A model-based cost-utility analysis of an automated notification system for deteriorating patients on general wards.

BACKGROUND: Delayed response to clinical deterioration of hospital inpatients is common. Deployment of an electronic automated advisory vital signs monitoring and notification system to signal clinical deterioration is associated with significant improvements in clinical outcomes but there is no evidence on the cost-effectiveness compared with routine monitoring, in the National Health Service (NHS) in the United Kingdom (UK). METHODS: A decision analytic model was developed to estimate the cost-effectiveness of an electronic automated advisory notification system versus standard care, in adults admitted to a district general hospital. Analyses considered: (1) the cost-effectiveness of the technology based on secondary analysis of patient level data of 3787 inpatients in a before-and-after study; and (2) the cost-utility (cost per quality-adjusted life-year (QALY)) over a lifetime horizon, extrapolated using published data. Analysis was conducted from the perspective of the NHS. Uncertainty in the model was assessed using a range of sensitivity analyses. RESULTS: The study population had a mean age of 68 years, 48% male, with a median inpatient stay of 6 days. Expected life expectancy at discharge was assumed to be 17.74 years. (1) Cost-effectiveness analysis: The automated notification system was more effective (-0.027 reduction in mean events per patient) and provided a cost saving of -£12.17 (-182.07 to 154.80) per patient admission. (2) Cost-utility analysis: Over a lifetime horizon the automated notification system was dominant, demonstrating a positive incremental QALY gain (0.0287 QALYs, equivalent to ~10 days of perfect health) and a cost saving of £55.35. At a threshold of £20,000 per QALY, the probability of automated monitoring being cost-effective in the NHS was 81%. Increased use of cableless sensors may reduce cost-savings, however, the intervention remains cost-effective at 100% usage (ICER: £3,107/QALY). Stratified cost-effectiveness analysis by age, National Early Warning Score (NEWS) on admission, and primary diagnosis indicated the automated notification system was cost-effective for most strategies and that use representative of the patient population studied was the most cost-saving strategy. CONCLUSION: Automated notification system for adult patients admitted to general wards appears to be a cost-effective use in the NHS; adopting this technology could be good use of scarce resources with significance for patient safety.

Quality metrics for same day emergency care-Consensus of a multi-professional panel of experts using a modified Delphi process.

Same Day Emergency Care (SDEC) services are at the heart of recovery plans for Emergency Care in the National Health Service. There are no validated metrics for the quality of care in SDEC. The Society for Acute Medicine's Quality Improvement Committee invited to a three-stage modified Delphi process to gather metrics used by clinicians. Proposed metrics were ranked and further explored by 33 participating experts from a broad range of backgrounds including clinicians, data scientists and operational managers. Experts ranked five system-based metrics highest. These focus on optimisation of the proportion of patients receiving same day care in and out of SDEC units. Patient and staff experience metrics were ranked low, possibly due to present lack of viable examples. The paper adds a glossary with the rationale for ranking of metrics and their use for the improvement of quality and safety of clinical care.

Blockchain: What is the use case for physicians in 2024? A rapid review of the literature.

Blockchain is topical in many areas of science. The impact on clinical care of physicians is not known. We undertook a rapid review of the literature to identify areas of interest for clinicians in active practice focusing on evidence relevant to clinical care. We found limited evidence for use blockchain in clinical practice with most studies focusing on technical aspects of prototypes and implementation with no evidence of standardised metric to measure impact for patients, clinicians, and organisations. Personal Health Records for use across organisational and geographic boundaries emerged as the strongest clinical use-case. Defined metrics by professional bodies might aid research, development, and future impact.

Wearables in Wales: Entering clinical practice through the backdoor?

The number of people using wearable technology such as smartwatches and fitness trackers is increasing. Many of these devices can alert the user to a potential arrhythmia such as atrial fibrillation. We aimed to assess potential changes to cardiology practice resulting from their use. An online questionnaire consisting of 12 questions was created and distributed to all consultant cardiologists in Wales. 25 of 102 participants replied, with 92% of these using consumer wearable technology to diagnose atrial fibrillation either 'often' or 'sometimes'. One in four cardiologists received new referrals relating to wearable technology at least weekly. The results demonstrate that cardiologists across Wales are using data from wearable technology in the diagnosis and management of cardiac conditions in the absence of formal guidance. Standardisation of guidelines and pathways is needed to support patients and clinicians and avoid the introduction of wearables through the unregulated backdoor.

Digital Remote Monitoring Using an mHealth Solution for Survivors of Cancer: Protocol for a Pilot Observational Study.

BACKGROUND: Healthy lifestyle interventions have a positive impact on multiple disease trajectories, including cancer-related outcomes. Specifically, appropriate habitual physical activity, adequate sleep, and a regular wholesome diet are of paramount importance for the wellness and supportive care of survivors of cancer. Mobile health (mHealth) apps have the potential to support novel tailored lifestyle interventions. OBJECTIVE: This observational pilot study aims to assess the feasibility of mHealth multidimensional longitudinal monitoring in survivors of cancer. The primary objective is to test the compliance (user engagement) with the monitoring solution. Secondary objectives include recording clinically relevant subjective and objective measures collected through the digital solution. METHODS: This is a monocentric pilot study taking place in Bangor, Wales, United Kingdom. We plan to enroll up to 100 adult survivors of cancer not receiving toxic anticancer treatment, who will provide self-reported behavioral data recorded via a dedicated app and validated questionnaires and objective data automatically collected by a paired smartwatch over 16 weeks. The participants will continue with their normal routine surveillance care for their cancer. The primary end point is feasibility (eg, mHealth monitoring acceptability). Composite secondary end points include clinically relevant patient-reported outcome measures (eg, the Edmonton Symptom Assessment System score) and objective physiological measures (eg, step counts). This trial received a favorable ethical review in May 2023 (Integrated Research Application System 301068). RESULTS: This study is part of an array of pilots within a European Union funded project, entitled "GATEKEEPER," conducted at different sites across Europe and covering various chronic diseases. Study accrual is anticipated to commence in January 2024 and continue until June 2024. It is hypothesized that mHealth monitoring will be feasible in survivors of cancer; specifically, at least 50% (50/100) of the participants will engage with the app at least once a week in 8 of the 16 study weeks. CONCLUSIONS: In a population with potentially complex clinical needs, this pilot study will test the feasibility of multidimensional remote monitoring of patient-reported outcomes and physiological parameters. Satisfactory compliance with the use of the app and smartwatch, whether confirmed or infirmed through this study, will be propaedeutic to the development of innovative mHealth interventions in survivors of cancer. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/52957.

Martha's rule: applying a behaviour change framework to understand the potential of complementary roles of clinicians and patients in improving safety of patients deteriorating in hospital.

AIMS/BACKGROUND: Martha's rule stipulates the right of patients and their families to escalate care as a way to improve safety while in hospital. This article analyses the possible impact of the proposed policy through the lens of a behaviour change framework and explores new opportunities presented by the implementation of Martha's rule.. METHODS: A descriptive analysis was undertaken of interactions between patients, family, friends and clinicians during clinical deterioration in hospital. The capability-opportunity-motivation behaviour change framework was applied to understand reasons for failure to respond to deterioration. RESULTS: Care of deteriorating patients requires recording of vital signs, recognition of abnormalities, reporting through escalation and response by a competent clinician. Regarding the care of patients who deteriorate in hospital, healthcare professionals have capability and motivation to provide safe, high-quality care, but often lack the physical and social opportunity to report or respond through lack of time and peer pressure. Patients and family members have motivation and might have time to support safety systems. Martha's rule or similar arrangements allow healthcare organisations to create opportunities for patients and families to report and escalate care to experts in critical care when they recognise deterioration. CONCLUSIONS: The capability-opportunity-motivation behaviour change framework provides insights into the causes of failure to rescue in deteriorating patients and an argument for opportunities through escalation by patients and families through Martha's rule. This might reduce the number of system failures and enable safer care.

Can acutely ill patients predict their outcomes? A scoping review.

INTRODUCTION: The full impact of an acute illness on subsequent health is seldom explicitly discussed with patients. Patients' estimates of their likely prognosis have been explored in chronic care settings and can contribute to the improvement of clinical outcomes and patient satisfaction. This scoping review aimed to identify studies of acutely ill patients' estimates of their outcomes and potential benefits for their care. METHODS: A search was conducted in PubMed, Embase, Web of Science and Google Scholar, using terms related to prognostication and acute care. After removal of duplicates, all articles were assessed for relevance by six investigator pairs; disagreements were resolved by a third investigator. Risk of bias was assessed according to the Cochrane Handbook for Systematic Reviews of Interventions. RESULTS: Our search identified 3265 articles, of which 10 were included. The methods of assessing self-prognostication were very heterogeneous. Patients seem to be able to predict their need for hospital admission in certain settings, but not their length of stay. The severity of their symptoms and the burden of their disease are often overestimated or underestimated by patients. Patients with severe health conditions and their relatives tend to be overoptimistic about the likely outcome. CONCLUSION: The understanding of acutely ill patients of their likely outcomes and benefits of treatment has not been adequately studied and is a major knowledge gap. Limited published literature suggests patients may be able to predict their need for hospital admission. Illness perception may influence help-seeking behaviour, speed of recovery and subsequent quality of life. Knowledge of patients' self-prognosis may enhance communication between patients and their physicians, which improves patient-centred care.

Circadian lifestyle determinants of immune checkpoint inhibitor efficacy.

Immune Checkpoint Inhibitors (ICI) have revolutionised cancer care in recent years. Despite a global improvement in the efficacy and tolerability of systemic anticancer treatments, a sizeable proportion of patients still do not benefit maximally from ICI. Extensive research has been undertaken to reveal the immune- and cancer-related mechanisms underlying resistance and response to ICI, yet more limited investigations have explored potentially modifiable lifestyle host factors and their impact on ICI efficacy and tolerability. Moreover, multiple trials have reported a marked and coherent effect of time-of-day ICI administration and patients' outcomes. The biological circadian clock indeed temporally controls multiple aspects of the immune system, both directly and through mediation of timing of lifestyle actions, including food intake, physical exercise, exposure to bright light and sleep. These factors potentially modulate the immune response also through the microbiome, emerging as an important mediator of a patient's immune system. Thus, this review will look at critically amalgamating the existing clinical and experimental evidence to postulate how modifiable lifestyle factors could be used to improve the outcomes of cancer patients on immunotherapy through appropriate and individualised entrainment of the circadian timing system and temporal orchestration of the immune system functions.

The third Medical Emergency Teams - Hospital outcomes in a day (METHOD3) study: The application of quality metrics for rapid response systems around the world.

Aim: This cross-sectional study aimed to assess the readiness of international hospitals to implement consensus-based quality metrics for rapid response systems (RRS) and evaluate the feasibility of collecting these metrics. Methods: A digital survey was developed and distributed to hospital administrators and clinicians worldwide. The survey captured data on the recommended quality metrics for RRS and collected information on hospital characteristics. Statistical analysis included descriptive evaluations and comparisons by country and hospital type. Results: A total of 109 hospitals from 11 countries participated in the survey. Most hospitals had some form of RRS in place, with multiple parameter track and trigger systems being commonly used. The survey revealed variations in the adoption of quality metrics among hospitals. Metrics related to patient-activated rapid response and organizational culture were collected less frequently. Geographical differences were observed, with hospitals in Australia and New Zealand demonstrating higher adoption of core quality metrics. Urban hospitals reported a lower number of recorded metrics compared to metropolitan and rural hospitals. Conclusion: The study highlights the feasibility of collecting consensus-based quality metrics for RRS in international hospitals. However, variations in data collection and adoption of specific metrics suggest potential barriers and the need for further exploration. Standardized quality metrics are crucial for effective RRS functioning and continuous improvement in patient care. Collaborative initiatives and further research are needed to overcome barriers, enhance data collection capabilities, and facilitate knowledge sharing among healthcare providers to improve the quality and safety of RRS implementation globally.

Exercise testing to guide safe discharge from hospital in COVID-19: a scoping review to identify candidate tests.

OBJECTIVES: We aimed to identify exercise tests that have been validated to support a safe discharge to home in patients with or without COVID-19. STUDY DESIGN: Scoping review, using PRISMA-ScR reporting standards. Medline, PubMed, AMED, Embase, CINAHL and LitCovid databases were searched between 16 and 22 February 2021, with studies included from any publication date up to and including the search date. INTERVENTION: Short exercise tests. PRIMARY OUTCOME MEASURES: Safe discharge from hospital, readmission rate, length of hospital stay, mortality. Secondary outcomes measures: safety, feasibility and reliability. RESULTS: Of 1612 original records screened, 19 studies were included in the analysis. These used a variety of exercise tests in patients with chronic obstructive pulmonary disease, suspected pulmonary embolism and pneumocystis carinii pneumonia, heart failure or critical illness. Only six studies had examined patients with COVID-19, of these two were still recruiting to evaluate the 1 min sit-to-stand test and the 40-steps test. There was heterogeneity in patient populations, tests used and outcome measures. Few exercise tests have been validated to support discharge decisions. There is currently no support for short exercise tests for triage of care in patients with COVID-19. CONCLUSIONS: Further research is needed to aid clinical decision-making at discharge from hospital.

Value of improving patient safety: health economic considerations for rapid response systems-a rapid review of the literature and expert round table.

OBJECTIVES: Failure to rescue deteriorating patients in hospital is a well-researched topic. We aimed to explore the impact of safer care on health economic considerations for clinicians, providers and policymakers. DESIGN: We undertook a rapid review of the available literature and convened a round table of international specialists in the field including experts on health economics and value-based healthcare to better understand health economics of clinical deterioration and impact of systems to reduce failure to rescue. RESULTS: Only a limited number of publications have examined the health economic impact of failure to rescue. Literature examining this topic lacked detail and we identified no publications on long-term cost outside the hospital following a deterioration event. The recent pandemic has added limited literature on prevention of deterioration in the patients' home.Cost-effectiveness and cost-efficiency are dependent on broader system effects of adverse events. We suggest including the care needs beyond the hospital and loss of income of patients and/or their informal carers as well as sickness of healthcare staff exposed to serious adverse events in the analysis of adverse events. They are likely to have a larger health economic impact than the direct attributable cost of the hospital admission of the patient suffering the adverse event. Premorbid status of a patient is a major confounder for health economic considerations. CONCLUSION: In order to optimise health at the population level, we must limit long-term effects of adverse events through improvement of our ability to rapidly recognise and respond to acute illness and worsening chronic illness both in the home and the hospital.

National Early Warning Scores Following Emergency Hospital Transfer: Implications for Care Home Residents.

OBJECTIVE: Care home residents have high rates of hospital admission. The UK National Early Warning Score (NEWS2) standardizes the secondary care response to acute illness. However, the ability of NEWS2 to predict adverse health outcomes specifically for care home residents is unknown. This study explored the relationship between NEWS2 on admission to hospital and resident outcome 7 days later. DESIGN: Repeated cross-sectional study. SETTING AND PARTICIPANTS: Data on UK care home residents admitted to 160 hospitals in two 24-hour periods (2019 and 2020). METHOD: Chi-squared and Kruskal-Wallis tests, and multinomial regression were used to explore the association between low (score ≤2), intermediate (3-4), high (5-6), and critically high (≥7) NEWS2 on admission and each of the following: discharge on day of admission, admission and discharge within 7 days, prolonged hospital admission (>7 days), and death. RESULTS: From 665 resident admissions across 160 hospital sites, NEWS2 was low for 54%, intermediate for 18%, high for 13%, and critically high for 16%. The 7-day outcome was 10% same-day discharge, 47% admitted and subsequently discharged, 34% remained inpatients, and 8% died. There is a significant association between NEWS2 and these outcomes (P < .001). Compared with those with low NEWS2, residents with high and critically high NEWS2 had 3.6 and 9.5 times increased risk of prolonged hospitalization [relative risk ratio (RRR) 3.56; 95% CI 1.02-12.37; RRR 9.47; CI 2.20-40.67], respectively. The risk of death was approximately 14 times higher for residents with high NEWS2 (RRR 13.62; CI 3.17-58.49) and 54 times higher (RRR 53.50; CI 11.03-259.54) for critically high NEWS2. CONCLUSION AND IMPLICATIONS: Higher NEWS2 measurements on admission are associated with an increased risk of hospitalization up to 7 days duration, prolonged admission, and mortality for care home residents. NEWS2 may have a role as an adjunct to acute care decision making for hospitalized residents.

Digital NEWS? How to amplify the benefits of NEWS in a digital healthcare system.

With the transition of documentation systems, the National Early Warning Score (NEWS) is moving into a digital environment as a part of electronic health records. This paper aims to explore the opportunities and challenges of the digital environment for delivery of NEWS and the impact on safety of deteriorating patients. We make five recommendations to maximise the impact of a change to digital systems for patients, clinicians and healthcare organisations.

Protocol describing a systematic review and mixed methods consensus process to define the deteriorated ward patient.

INTRODUCTION: Most patients admitted to hospital recover with treatments that can be administered on the general ward. A small but important group deteriorate however and require augmented organ support in areas with increased nursing to patient ratios. In observational studies evaluating this cohort, proxy outcomes such as unplanned intensive care unit admission, cardiac arrest and death are used. These outcome measures introduce subjectivity and variability, which in turn hinders the development and accuracy of the increasing numbers of electronic medical record (EMR) linked digital tools designed to predict clinical deterioration. Here, we describe a protocol for developing a new outcome measure using mixed methods to address these limitations. METHODS AND ANALYSIS: We will undertake firstly, a systematic literature review to identify existing generic, syndrome-specific and organ-specific definitions for clinically deteriorated, hospitalised adult patients. Secondly, an international modified Delphi study to generate a short list of candidate definitions. Thirdly, a nominal group technique (NGT) (using a trained facilitator) will take a diverse group of stakeholders through a structured process to generate a consensus definition. The NGT process will be informed by the data generated from the first two stages. The definition(s) for the deteriorated ward patient will be readily extractable from the EMR. ETHICS AND DISSEMINATION: This study has ethics approval (reference 16399) from the Central Adelaide Local Health Network Human Research Ethics Committee. Results generated from this study will be disseminated through publication and presentation at national and international scientific meetings.

Feasibility and accuracy of the 40-steps desaturation test to determine outcomes in a cohort of patients presenting to hospital with and without COVID-19.

Desaturation on exercise has been suggested as a predictive feature for deterioration in COVID-19. The objective of this paper was to determine the feasibility and validity for the 40-steps desaturation test.A prospective observational cohort study was undertaken in patients assessed in hospital prior to discharge. One-hundred and fifty-two participants were screened between November 2020 and February 2021, and 64 were recruited to perform a 40-steps desaturation test. Patients who were able to perform the test were younger and less frail. Four patients were readmitted to hospital and one patient deteriorated within 30 days but no patient died.The majority of patients showed little change in saturations during the test, even with pre-existing respiratory pathology. Change in saturations, respiratory rate, heart rate and breathlessness were not predictive of death or readmission to hospital within 30 days. Of 13 patients who had a desaturation of 3% or more during exercise, none was readmitted to hospital within 30 days.Not enough patients with COVID-19 could be recruited to the study to provide evidence for the safety of the test in this patient group.The 40-steps desaturation test requires further evaluation to assess clinical utility.

How To Hospital: barriers to developing a patient 'Hospital Survival Guide' to support information transfer during ward-rounds on the patient journey from admission to hospital to discharge.

Clinicians can enable patients to actively participate in their care but communication with patients is often poor and highly variable. The aim of this study was to explore patients' understanding of their current illness while in hospital and using a codesign process to create prototype tools to facilitate better communication during ward rounds.A mixed-methods, multistep design with step 1: Application of a questionnaire addressing domains of care in the acute medical unit; step 2: Development of communication aids that were codesigned with active help of patients, students and a specialist in user centric design to address patient needs and step 3: Evaluation of tools with patients in four Plan-Do-Study-Act cycles.In the initial survey of 30 patients 12 (40%) patients did not know what their diagnosis was and 5 (17%) did not know the results of recent key tests. 20 (67%) patients felt that staff communication and coordination could be improved.An intervention was prototyped with four variations: (1) An A6 ward-round summary sheet completed by doctors during ward rounds. The system worked well but was highly person dependent. (2) An A4 patient-owned diary ('How to Hospital') that contained information about key processes in hospital and space to document conversations from rounds and prompts for questions. 10 patients read the diary and commented favourably but did not complete any pages. (3) 'Diary-cards': a basic set of information cards was given to patients on admission to hospital. (4) Patient specific 'diary-cards' were completed by clinicians-10 forms were piloted during rounds and improved subsequent day information retention of diagnosis to 80%.Our study identified interventions that were feasible but remained person-dependent. The patients' ownership of information in relation to their care might facilitate retention and satisfaction but the optimal format for these interventions for enhancing communication remains unclear.

An audible patient voice: How can we ensure that patients are treated as partners in their own safety?

How can patients and their relatives make their concerns heard by healthcare professionals? Many serious adverse events are preceded by patients' worry and concern. This article explores changes in the structures and processes of healthcare that might facilitate safer systems. One important tool might be the ability of patients to become equal partners in the recording of their clinical history.

When patients (and families) raise the alarm: Patient and family activated rapid response as a safety strategy for hospitals.

Patients and those close to them often have an intimate understanding of their condition and can participate in a broad range of clinical processes. During times of deterioration, their concerns might go unheard. Advocacy of family and friends can fulfil an important safety function and can support patients and healthcare professionals looking after them. If concerns by patients are not heard by the patient's primary team in hospital, patient and family activated rapid response systems allow patients and family members to alert critical care outreach teams directly. These types of systems are stipulated by regulators in Australia and in parts of the USA, and there are examples in the UK built around the 'Call for Concern' model championed by the Royal Berkshire Hospital. Implementation is not without its problems and requires a deep understanding of barriers and enablers. Empowering patients to escalate directly might help to change safety culture and have protective effects for patients and staff. Policy makers are urged to consider standardised regulation to aid implementation.

The Use of Different Sepsis Risk Stratification Tools on the Wards and in Emergency Departments Uncovers Different Mortality Risks: Results of the Three Welsh National Multicenter Point-Prevalence Studies.

OBJECTIVES: To compare the performance of Sequential Organ Failure Assessment, systemic inflammatory response syndrome, Red Flag Sepsis, and National Institute of Clinical Excellence sepsis risk stratification tools in the identification of patients at greatest risk of mortality from sepsis in nonintensive care environments. DESIGN: Secondary analysis of three annual 24-hour point-prevalence study periods. SETTING: The general wards and emergency departments of 14 acute hospitals across Wales. Studies were conducted on the third Wednesday of October in 2017, 2018, and 2019. PATIENTS: We screened all patients presenting to the emergency department and on the general wards. MEASUREMENTS AND MAIN RESULTS: We recruited 1,271 patients, of which 724 (56.9%) had systemic inflammatory response syndrome greater than or equal to 2, 679 (53.4%) had Sequential Organ Failure Assessment greater than or equal to 2, and 977 (76.9%) had Red Flag Sepsis. When stratified according to National Institute of Clinical Excellence guidelines, 450 patients (35.4%) were in the "High risk" category in comparison with 665 (52.3%) in "Moderate to High risk" and 156 (12.3%) in "Low risk" category. In a planned sensitivity analysis, we found that none of the tools accurately predicted mortality at 90 days, and Sequential Organ Failure Assessment and National Institute of Clinical Excellence tools showed only moderate discriminatory power for mortality at 7 and 14 days. Furthermore, we could not find any significant correlation with any of the tools at any of the mortality time points. CONCLUSIONS: Our data suggest that the sepsis risk stratification tools currently utilized in emergency departments and on the general wards do not predict mortality adequately. This is illustrated by the disparity in mortality risk of the populations captured by each instrument, as well as the weak concordance between them. We propose that future studies on the development of sepsis identification tools should focus on identifying predicator values of both the short- and long-term outcomes of sepsis.