Spearcon Sequences for Monitoring Multiple Patients: Laboratory Investigation Comparing Two Auditory Display Designs

Objective: The aim was to compare the effectiveness of two auditory displays, implemented with spearcons (time-compressed speech), for monitoring multiple patients. Background: Sequences of sounds can convey information about patients’ vital signs, such as oxygen saturation (SpO2) and heart rate (HR). We tested whether participants could monitor five patients using spearcon-based sound sequences. Method: A 2 × 3 within-subjects design was used. The first factor was interface, with two levels: the ALL interface used spearcons to convey vital signs for all five patients, whereas the ABN (abnormal) interface represented patients who had normal vital signs with a low-pitched single-tone sound and patients who had at least one abnormal vital sign with spearcons. The second factor was the number of patients who had at least one abnormal vital sign: there were one, two, or three such patients in each monitoring sequence. Participants were 40 nonclinicians. Results: Participants identified abnormal patients’ SpO2 and HR levels and located abnormal patients in the sound sequence more accurately with the ABN interface than the ALL interface. Accuracy declined as the number of abnormal patients increased. Participants associated ABN with easier identification of vital signs, resulting in higher ratings of confidence and pleasantness compared with ALL. Conclusion: Sequences of spearcons may support effective eyes-free monitoring of multiple patients. Application: Sequences of spearcons may be useful in monitoring multiple patients and the underlying design principles may extend to monitoring in other domains such as industrial process control or control of multiple autonomous vehicles.

The association between abnormal vital sign groups and undesirable patient outcomes

Introduction: To determine the association between both abnormal individual vital signs and abnormal vital sign groups in the emergency department, and undesirable patient outcomes: hospital admission, medical emergency team calls and death. Method: We undertook a prospective cohort study in a tertiary referral emergency department (February–May 2015). Vital signs were collected prospectively in the emergency department and undesirable outcomes from the medical records. The primary outcomes were undesirable outcomes for individual vital signs (multivariate logistic regression) and vital sign groups (univariate analyses). Results: Data from 1438 patients were analysed. Admission was associated with tachycardia, tachypnoea, fever, ≥1 abnormal vital sign on admission to the emergency department, ≥1 abnormal vital sign at any time in the emergency department, a persistently abnormal vital sign, and vital signs consistent with both sepsis (tachycardia/hypotension/abnormal temperature) and pneumonia (tachypnoea/fever) (p < 0.05). Medical emergency team calls were associated with tachycardia, tachypnoea, ≥1 abnormal vital sign on admission (odds ratio: 2.3, 95% confidence interval: 1.4–3.8), ≥2 abnormal vital signs at any time (odds ratio: 2.4, 95% confidence interval: 1.2–4.7), and a persistently abnormal vital sign (odds ratio: 2.7, 95% confidence interval: 1.6–4.6). Death was associated with Glasgow Coma Score ≤13 (odds ratio: 6.3, 95% confidence interval: 2.5–16.0), ≥1 abnormal vital sign on admission (odds ratio: 2.6, 95% confidence interval: 1.2–5.6), ≥2 abnormal vital signs at any time (odds ratio: 6.4, 95% confidence interval: 1.4–29.5), a persistently abnormal vital sign (odds ratio: 4.3, 95% confidence interval: 2.0–9.0), and vital signs consistent with pneumonia (odds ratio: 5.3, 95% confidence interval: 1.9–14.8). Conclusion: Abnormal vital sign groups are generally superior to individual vital signs in predicting undesirable outcomes. They could inform best practice management, emergency department disposition, and communication with the patient and family.

Sickle Cell Crisis: Safety Of a High-Dose Opioid Protocol In The Emergency Department

Background Vaso-occlusive crisis (VOC) management of patients with sickle cell disease (SCD) in emergency departments (EDs) is typically reported as sub-optimal. As part of a larger research and quality improvement study, a nurse-initiated high dose, opioid protocol for adults with VOC was implemented in one ED. The protocol allowed for administration of a total of morphine sulfate (MS) 50 mg, or hydromorphone 10 mg intravenous push (IVP), over three doses (every 20 minutes) and within 60 minutes for patients who received opioid therapy in the last 24 hours, and half the dose for patients who had not taken opioids in the last 24 hours. Additional analgesic administration was at the discretion of the ED physician. Objective Protocol fidelity [total IV MS equivalents (IVMSE) in mgs administered] and safety was evaluated. Methods A structured medical record (MR) review was conducted for all ED visits in patients with a diagnosis of VOC during the 13 month time period immediately after protocol initiation in a single urban ED. All opioids, doses and routes administered during the entire ED stay, and six hours into the hospital admission (when applicable) were abstracted and the total IVMSE administered was calculated for the ED, hospital (First 6 hours), and a total ED + hospital. The period of six hours post admission was selected to be able to identify possible negative effects of opioids administered in the ED; thus it was necessary to also abstract additional opioid doses received by the patient during this six our time period. After six hours, negative effects would not be the result of dosing done in the ED. All documented Oxygen saturations (SPO2) and respiratory rates were abstracted. The ED and hospital MR were searched for administration of naloxone, vasoactive medications, and evidence of respiratory arrest, or any other type of resuscitation effort. A respiratory rate (RR) < 10, or SPO2 <92 were coded as abnormal. Descriptive statistics were used to report the total IVMSE while in ED, six hours post ED while in the hospital, and total (ED and hospital). Inter-rater reliability of IVMSE doses was good (n=80, Pearson r = .84). Logistic regression was used to predict abnormal events. Predictors in the model were age, gender, and ED IVMSE administered. Results 72 patients (mean age 36, 54% male) had 603 visits, of those 276 were admitted. The total mean (95% CI) mg IVMSE administered in the ED and first 6 hours of hospital combined was 93 mg (CI 86, 100), ED visit 63 mg (CI 59, 67) and hospital 66 mg (CI 59, 72). No administration of naloxone, vasoactive medications, or resuscitative measures was required during any visit. During two visits, patients experienced a RR < 10 and 61 visits were associated with a SPO2 <92%. It was not possible to determine if oxygen administration was additionally required because many patients routinely received oxygen during VOC. Older age and higher IVMSE dose were associated with abnormal vital sign occurrence. For every one year increase in age, patients were 4%, or 1.04 times more likely to experience an abnormal vital sign (p=0.012). For every 10 mg IVMSE increase in the ED dose, patients were 4.6%, or 1.046 times more likely to experience an abnormal vital sign (p=0.049). Conclusion A high dose opioid protocol to treat VOC in the ED was found to be feasible, importantly, the protocol was safe. Older age and higher IVMSE dose were associated with abnormal vital sign occurrence. While some patients experienced a SPO2 <92%, no additional interventions or opioids discontinuation were required. Disclosures: No relevant conflicts of interest to declare.