PPE such as L-PAPR have not been thoroughly studied. The population of interest is health care professionals, the intervention is the performance by PPE during tasks across the three PPE types 1.) N95 respirators and face shields, 2.)traditional powered air-purifying respirator(PAPR), and 3.) L-PAPR. The outcomes are user error, communications, safety, and end-user preferences. OBJECTIVE: This study will assess whether the L-PAPR improves health care professionals' comfort in terms of perceived workload and physical and psychological burden during direct patient care when compared with the traditional PAPR or N95 and face shield. This study also aims to evaluate human factors during the comparison of the use of L-PAPR with a combination of N95 respirators plus face shields or the traditional PAPRs. METHODS: This is an interventional randomized crossover quality improvement feasibility study consisting of a 3-site simulation phase with 10 participants per site and subsequent field testing in 2 sites with 30 participants at each site. The 3 types of respiratory PPE will be compared across medical tasks and while donning and doffing. We will evaluate the user's perceived workload, usability, usage errors, and heart rate. We will conduct semistructured interviews to identify barriers and enablers to implementation across each PPE type over a single continuous wear episode and observe interpersonal communications across conditions and PPE types. RESULTS: We expect the research may highlight communication challenges and differences in usability and convenience across PPE types along with error frequency during PPE use across PPE types, tasks, and time. CONCLUSIONS: The design of PPE may affect overall well-being and hinder or facilitate clinical work. Combining 2 pieces of PPE into a single integrated item may improve usability and reduce occupational-acquired diseases. The human factors affecting the implementation of an alternative PPE such as L-PAPR or PAPR have not been thoroughly studied. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/36549.

A mixed methods study on effectiveness and appropriateness of face shield use as COVID-19 PPE in middle income countries.

BACKGROUND: Face shields were widely used in 2020-2021 as facial personal protective equipment (PPE). Laboratory evidence about how protective face shields might be and whether real world user priorities and usage habits conflicted with best practice for maximum possible protection was lacking - especially in limited resource settings. METHODS: Relative protective potential of 13 face shield designs were tested in a controlled laboratory setting. Community and health care workers were surveyed in middle income country cities (Brazil and Nigeria) about their preferences and perspectives on face shields as facial PPE. Priorities about facial PPE held by survey participants were compared with the implications of the laboratory-generated test results. RESULTS: No face shield tested totally eliminated exposure. Head orientation and design features influenced the level of protection. Over 600 individuals were interviewed in Brazil and Nigeria (including 240 health care workers) in March-April 2021. Respondents commented on what influenced their preferred forms of facial PPE, how they tended to clean face shields, and their priorities in choosing a face cover product. Surveyed health care workers commonly bought personal protection equipment for use at work. CONCLUSIONS: All face shields provided some protection but none gave high levels of protection against external droplet contamination. Respondents wanted facial PPE that considered good communication, secure fixture, good visibility, comfort, fashion, and has validated protectiveness.

Combining Machine Learning, Patient-Reported Outcomes, and Value-Based Health Care: Protocol for Scoping Reviews.

BACKGROUND: Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are self-reporting tools that can measure important information about patients, such as health priorities, experience, and perception of outcome. The use of traditional objective measures such as vital signs and lab values can be supplemented with these self-reported patient measures to provide a more complete picture of a patient's health status. Machine learning, the use of computer algorithms that improve automatically through experience, is a powerful tool in health care that often does not use subjective information shared by patients. However, machine learning has largely been based on objective measures and has been developed without patient or public input. Algorithms often do not have access to critical information from patients and may be missing priorities and measures that matter to patients. Combining objective measures with patient-reported measures can improve the ability of machine learning algorithms to assess patients' health status and improve the delivery of health care. OBJECTIVE: The objective of this scoping review is to identify gaps and benefits in the way machine learning is integrated with patient-reported outcomes for the development of improved public and patient partnerships in research and health care. METHODS: We reviewed the following 3 questions to learn from existing literature about the reported gaps and best methods for combining machine learning and patient-reported outcomes: (1) How are the public engaged as involved partners in the development of artificial intelligence in medicine? (2) What examples of good practice can we identify for the integration of PROMs into machine learning algorithms? (3) How has value-based health care influenced the development of artificial intelligence in health care? We searched Ovid MEDLINE(R), Embase, PsycINFO, Science Citation Index, Cochrane Library, and Database of Abstracts of Reviews of Effects in addition to PROSPERO and the ClinicalTrials website. The authors will use Covidence to screen titles and abstracts and to conduct the review. We will include systematic reviews and overviews published in any language and may explore additional study types. Quantitative, qualitative, and mixed methods studies are included in the reviews. RESULTS: The search is completed, and Covidence software will be used to work collaboratively. We will report the review using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and Critical Appraisal Skills Programme for systematic reviews. CONCLUSIONS: Findings from our review will help us identify examples of good practice for how to involve the public in the development of machine learning systems as well as interventions and outcomes that have used PROMs and PREMs. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/36395.

Patient and Public Involvement in research: A journey to co-production.

The public and patients can be powerful sensors for shaping and powering healthcare research. They are joining research teams as investigators and collaborators to co-produce evidence for the practical use of interventions in clinical practice. While clinicians and researchers are encouraged by funders and policymakers to involve the public and patients as partners in research, knowledge on what involvement consists of is limited, and the continuum between consultation, collaboration and co-production are not clearly defined. In this article, we explore Patient and Public Involvement (PPI) and introduce greater involvement through research co-production. Co-production describes ways that research partnership can work through public and patient involvement and we outline the similarities of co-production to "The Commons", a strategy utilized by economists to increase effective use of resources. We share examples of how public and patient involvement have used co-production, to demonstrate financial and health benefits. We then outline practical challenges at system, social and cultural levels and consider how others have worked to resolve them.

Addressing personal protective equipment (PPE) decontamination: Methylene blue and light inactivates severe acute respiratory coronavirus virus 2 (SARS-CoV-2) on N95 respirators and medical masks with maintenance of integrity and fit.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has resulted in shortages of personal protective equipment (PPE), underscoring the urgent need for simple, efficient, and inexpensive methods to decontaminate masks and respirators exposed to severe acute respiratory coronavirus virus 2 (SARS-CoV-2). We hypothesized that methylene blue (MB) photochemical treatment, which has various clinical applications, could decontaminate PPE contaminated with coronavirus. DESIGN: The 2 arms of the study included (1) PPE inoculation with coronaviruses followed by MB with light (MBL) decontamination treatment and (2) PPE treatment with MBL for 5 cycles of decontamination to determine maintenance of PPE performance. METHODS: MBL treatment was used to inactivate coronaviruses on 3 N95 filtering facepiece respirator (FFR) and 2 medical mask models. We inoculated FFR and medical mask materials with 3 coronaviruses, including SARS-CoV-2, and we treated them with 10 µM MB and exposed them to 50,000 lux of white light or 12,500 lux of red light for 30 minutes. In parallel, integrity was assessed after 5 cycles of decontamination using multiple US and international test methods, and the process was compared with the FDA-authorized vaporized hydrogen peroxide plus ozone (VHP+O3) decontamination method. RESULTS: Overall, MBL robustly and consistently inactivated all 3 coronaviruses with 99.8% to >99.9% virus inactivation across all FFRs and medical masks tested. FFR and medical mask integrity was maintained after 5 cycles of MBL treatment, whereas 1 FFR model failed after 5 cycles of VHP+O3. CONCLUSIONS: MBL treatment decontaminated respirators and masks by inactivating 3 tested coronaviruses without compromising integrity through 5 cycles of decontamination. MBL decontamination is effective, is low cost, and does not require specialized equipment, making it applicable in low- to high-resource settings.

Coproduction, Coeducation, and Patient Involvement: Everyone Included Framework for Medical Education Across Age Groups and Cultures.

Medical education, research, and health care practice continue to grow with minimal coproduction guidance. We suggest the Commons Principle approach to medical education as modeled by Ostrom and Williamson, where we share how adapting these models to multiple settings can enhance empathy, increase psychological safety, and provide robust just-in-time learning tools for practice. We here describe patient and public coproduction in diverse areas within health care using the commons philosophy across populations, cultures, and generations with learning examples across age groups and cultures. We further explore descriptive, mixed methods participatory action in medical and research education. We adopt an "Everyone Included" perspective and sought to identify its use in continuing medical education, citizen science, marginalized groups, publishing, and student internships. Overall, we outline coproduction at the point of need, as we report on strategies that improved engagement. This work demonstrates coproduction with the public across multiple settings and cultures, showing that even with minimal resources and experience, this partnership can improve medical education and care.

The Burnout Dyad: A Collaborative Approach for Including Patients in a Model of Provider Burnout.

ABSTRACT: Both patients and providers in the United States (US) suffer from burnout, which can impact the clinical relationship and quality of care. Among providers, burnout is a state of exhaustion including heightened depersonalization; among patients, burnout can negatively affect clinical outcomes. More than half of clinical providers in the United States suffer from burnout; less is known about the magnitude and prevalence among patients. Understanding patient burnout will improve our recognition of treatment barriers, understanding of patient-provider communication, and perceived quality of care. The purpose of the 2019 Stanford University MedicineX Burnout Workgroup was to use a collaborative approach to expand on the National Academy of Medicine (NAM) Wellness and Resilience Model, which does not currently include the patient as an influential member of the care team potentially experiencing burnout. This collaboration among patients, physicians, students, caregivers, technologists, and researchers used a convenience sample of conference attendees, broken into three focus groups to (1) provide an expanded definition of burnout that includes patients' perspectives, (2) analyze the NAM burnout model for inclusion of the patient experience, and (3) define a care experience that includes both patients and providers. The design of this workgroup was informed by Everyone Included, a model that recognizes and rejects hierarchical traditions in clinical practice. This approach allowed for the creation of a safe space for the exchange of knowledge between the various stakeholders. The resulting inclusive conceptual model, The Burnout Dyad, describes a cocreated care experience informed by both patient and provider characteristics.

Graduate medical education in anaesthesiology and COVID-19: lessons learned from a global pandemic.

PURPOSE OF REVIEW: The recent global pandemic has dramatically altered the anaesthesiology educational landscape in unexpected ways. It is important that we pause to learn from this crisis. RECENT FINDINGS: Most resident trainees actively caring for COVID-19 patients present with probable or subclinical finding of post-traumatic stress disorder. Anaesthesia resident training programmes evolved to continue the mission of anaesthesia education in the face of institutional restrictions and evolving clinical crises. SUMMARY: The recent global COVID-19 pandemic has illustrated how external stressors can cause significant disruption to traditional medical education pathways. Resilience to external disruptive forces in anaesthesia education include a willingness of leadership to understand the problem, flexibility in adapting to the needs of learners and instructors in the face of key challenges, deployment of technology and innovation-minded solution-finding where appropriate, and attention to Maslow's hierarchy of needs. VIDEO ABSTRACT: http://links.lww.com/COAN/A77.

Effects of a 2-Week Remote Learning Program on Empathy and Clinical and Communication Skills in Premedical Students: Mixed Methods Evaluation Study.

BACKGROUND: Expressing empathy builds trust with patients, increases patient satisfaction, and is associated with better health outcomes. Research shows that expressing empathy to patients improves patient adherence to medications and decreases patient anxiety and the number of malpractice lawsuits. However, there is a dearth of research on teaching empathy to premedical students. The Clinical Science, Technology, and Medicine Summer Internship of Stanford Medicine (also called the Stanford Anesthesia Summer Institute) is a 2-week collaborative medical internship for high school and undergraduate students to inspire learners to be compassionate health care providers. The summer 2020 program was adapted to accomplish these objectives in a fully remote environment because of the COVID-19 global pandemic. OBJECTIVE: This study aims to measure the change in empathy and competencies of participants in clinical and communication skills before and after program participation. METHODS: A total of 41 participants completed only the core track of this program, and 39 participants completed the core + research track of this program. Participants in both tracks received instructions in selected clinical skills and interacted directly with patients to improve their interviewing skills. Research track participants received additional instructions in research methodology. All participants completed web-based pre- and postsurveys containing Knowledge and Skills Assessment (KSA) questions. Participant empathy was assessed using the validated Consultation and Relational Empathy measure. A subset of participants completed optional focus groups to discuss empathy. The pre- and post-KSA and Consultation and Relational Empathy measure scores were compared using paired 2-tailed t tests and a linear regression model. Open-ended focus group answers were then analyzed thematically. RESULTS: Participants in both tracks demonstrated significant improvement in empathy after the 2-week remote learning course (P=.007 in core track; P<.001 in research track). These results remained significant when controlling for gender and age. A lower pretest score was associated with a greater change in empathy. Participants in both tracks demonstrated significant improvement in KSA questions related to surgical skills (P<.001 in core track; P<.001 in research track), epinephrine pen use (P<.001 in core track; P<.001 in research track), x-ray image interpretation (P<.001 in core track; P<.001 in research track), and synthesizing information to solve problems (P<.001 in core track; P=.05 in research track). The core track participants also showed significant improvements in health communication skills (P=.001). Qualitative analysis yielded 3 themes: empathy as action, empathy as a mindset, and empathy in designing health care systems. CONCLUSIONS: Summer internships that introduce high school and undergraduate students to the field of health care through hands-on interaction and patient involvement may be an effective way to develop measurable empathy skills when combined with clinical skills training and mentorship. Notably, increases in empathy were observed in a program administered via a remote learning environment.

An evidence review of face masks against COVID-19.

The science around the use of masks by the public to impede COVID-19 transmission is advancing rapidly. In this narrative review, we develop an analytical framework to examine mask usage, synthesizing the relevant literature to inform multiple areas: population impact, transmission characteristics, source control, wearer protection, sociological considerations, and implementation considerations. A primary route of transmission of COVID-19 is via respiratory particles, and it is known to be transmissible from presymptomatic, paucisymptomatic, and asymptomatic individuals. Reducing disease spread requires two things: limiting contacts of infected individuals via physical distancing and other measures and reducing the transmission probability per contact. The preponderance of evidence indicates that mask wearing reduces transmissibility per contact by reducing transmission of infected respiratory particles in both laboratory and clinical contexts. Public mask wearing is most effective at reducing spread of the virus when compliance is high. Given the current shortages of medical masks, we recommend the adoption of public cloth mask wearing, as an effective form of source control, in conjunction with existing hygiene, distancing, and contact tracing strategies. Because many respiratory particles become smaller due to evaporation, we recommend increasing focus on a previously overlooked aspect of mask usage: mask wearing by infectious people ("source control") with benefits at the population level, rather than only mask wearing by susceptible people, such as health care workers, with focus on individual outcomes. We recommend that public officials and governments strongly encourage the use of widespread face masks in public, including the use of appropriate regulation.

Critical patient insights from the same-day feedback programme at Stanford Health Care.

PATIENT-CENTERED ORGANISATIONS: Healthcare organisations now integrate patient feedback into value-based compensation formulas. This research considered Stanford Healthcare's same-day feedback, a programme designed to evaluate the patient experience. Specifically, how did patients with cancer interviewed in the programme assess their physicians? Furthermore, how did assessments differ across emotional, physical, practical and informational needs when interviewed by volunteer patient and family partners (PAFPs) versus hospital staff? PATIENT-PHYSICIAN COMMUNICATION BARRIERS: Integral to this research was Communication Accommodation Theory (CAT), which suggests individuals adjust interactions based on conversational roles, needs and understanding. Previous influential research was conducted by Frosch et al (2012) and Di Bartolo et al (2017), who revealed barriers to patient-physician communication, and Baker et al (2011) who associated CAT with these interactions. However, we still did not know if patients alter physician assessments between interviewers. VOLUNTEERS COLLECT PATIENT NEEDS: This mixed methods study worked with 190 oncology unit patient interviews from 2009 to 2017. Open-ended interview responses underwent thematic analysis. When compared with hospital staff, PAFPs collected more practical and informational needs from patients. PAFPs also collected more verbose responses that resembled detailed narratives of the patients' hospital experiences. This study contributed insightful patient perspectives of physician care in a novel hospital programme.

Managing ICU surge during the COVID-19 crisis: rapid guidelines.

Given the rapidly changing nature of COVID-19, clinicians and policy makers require urgent review and summary of the literature, and synthesis of evidence-based guidelines to inform practice. The WHO advocates for rapid reviews in these circumstances. The purpose of this rapid guideline is to provide recommendations on the organizational management of intensive care units caring for patients with COVID-19 including: planning a crisis surge response; crisis surge response strategies; triage, supporting families, and staff.

Household Materials Selection for Homemade Cloth Face Coverings and Their Filtration Efficiency Enhancement with Triboelectric Charging.

The COVID-19 pandemic is currently causing a severe disruption and shortage in the global supply chain of necessary personal protective equipment (e.g., N95 respirators). The U.S. CDC has recommended use of household cloth by the general public to make cloth face coverings as a method of source control. We evaluated the filtration properties of natural and synthetic materials using a modified procedure for N95 respirator approval. Common fabrics of cotton, polyester, nylon, and silk had filtration efficiency of 5-25%, polypropylene spunbond had filtration efficiency 6-10%, and paper-based products had filtration efficiency of 10-20%. An advantage of polypropylene spunbond is that it can be simply triboelectrically charged to enhance the filtration efficiency (from 6 to >10%) without any increase in pressure (stable overnight and in humid environments). Using the filtration quality factor, fabric microstructure, and charging ability, we are able to provide an assessment of suggested fabric materials for homemade facial coverings.

I Tweet, Therefore I Learn: An Analysis of Twitter Use Across Anesthesiology Conferences.

BACKGROUND: Twitter in anesthesiology conferences promotes rapid science dissemination, global audience participation, and real-time updates of simultaneous sessions. We designed this study to determine if an association exists between conference attendance/registration and 4 defined Twitter metrics. METHODS: Using publicly available data through the Symplur Healthcare Hashtags Project and the Symplur Signals, we collected data on total tweets, impressions, retweets, and replies as 4 primary outcome metrics for all registered anesthesiology conferences occurring from May 1, 2016 to April 30, 2017. The number of Twitter participants, defined as users who contributed a tweet, retweet, or reply 3 days before through 3 days after the conference, was collected. We also collected influencer data as determined by mentions (number of times a user is referenced). Two authors independently verified the categories for influencers assigned by Symplur. Conference demographic data were obtained by e-mail inquiries. Associations between meeting attendees/registrants and Twitter metrics, between Twitter participants and the metrics, and between physician influencers and Twitter participants were tested using Spearman rho. RESULTS: Fourteen conferences with 63,180 tweets were included. With the American Society of Anesthesiologists annual meeting included, the correlations between meeting attendance/registration and total tweets (rs = 0.588; P = .074), impressions (rs = 0.527; P = .117), and retweets (rs = 0.539; P = .108) were not statistically significant; for replies, it was moderately positive (rs = 0.648; P = .043). Without the American Society of Anesthesiologists annual meeting, total tweets (rs = 0.433; P = .244), impressions (rs = 0.350; P = .356), retweets (rs = 0.367; P = .332), and replies (rs = 0.517; P = .154) were not statistically significant. Secondary outcomes include a highly positive correlation between Twitter participation and total tweets (rs = 0.855; P < .001), very highly positive correlations between Twitter participation and impressions (rs = 0.938; P < .001), retweets (rs = 0.925; P < .001), and a moderately positive correlation between Twitter participation and replies (rs = 0.652; P = .044). Doctors were top influencers in 8 of 14 conferences, and the number of physician influencers in the top 10 influencers list at each conference had a moderately positive correlation with Twitter participation (rs = 0.602; P = .023). CONCLUSIONS: We observed that the number of Twitter participants for a conference is positively associated with Twitter activity metrics. No relationship between conference size and Twitter metrics was observed. Physician influencers may be an important driver of participants.

Internet searches for opioids predict future emergency department heroin admissions.

BACKGROUND: For a number of fiscal and practical reasons, data on heroin use have been of poor quality, which has hampered the ability to halt the growing epidemic. Internet search data, such as those made available by Google Trends, have been used as a low-cost, real-time data source for monitoring and predicting a variety of public health outcomes. We aimed to determine whether data on opioid-related internet searches might predict future heroin-related admissions to emergency departments (ED). METHODS: Across nine metropolitan statistical areas (MSAs) in the United States, we obtained data on Google searches for prescription and non-prescription opioids, as well as Substance Abuse and Mental Health Services Administration (SAMHSA) data on heroin-related ED visits from 2004 to 2011. A linear mixed model assessed the relationship between opioid-related Internet searches and following year heroin-related visits, controlling for MSA GINI index and total number of ED visits. RESULTS: The best-fitting model explained 72% of the variance in heroin-related ED visits. The final model included the search keywords "Avinza," "Brown Sugar," "China White," "Codeine," "Kadian," "Methadone," and "Oxymorphone." We found regional differences in where and how people searched for opioid-related information. CONCLUSIONS: Internet search-based modeling should be explored as a new source of insights for predicting heroin-related admissions. In geographic regions where no current heroin-related data exist, Internet search modeling might be a particularly valuable and inexpensive tool for estimating changing heroin use trends. We discuss the immediate implications for using this approach to assist in managing opioid-related morbidity and mortality in the United States.

Improving Health-Related Quality of Life of Patients With an Ostomy Using a Novel Digital Wearable Device: Protocol for a Pilot Study.

BACKGROUND: Ostomy surgeries involving the placement of an ostomy bag (eg, colostomy, ileostomy, urostomy, etc) have been shown to have a negative impact on health-related quality of life. To date, no studies have been conducted examining what impact, if any, wearable biosensors have on the health-related quality of life of ostomy patients. OBJECTIVE: In the present study, we plan to assess the quality of life of ostomy patients using the Ostom-i alert sensor, a portable, wearable, Bluetooth-linked biosensor that facilitates easier ostomy bag output measurements. We hypothesize that using the Ostom-i alert sensor will result in an improved, ostomy-specific, health-related quality of life as compared to baseline measurement before the use of the sensor. METHODS: A total of 20 ostomy patients will be screened and recruited to participate in this prospective, observational, cross-over pilot study using an Ostom-i alert sensor for one month. The primary outcome of this study will compare ostomy-specific, health-related quality of life at baseline (prior to Ostom-i alert sensor use) to ostomy-specific, health-related quality of life after 2 and 4 weeks of Ostom-i use by utilizing the City of Hope Quality of Life Questionnaire for Patients with an Ostomy. Secondary outcomes of general health-related quality of life and adjustment to ostomy will be evaluated using the Medical Outcomes Study 36-item short form health survey and the Olbrisch Ostomy Adjustment Scale Short Form 2. RESULTS: The project was funded by the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University School of Medicine. Enrollment is currently underway and data analysis is expected to be completed in 2018. CONCLUSIONS: Proposed benefits of mobile, internet-linked personal health monitors, such as the Ostom-i, include a reduction in the cost of care by reducing resource utilization and infection rates, improving patient-provider communication, reducing time spent as an inpatient as well as improved quality of life. Prior studies have demonstrated decreased health-related quality of life in patients with an ostomy bag. We aim to examine the extent to which the Ostom-i alert sensor affects the health-related quality of life of its users. The Ostom-i alert sensor has the potential to improve quality of life of users by giving them the freedom and confidence to partake in daily activities with the knowledge that they can check how full their ostomy bag is in a private, discrete manner. TRIAL REGISTRATION: ClinicalTrials.gov NCT02319434; https://clinicaltrials.gov/ct2/show/NCT02319434 (Archived at WebCite at http://www.webcitation.org/6xhFDThmq).