A crossover study assessing the protective efficacy of improvised snorkel-based improvised respirators.

Introduction: This study was designed to determine whether improvised respirators based on modified full-face snorkel masks are able to pass a standard qualitative fit test. Methods: This is a prospective crossover study conducted in 16 staff. Fit-tests were conducted on masks mated to (1) an anaesthetic breathing circuit heat and moisture exchange filter and (2) a CE-marked P3 grade filter. P3 filters were mounted using both epoxy-coated and uncoated adaptors. Results: None of the tests using anaesthetic filters passed. Only one overall pass was observed using the P3-rated filter mated to the snorkel mask. Conclusions: These data suggest that improvised PPE designs cannot provide reliable protection against aerosols. Failures are likely due to poor fit, but the suitability of 3D printed materials is also uncertain as fused-filament manufacturing yields parts that are not reliably gas-tight. Improvised PPE cannot be recommended as a substitute for purpose designed systems.

A crossover trial investigating the atmospheric content of improvised respirators.

Introduction: This study was designed to determine the respiratory safety of improvised respirators based on modified full-face snorkel masks, making comparisons with a purpose-designed mask. Methods: This is a prospective crossover study conducted on ten recruits. Volunteers wore snorkel masks mated to an anaesthetic heat and moisture exchange filter. The system was worn at rest then during exercise. Gases were sampled from the mask at 5-min intervals. Results: The modified snorkel was satisfactory in seven participants. For three carbon dioxide concentrations were >1%. Two participants exposed to excessive CO2 also experienced oxygen concentrations <19%. All participants exposed to unsatisfactory gas mixtures were non-white. Conclusions: Modifying snorkel masks changes the way that gases circulate through the system. These modifications increase the risk of rebreathing in some users, which may yield an unsafe gas mixture. These improvised masks cannot be recommended as a substitute for purpose-designed equipment.

Monitoring sound levels in the intensive care unit: A mixed-methods system development project to optimize design features for a new electronic interface in the healthcare environment.

BACKGROUND: Intensive care units (ICU) are busy round the clock and it is difficult to maintain low sound levels that support patient rest. To help ICU staff manage activities we developed a visual display that monitors and reports sound levels in real-time. This facilitates immediate feedback, encouraging proactive behavior change to limit disturbances. METHODS: Following the principles of user-centered design practices we created our 'user persona' to understand the needs and goals of potential users of the system. We then conducted iterative user testing with current members of the ICU team, primarily using the 'think aloud' method to refine the design and functionality of our novel system. Ethnography evaluated team use of the display. RESULTS: The final design was simple, clear, and efficient, and both functional and aesthetically pleasing for the key user demographic. We identified challenges in the implementation and adoption process that were separate from the 'usability' of the system itself. CONCLUSIONS: Embedding the design process within the core user demographic ensured the final product delivered relevant information for key users, and that this information was intuitive to interpret. Initiating sustainable change is not straightforward. It requires recognition of cultural practices within teams, departments, professions, organizations, and strategies to maximize engagement.

Observer-based tools for non-technical skills assessment in simulated and real clinical environments in healthcare: a systematic review.

BACKGROUND: Over the past three decades multiple tools have been developed for the assessment of non-technical skills (NTS) in healthcare. This study was designed primarily to analyse how they have been designed and tested but also to consider guidance on how to select them. OBJECTIVES: To analyse the context of use, method of development, evidence of validity (including reliability) and usability of tools for the observer-based assessment of NTS in healthcare. DESIGN: Systematic review. DATA SOURCES: Search of electronic resources, including PubMed, Embase, CINAHL, ERIC, PsycNet, Scopus, Google Scholar and Web of Science. Additional records identified through searching grey literature (OpenGrey, ProQuest, AHRQ, King's Fund, Health Foundation). STUDY SELECTION: Studies of observer-based tools for NTS assessment in healthcare professionals (or undergraduates) were included if they: were available in English; published between January 1990 and March 2018; assessed two or more NTS; were designed for simulated or real clinical settings and had provided evidence of validity plus or minus usability. 11,101 articles were identified. After limits were applied, 576 were retrieved for evaluation and 118 articles included in this review. RESULTS: One hundred and eighteen studies describing 76 tools for assessment of NTS in healthcare met the eligibility criteria. There was substantial variation in the method of design of the tools and the extent of validity, and usability testing. There was considerable overlap in the skills assessed, and the contexts of use of the tools. CONCLUSION: This study suggests a need for rationalisation and standardisation of the way we assess NTS in healthcare and greater consistency in how tools are developed and deployed.

Correction: "I Can Remember Sort of Vivid People but to Me They Were Plasticine." Delusions on the Intensive Care Unit: What Do Patients Think Is Going On?

[This corrects the article DOI: 10.1371/journal.pone.0153775.].

"I Can Remember Sort of Vivid People but to Me They Were Plasticine." Delusions on the Intensive Care Unit: What Do Patients Think Is Going On?

INTRODUCTION: Patients who develop intensive care unit (ICU) acquired delirium stay longer in the ICU, and hospital, and are at risk of long-term mental and physical health problems. Despite guidelines for patient assessment, risk limitation, and treatment in the ICU population, delirium and associated delusions remain a relatively common occurrence on the ICU. There is considerable information in the literature describing the incidence, suspected causes of, and discussion of the benefits and side-effects of the various treatments for delirium in the ICU. But peer-reviewed patient-focused research is almost non-existent. There is therefore a very limited understanding of the reality of delusions in the intensive care unit from the patient's point of view. METHOD: A secondary analysis of the original interviews conducted by the University of Oxford Health Experiences Research Group was undertaken to explore themes relating specifically to sleep and delirium. RESULTS: Patients describe a liminal existence on the ICU. On the threshold of consciousness their reality is uncertain and their sense of self is exposed. Lack of autonomy in an unfamiliar environment prompts patients to develop explanations and understandings for themselves with no foothold in fact. CONCLUSION: Patients on the ICU are perhaps more disoriented than they appear and early psychological intervention in the form of repeated orientation whilst in the ICU might improve the patient experience and defend against development of side-effects.

Failure to perceive clinical events: an under-recognised source of error.

INTRODUCTION: Attentional focus narrows as individuals concentrate on tasks. Missing an event that would otherwise appear obvious is termed a perceptual error. These forms of perceptual failure are well-recognised in psychological literature, but little attention has been paid to them in medicine. Cognitive workload and expertise modulate risk, although how these factors interplay in practice is unclear. This video-based experiment was designed to explore the hypothesis that perceptual errors affect clinicians. METHODS: 142 volunteers with varying levels of experience of adult resuscitation were shown a short video depicting a simulated cardiac arrest. This video included a series of change-events designed to elicit perceptual errors. The experiment was conducted on-line, with participants watching the video and then responding via combinations of open-ended free-text and directed questioning. RESULTS: 141 people experienced at least a single perceptual error. Even the most clinically significant event (disconnection of the patient's oxygen supply) was missed by three in four viewers. Although expertise was associated with increased likelihood of detecting an occurrence, even highly significant events were missed by up to two thirds of the most experienced observers. DISCUSSION: This study demonstrates, for the first time, that perceptual errors occur during healthcare-relevant scenarios at significant levels. Events such as an oxygen malfunction would meaningfully affect patient outcome and, although expertise conferred some advantages, events were still missed more often than not. Data acquisition is fundamental to good-quality situational awareness. These results suggest perceptual error may be a contributor to adverse events in practice.