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Critical care research

Computer Alerting Monitoring System (CALMS)

The study hypothesis is that an automated alerting system will better identify patients after upper GI surgery who are at risk of clinical deterioration than a standard paper based 'Track-and-Trigger' system (a system that gives a score for heart rate, respiratory rate, blood pressure and blood oxygen levels).

This study was conducted in two recruitment phases. In Phase 1 a monitoring device was used to record observations on ward patients, without allowing staff the benefit of the data. These readings were validated by subsequent comparison with the ward nurses observation charts. In Phase 2 the monitoring devices were 'live' and alerted ward staff in real time. These patients were urgently reviewed by the ICU team.

Comparison of the outcomes of the patients in the two phases of the study will be used to demonstrate the benefits of this technology.

Research Ethics Committee Reference: 11/YH/0056
European Clinical Trials Database Reference: EudraCT: 2011/000928-15
International Standard Randomised Controlled Trial Number: ISRCTN: 72502609

Observational study to assess the incidence and reversibility of acute left ventricular myocardial dysfunction in critically ill adults

This study was designed to accurately define the proportion of patients who have abnormalities of their heart muscle who are admitted as an emergency to the general Adult Intensive Care Unit (ICU). Study participants received three ultrasound scans of the chest (a transthoracic echocardiogram, or TTE) in the first week of their ICU stay. Information was also collected from their medical records to assess what impact the development of acute heart impairment had on their critical illness. In those whom acute heart impairment was detected, repeat TTEs were performed 1 week after ICU discharge and three and twelve months after ICU admission to assess the degree of recovery of heart function. Length of stay, duration of assisted ventilation, disorders of heart rhythm and amount of medication required to support the function of the heart will be compared between those who develop heart impairment and those who do not.

The results of this study will provide a greater understanding of the incidence of acute heart impairment in critically ill patients, what effect it has on their illness and the degree of recovery of heart function following ICU discharge.

Research Ethics Committee Reference: 12/SC/0999

A retrospective analysis of the natural history of reversible myocardial dysfunction in critically ill patients

Each year over 100,000 patients experiencing critical illness are admitted to Intensive Care Units (ICU) across the United Kingdom. Acute, reversible heart impairment has been described in some patient groups of critical illness, such as those suffering from severe infections.

Despite studies in some ICU patient groups showing that this condition is associated with clinical instability, this condition remains poorly understood in the general ICU population. We are undertaking a retrospective analysis of repeated heart ultrasound studies, matched with vital signs, performed in the Intensive Care Unit between June 2008 and June 2013. We aim to characterise the natural history and outcomes of patients experiencing reversible heart impairment during critical illness.

Research Ethics Committee Reference: 13/SC/0399
Confidentiality Advisory Group Reference: CAG 6-03(PR2)/2013

Evaluation of the time course of acute, reversible myocardial dysfunction in the general adult intensive care population

This study aims to describe the time course of reversible heart function in patients experiencing critical illness. It is known that reversible heart impairment can occur in patients with certain types of critical illness, such as severe infections. Little is known about how this condition may affect other types of patients admitted to Intensive Care, or if the results seen in patients with infections are applicable to other groups. We will use both ultrasound (echocardiography) and cardiac magnetic resonance imaging (CMRI) to look at in detail any changes in, and the recovery of, heart function during critical illness. Whilst participants are admitted to the Intensive Care Unit, we will assess changes in heart function using bedside echocardiography. When some of these participants have been discharged to the wards, and are medically stable, we will use CMRI to add further, highly detailed, information about the recovery of the heart following critical illness.

Finally, in participants who demonstrate impaired heart function whilst in hospital and who are not receiving certain heart medications (e.g. noradrenaline), we will take a small blood sample at the time of heart assessments to see if the reversible heart impairment seen in critically ill patients share common features with other reversible heart conditions (elevated stress hormones). We will use both ultrasound (echocardiography) and cardiac magnetic resonance imaging (CMRI) to look at in detail any changes in, and the recovery of, heart function during critical illness.

Research Ethics Committee Reference: 14/SC/0305

Intensive Care Outcome Network Study (ICON)

Patients who have spent time on an Intensive Care Unit (ICU) often suffer severe psychological after-effects such as nightmares and flashbacks. The Intensive Care Outcome Network (ICON) is collecting long-term information on the psychological and physical health of patients who spent time on ICU at hospitals which are involved with the study. With this very direct patient information, ICON will be able to identify the risk factors for poor psychological and physical outcomes. This information will inform future health professionals and could lead to the development of effective diagnoses that will ultimately improve patients' quality of life after ICU.

Research Ethics Committee Reference: 11/SC/0172

Measurement of oxygen consumption in critical illness using optical gas analysis

This is a prospective longitudinal observational study in thirty intubated, ventilated patients (those on a machine to help them breathe).

Many serious illnesses are characterised by a lack of oxygen supply to the body's tissues and many treatments aim to correct this. These include drugs to increase blood pressure, blood transfusions and breathing machines. One important factor used to guide decisions about treatment is an assessment of how much oxygen a patient is consuming. Unfortunately, the equipment and techniques needed to measure this properly have until now not been practical for routine use in intensive care. Doctors instead have to rely on a number of indicators of the adequacy of the amount of oxygen being provided, which all have limitations.

We have developed a way to accurately and rapidly measure how much oxygen is being consumed when a patient is on a breathing machine. This study will provide data to identify how changes in a patient's condition and treatments alter this. Future studies might then seek to improve patient care by monitoring and optimising oxygen consumption.

Research Ethics Committee Reference: 14/EE/0003

Post-Intensive Care Risk-Adjusted Alerting & Monitoring (PICRAM)

One tenth of the 85,000 patients discharged annually from UK intensive care units (ICUs) recovering from their acute illness, die before leaving hospital. Frequent visits to the patients' wards by the ICU team reduce this risk, but suitably trained nurses are expensive and in short supply.

We plan to develop a comfortable, wearable device to automatically measure vital signs in patients discharged from the ICU. Using the hospital wi-fi network we will monitor the patients' vital signs continuously with a computer system, which will also be programmed with information on each individual patient's risk of deterioration. If the computer detects a change in the patients' vital signs, it will alert medical staff. This approach allows us to monitor far more patients, for a far longer time, than would be possible using nurses alone, whilst minimising false alarms by tailoring the alarm limits to each individual patient.

Research Ethics Committee Reference: 11/SC/0440 and 12/SC/0357
International Standard Randomised Controlled Trial Number: ISRCTN: 32008295

System for Electronic Notification and Documentation (SEND)

Research has shown that physiological deteriorations in patients are commonly unrecognised and suggests that clinical staff make errors in calculating Track and Trigger (T&T) scores, leading to potential delays in appropriately escalating the care of deteriorating patients.

In 2007 NICE recommended the assessment of the clinical effectiveness of automated (electronic) monitoring systems in identifying deteriorating patients earlier, and improving the ability of nursing and medical staff to deliver more timely interventions and treatments.

A multidisciplinary team of clinicians, nurses, human factors scientists, biomedical engineers and computer scientists from across the OUH and the University of Oxford was formed to design and develop a system for documenting and displaying patients' observations tailored to the needs of the OUH.

The SEND project aims to improve patient care and clinical practice by promoting safe, high-quality clinical care which complements current practice and by reducing the burden on clinical staff of reviewing patient data.

Sleep in the ICU - Lowering Elements of Noise in the Critical Care Environment (SILENCE)

Sound levels in the Intensive Care Unit (ICU) are well above the recommended levels suggested by the World Health Organisation. Lowering these levels, even modestly, may help patients to sleep, and may result in fewer episodes of ICU-acquired delirium experienced by patients during their stay. Patients who develop delirium tend to have longer hospital stays and often have long-term health problems after they have been discharged home.

The SILENCE Programme is a series of studies designed to lower noise levels, improve sleep hygiene, and ultimately reduce the incidence of ICU-acquired delirium.

In parallel with unit level assessments data will be collected on patient experience. Interview transcripts and patient feedback questionnaires will be reviewed, and in-situ observations will be completed in the ICU to gather information about key sources of noise and how different noises affect patients, visitors, and staff. A patient-led exercise will identify areas of particular concern and prioritise practice change.

The research programme has been funded through a project grant awarded by the NIHR Research for Patient Benefit scheme, and a small grant awarded by the University of Oxford Medical Sciences Division, and is sponsored by the University of Oxford.

Research Ethics Committee Reference: 14/SC/0164