Simon Woodworth

Changes and their prognostic implications in the abbreviated Vitalpac™ early warning score (ViEWS) after admission to hospital of 18,853 acutely ill medical patients

BACKGROUND The best performing early warning score is Vitalpac™ Early Warning Score (ViEWS). However, it is not known how often, to what extent and over what time frame any early warning scores change, and what the implications of these changes are. SETTING Thunder Bay Regional Health Sciences Center, Ontario, Canada. METHODS The changes in the first three complete sets of the six variables required to retrospectively calculate the abbreviated version of ViEWS (that did not include mental status) after admission to hospital of 18,853 acutely ill medical patients, and their relationship to subsequent in-hospital mortality were examined. RESULTS In the 10.4 SD 20.1 (median 5.0) hours between admission and the second recording the score changed in only 5.9% of patients and these changes were of no prognostic value. By the time of the third recording 34.9 SD 21.7 (median 30.0) hours after admission a change in score was clearly associated with a corresponding change in in-hospital mortality (e.g. for patients with an initial score of 5 an increase between the first and third recording of ≥4 points was associated with an increased mortality (OR 6.5 95% CI 2.3-15.9, p<0.00001), whereas a reduction of ≤-4 points was associated with a reduced mortality (OR 0.4 95% CI 0.2-0.9, p 0.03)). CONCLUSION After a median interval of 30 h both the initial abbreviated ViEWS recording and subsequent changes in it both predict clinical outcome. It remains to be determined what interventions during this time frame will improve patient outcomes.

An integrated patient journey mapping tool for embedding quality in healthcare service reform

Abstract The healthcare sector is a highly regulated environment that is subject to numerous constraints. Standards around medical protocol, medical device certification, and data protection ensure that the wellbeing and privacy of patients is protected during all encounters with the healthcare system. However, a gap has opened up between the need to meet these constraints, improve performance, and also deliver good patient experience. For example, the medical protocol for hypertension during pregnancy establishes a set of clinically validated treatment guidelines, but does not consider the unique nature of patient experience. We assert that design research principles can be used to create visual tools that pay homage to these constraints and performance improvement goals without compromising patient experience. In this paper, we describe such a tool that has been developed during a healthcare project using a human-centred design research approach. The integrated tool for patient journey mapping addresses the shortcomings of existing methodologies by supporting multidisciplinary practitioners in designing healthcare solutions that meet the demands of existing constraints, performance improvement, and patient experience. In addition, we document how patient journey maps were used on the project to facilitate collaboration among a team of multidisciplinary stakeholders.

Managing social media uncertainty to support the decision making process during Emergencies

Abstract Recent emergencies have shown the positive impact of using social media and social networks for communicating and exchanging information. Citizens and authorities can make safer decisions during emergencies based on the real-time information available on social media. Decision-making starts with information gathering and social media provides the opportunity to inform multiple citizens at once. However, message and source uncertainty can place emergency stakeholders in a risky position, as it is not always possible to know if messages are accurate, rumours or even malicious. Current approaches for social media information verification focuses on technical resources like analytical packages. Little research has been developed to provide citizens and field workers with tools to evaluate social media information. This paper presents research in progress for developing a verification framework – for all emergency stakeholders – to support their decision-making process by managing social media uncertainty during emergencies.

Variation in health care providers’ perceptions: decision making based on patient vital signs

Clinical decision making plays an imperative role when delivering healthcare services. To assist healthcare practitioners in decision making activities, Early Warning Scorecards (EWS) have been developed to classify patients based on their vital sign readings. This paper aims to evaluate the variation among healthcare practitioners’ perceptions of vital signs critical ranges and priorities, and if there is a variation between decisions made based on paper-based Modified EWS (MEWS) and electronic MEWS. A survey is conducted to analyse these variations for six vital sign parameters. Further investigation is carried out on the variations in decisions made for six simulated patients using the paper-based MEWS and eMEWS. Thus, the variations of decisions made for a given patient among the survey participants are analysed in light of paper-based MEWS and eMEWS. Therefore, this paper contributes to both theory and practice by identifying variations in health care providers’ perceptions when deciding the actions/treatment of patients.

Using smart phone technology to teach neonatal endotracheal intubation (NeoTube): application development and uptake

Neonatal intubation is one of the core competencies of neonatal training. Training in neonatal intubation is commonly gained through direct supervision of novice trainees by experienced personnel and through simulation training using neonatal manikins. Experience in this procedure increases the likelihood of success and reduces the time taken to intubate (1,2). Reduced working hours, as well as changes in the indications for intubation at birth following meconium-stained amniotic fluid (3), and increased use of continuous positive airway pressure (CPAP) (4,5) have resulted in a decline in opportunities to learn neonatal intubation (1). Many infants who would previously have been intubated, received surfactant and commenced on mechanical ventilation are now being managed successfully with CPAP (4,5). In the setting of declining opportunity to learn this important, but challenging skill, trainers need to find alternative means of ensuring acquisition of this core competency. Theoretical knowledge is gained through textbooks, review articles and training courses such as the NRP. Practical sessions involving simulation are useful and commonly take place during neonatal resuscitation training days. The smart phone is a relatively new addition to the trainee’s learning repertoire, but smart phone applications have not previously been used to teach endotracheal intubation skills in neonatology. We describe the development, implementation and early usage of a new iPhone application, NeoTube, which was designed to assist novice and experienced users in acquiring the knowledge and skills required for neonatal endotracheal intubation. A medical team of two neonatal consultants (EMD and CAR), one neonatal registrar (CPH) and an information technology team (SH, BO’F and SW) collaborated on this project. The medical team was responsible for the content of the application as well as the structural layout. The information technology team was responsible for application design, programming and ensuring that the application met Apple’s requirements for applications. The project is described in the following five steps.

Features of electronic Early Warning systems which impact clinical decision making

Paper-based Modified Early Warning Scorecards (MEWS) have been developed to help nursing staff detect hospital in-patient deterioration at an early stage. MEWS is based on patient vital signs where these values are transformed into a MEWS score. An electronic Modified Early Warning Scorecard (eMEWS) prototype has been designed and developed to fulfill the role of a computerized Clinical Decision Support System (CDSS) and to assist healthcare professionals in their decision making activities. A review of the existing electronic Early Warning Scorecards (eEWS) revealed they lack certain features that assist in capturing a holistic view of the patient health status for example color codes and vital sign trends. The proposed eMEWS prototype employs these features with the aim of assisting healthcare professionals to obtain a clear understanding of the patient status. A survey was conducted to evaluate the impact of paper-based MEWS and eMEWS as part of the decision making process. The advantages and disadvantages of eMEWS over the paper-based MEWS are presented.

A Comprehensive Decision Support System for Enhanced Emergency Decision Management and Training

Emergency decision makers face a challenge taking rapid and high-risk decisions during an emergency situation, especially when the emergency is cross-border and requires multi-agency cooperation. The emergency decision makers use emergency management (EM) system and sometimes decision support systems (DSS) when responding to a crisis. To date the emergency decision makers have not had access to a system that supports them in all facets of the full EM cycle. This paper describes work in progress designing and building a comprehensive system of systems that intend to be that support for emergency decision makers. The system has successfully demonstrated its value from a technical and user perspective. Future tests will demonstrate if it will enhance decision management in reality-based emergency scenarios.

An Approach for Reflectively Discovering and Synthesizing Design Knowledge for Situated Artifacts: The Case of the Early Warning Score Chart

This paper presents an approach for reflectively evaluating systems from a design science perspective. Design science research typically follows a design-build-evaluate methodology, where the evaluation is dependent on the utility requirements defined in the design phase. This methodology is appropriate when designing new systems, but is suboptimal when developing iterative design improvements for existing situated artifacts or legacy systems. For iterative design, there is a necessity to understand the problem system the previous iteration was designed for and what changes to the problem system the artifact was designed to affect. Often the design process for these solutions will not have been adequately documented, and as such a process of discovery must be undertaken to document each stage of the design process. Once documented, an evaluate-build-evaluate design approach can be taken. The purpose of this paper is to outline an approach for acquiring and synthesizing design knowledge, which allows for rigorous evaluation of a situated artifact.

An Exploration of Customer-Centric Cloud Service Design

Cloud computing applications and services go hand in hand, yet there is no clear mechanism for ensuring that the cloud applications are designed from a customer’s perspective. This paper describes the initial design and development of a predictive analytics cloud service application, which uses historic customer data to predict the existing customers that are most likely to churn. Service blueprinting, a service innovation method, was being used as the underlying design model for developing an initial shared understanding of the required service. The Design Science paradigm can focus on the development of the IT artifact, but it can also develop an Information Systems Design Theory (ISDT) as a research outcome. This paper considers service blueprinting as kernel theory or underpinning mechanism for a Cloud Service Design Theory (CSDT), which will enable developers to prescribe designs of customer centric cloud based service applications. Using the design science paradigm an extended cloud service design theory is proposed, as an outcome of the ongoing development of this analytics platform.