40 research outputs found
Monitoring vital instability in patients outside high care facilities
No full textComplications that are associated with surgery and hospitalization cannot be entirely ruled out. To prevent patients from experiencing additional harm, it is essential that complications during hospitalization are recognized and treated adequately. A patient’s respiratory status can provide us with valuable information about the presence and progression of these complications. Unfortunately, respiratory assessment is still infrequently performed and technical solutions for (continuous) respiratory monitoring are generally not available outside high care facilities. This thesis aims to provide a strong basis for future development of continuous monitoring strategies outside high care facilities. The implementation of a system for continuous respiratory monitoring in order to improve patient outcomes is a ‘complex intervention’. That is illustrated by our systematic review as incomplete and suboptimal implementation of one of the components of the monitoring strategy jeopardizes the success of the complete monitoring strategy. The first of those components is the sensor technology. It is essential for success to develop sensor technologies that are explicitly suitable for the low care clinical setting. The frequency-modulated continuous wave radar that monitors respiratory rate would fit the low care requirements, as it operates in a non-invasive wireless, and contactless mode. However, a monitoring strategy is more than just the sensor technology. The success of a monitoring strategy depends on several other components, including signal analysis, alarm strategy, as well as the diagnostic and treatment algorithms used. Illustrated by the clinical evaluations of the radar and capnograph sensor technology in this thesis. The radar prototype signal analysis was not sophisticated enough to recognize voluntary movement, that resulted in artifacts and limited the diagnostic accuracy. The additive value of monitoring with a capnograph during procedural sedation depends on the therapeutic interventions and choices that interact with the monitoring strategy. In this example, something elementary as the administration of supplemental oxygen makes the difference. Successful development of continuous respiratory monitoring strategies for use outside high care facilities also depends on the methodology that is used to study them. We compared three statistical methods to derive limits of agreement in method comparison studies in a simulation study and found that it does indeed matter which statistical method is used to determine the accuracy of monitoring devices. Furthermore, we studied the association between the duration of vital instability before intensive care unit (ICU) admissions and mortality. Our findings suggest that ICU admission should be cautiously used as surrogate endpoint in studies evaluating a monitoring strategy to detect deteriorating patients. Based on the findings of our clinical studies and systematic review implementation of routine continuous non-invasive respiratory monitoring on general hospital wards cannot yet be advocated, however the monitoring strategy should be intensified, and this thesis reveals that technical monitoring solutions are getting closer
Evaluating an Implementation Protocol for Digitization and Devices in Operating Rooms: a Case Study
No full textDigitization of activities in hospitals receives more attention, due to Covid-19 related regulations. The use of e-health to support patient care is increasing and efficient ways to implement digitization of processes and other technological equipment are needed. We constructed a protocol for implementation and in this study, we evaluate this protocol based on a case to implement a device in the OR. We used various data sources to evaluate this protocol: semi-structured interviews, questionnaires, and project documents. Based on these findings, this protocol, including identified implementation activities and implementation instructions can be used for implementations of other devices. Implementation activities include setting up a project plan, organizational and technological preparation, maintenance, and training. In future research, these activities and instructions need to be evaluated in more complex projects and a flexible tool needs to be developed to select relevant activities and instructions for implementations of information systems or devices
From accuracy to patient outcome and cost-effectiveness evaluations of diagnostic tests and biomarkers: an exemplary modelling study
No full textBackground: Proper evaluation of new diagnostic tests is required to reduce overutilization and to limit potential negative health effects and costs related to testing. A decision analytic modelling approach may be worthwhile when a diagnostic randomized controlled trial is not feasible. We demonstrate this by assessing the cost-effectiveness of modified transesophageal echocardiography (TEE) compared with manual palpation for the detection of atherosclerosis in the ascending aorta. Methods. Based on a previous diagnostic accuracy study, actual Dutch reimbursement data, and evidence from literature we developed a Markov decision analytic model. Cost-effectiveness of modified TEE was assessed for a life time horizon and a health care perspective. Prevalence rates of atherosclerosis were age-dependent and low as well as high rates were applied. Probabilistic sensitivity analysis was applied. Results: The model synthesized all available evidence on the risk of stroke in cardiac surgery patients. The modified TEE strategy consistently resulted in more adapted surgical procedures and, hence, a lower risk of stroke and a slightly higher number of life-years. With 10% prevalence of atherosclerosis the incremental cost-effectiveness ratio was 4,651 and 481 per quality-adjusted life year in 55-year-old men and women, respectively. In all patients aged 65 years or older the modified TEE strategy was cost saving and resulted in additional health benefits. Conclusions: Decision analytic modelling to assess the cost-effectiveness of a new diagnostic test based on characteristics, costs and effects of the test itself and of the subsequent treatment options is both feasible and valuable. Our case study on modified TEE suggests that it may reduce the risk of stroke in cardiac surgery patients older than 55 years at acceptable cost-effectiveness levels
A protocol for the implementation of new technology in a highly complex hospital environment: the operating room
No full textMedical equipment is implemented in highly complex hospital environments, such as operating rooms, in hospitals around the world. In
operating rooms (ORs), technological equipment is used for surgical activities and activities in support of surgeries. The implementation of government policies in hospitals has resulted in varying implementation activities for (medical) equipment. These result in varying lead times and success rates. An integral and holistic protocol for implementation does not yet exist. In this study, we introduce a protocol for the implementation of (medical) equipment in ORs that consists of implementation factors and implementation activities.
Factors and activities are based on data from a systematic literature review and an explorative survey among surgical support staff on factors for the successful implementation of technological and (medical) equipment in ORs. The protocol consists of five factors and related implementation activities: the establishment of a project plan, organisational preparation, technological preparation, maintenance, and training
Typical rise and fall of troponin in (peri-procedural) myocardial infarction: A systematic review
No full textAIM: To identify the typical shape of the rise and fall curve of troponin (Tn) following the different types of myocardial infarction (MI). METHODS: We conducted a systematic search in PubMed and Embase including all studies which focused on the kinetics of Tn in MI type 1, type 4 and type 5. Tn levels were standardized using the 99(th) percentile, a pooled mean with 95%CI was calculated from the weighted means for each time point until 72 h. RESULTS: A total of 34 of the 2528 studies identified in the systematic search were included. The maximum peak level of the Tn was seen after 6 h after successful reperfusion of an acute MI, after 12 h for type 1 MI and after 72 h for type 5 MI. In type 1 MI there were additional smaller peaks at 1 h and at 24 h. After successful reperfusion of an acute MI there was a second peak at 24 h. There was not enough data available to analyze the Tn release after MI associated with percutaneous coronary intervention (type 4). CONCLUSION: The typical rise and fall of Tn is different for type 1 MI, successful reperfusion of an acute MI and type 5 MI, with different timing of the peak levels and different slopes of the fall phase
Implementing Medical Technological Equipment in the OR: Factors for Successful Implementations
No full textOperating rooms (ORs) more and more evolve into high-tech environments with increasing pressure on finances, logistics, and a not be neglected impact on patient safety. Safe and cost-effective implementation of technological equipment in ORs is notoriously difficult to manage, specifically as generic implementation activities omit as hospitals have implemented local policies for implementations of technological equipment. The purpose of this study is to identify success factors for effective implementations of new technologies and technological equipment in ORs, based on a systematic literature review. We accessed ten databases and reviewed included articles. The search resulted in 1592 titles for review, and finally 37 articles were included in this review. We distinguish influencing factors and resulting factors based on the outcomes of this research. Six main categories of influencing factors on successful implementations of medical equipment in ORs were identified: "processes and activities," "staff," "communication," "project management," "technology," and "training." We identified a seventh category "performance" referring to resulting factors during implementations. We argue that aligning the identified influencing factors during implementation impacts the success, adaptation, and safe use of new technological equipment in the OR and thus the outcome of an implementation. The identified categories in literature are considered to be a baseline, to identify factors as elements of a generic holistic implementation model or protocol for new technological equipment in ORs
Implementation of the third universal definition of myocardial infarction after coronary artery bypass grafting: a survey study in Western Europe
No full textBACKGROUND: Diagnosing a postoperative myocardial infarction in patients undergoing coronary artery bypass grafting is challenging, as the normally used criteria are more difficult to interpret. The rate of implementation of the consensus-based new diagnostic criteria for postoperative myocardial infarction proposed by the third universal definition of myocardial infarction is unknown. Therefore, the primary objective of this study was to address the implementation of the third universal definition of postoperative myocardial infarction following coronary artery bypass grafting. METHODS AND RESULTS: We conducted a web-based survey by sending 4 waves of invitations via e-mail to cardiothoracic surgeons in 12 Western European countries. Of the 302 participating cardiothoracic specialists, from 182 different centers, 213 (71%) were aware that troponin is the preferred biomarker and 112 (37%) knew that using a cut-off level of >10 times the 99th percentile is recommended. Overall, 90 (30%) participants (strongly) agreed with implementation of this cut-off level in their clinical practice. Troponin was used in clinical practice by 149 (49%) of the participants. In total, 117 (89%) of the 131 participants with a local guideline confirmed ECG changes as a diagnostic criterion in that guideline. ST segmental changes (75, 64%) were used more often for diagnosing postoperative myocardial infarction than Q waves (64, 55%) or new left bundle branch blocks (34, 29%). CONCLUSIONS: Cardiac biomarkers and ECG changes were not used in concordance with the third universal definition, and only a minority had a positive attitude toward implementation of the proposed cut-off level for troponin in their clinical practice
Accuracy of remote continuous respiratory rate monitoring technologies intended for low care clinical settings: a prospective observational study
No full textPurpose: Altered respiratory rate (RR) has been identified as an important predictor of serious adverse events during hospitalization. Introduction of a well-tolerated continuous RR monitor could potentially reduce serious adverse events such as opioid-induced respiratory depression. The purpose of this study was to investigate the ability of different monitor devices to detect RR in low care clinical settings. Methods: This was a prospective method-comparison study with a cross-sectional design. Thoracic impedance pneumography (IPG), frequency modulated continuous wave radar, and an acoustic breath sounds monitor were compared with the gold standard of capnography for their ability to detect RR in breaths per minute (breaths·min−1) in awake postoperative patients in the postanesthesia care unit. The Bland and Altman method for repeated measurements and mixed effect modelling was used to obtain bias and limits of agreement (LoA). Furthermore, the ability of the three devices to assist with correct treatment decisions was evaluated in Clarke Error Grids. Results: Twenty patients were monitored for 1,203 min, with a median [interquartile range] of 61 [60-63] min per patient. The bias (98.9% LoA) were 0.1 (−7.9 to 7.9) breaths·min−1 for the acoustic monitor, −1.6 (−10.8 to 7.6) for the radar, and −1.9 (−13.1 to 9.2) for the IPG. The extent to which the monitors guided adequate or led to inadequate treatment decisions (determined by Clarke Error Grid analysis) differed significantly between the monitors (P = 0.011). Decisions were correct 96% of the time for acoustic, 95% of the time for radar, and 94% of the time for IPG monitoring devices. Conclusions: None of the studied devices (acoustic, IPG, and radar monitor) had LoA that were within our predefined (based on clinical judgement) limits of ± 2 breaths·min−1. The acoustic breath sound monitor predicted the correct treatment more often than the IPG and the radar device
Comparison of approaches to estimate confidence intervals of post-test probabilities of diagnostic test results in a nested case-control study
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