Beware: the misuse of technology and the law of unintended consequences

Designing a trial for neonatal seizure treatment

Neonatal seizures are widely considered a neurological emergency with a need for prompt treatment, yet they are known to present a highly elusive target for bedside clinicians. Recent studies have suggested that the design of a neonatal seizure treatment trial will profoundly influence the sample size, which may readily increase to hundreds or even thousands as the achieved effect size diminishes to clinical irrelevance. The self-limiting and rapidly resolving nature of neonatal seizures diminishes the measurable treatment effect every hour after seizure onset and any effect may potentially be confused with spontaneous resolution, precluding the value of many observational studies. The large individual variability in seizure occurrence over time and between etiologies challenges group comparisons, while the absence of clinical signs mandates quantification of seizure occurrence with continuous multi-channel EEG monitoring. A biologically sound approach that views neonatal seizures as a functional cot-side biomarker rather than an object to treat can overcome these challenges.

Intermittent auscultation versus continuous fetal monitoring: exploring factors that influence birthing unit nurses' fetal surveillance practice using theoretical domains framework

BACKGROUND

Intermittent Auscultation (IA) is the recommended method of fetal surveillance for healthy women in labour. However, the majority of women receive continuous electronic monitoring. We used the Theoretical Domains Framework (TDF) to explore the views of Birthing Unit nurses about using IA as their primary method of fetal surveillance for healthy women in labour.

METHODS

Using a semi-structured interview guide, we interviewed a convenience sample of birthing unit nurses throughout Ontario, Canada to elicit their views about fetal surveillance. Interviews were recorded and transcribed verbatim. Transcripts were content analysed using the TDF and themes were framed as belief statements. Domains potentially key to changing fetal surveillance behaviour and informing intervention design were identified by noting the frequencies of beliefs, content, and their reported influence on the use of IA.

RESULTS

We interviewed 12 birthing unit nurses. Seven of the 12 TDF domains were perceived to be key to changing birthing unit nurses' behaviour The nurses reported that competing tasks, time constraints and the necessity to multitask often limit their ability to perform IA (domains Beliefs about capabilities; Environmental context and resources). Some nurses noted the decision to use IA was something that they consciously thought about with every patient while others stated it their default decision as long as there were no risk factors (Memory, attention and decision processes, Nature of behaviour). They identified positive consequences (e.g. avoid unnecessary interventions, mother-centered care) and negative consequences of using IA (e.g. legal concerns) and reported that the negative consequences can often outweigh positive consequences (Beliefs about consequences). Some reported that hospital policies and varying support from care teams inhibited their use of IA (Social influences), and that support from the entire team and hospital management would likely increase their use (Social influences; Behavioural regulation).

CONCLUSION

We identified potential influences on birthing unit nurses' use of IA as their primary method of fetal surveillance. These beliefs suggest potential targets for behaviour change interventions to promote IA use.

"Usability of data integration and visualization software for multidisciplinary pediatric intensive care: a human factors approach to assessing technology"

Background

Intensive care clinicians use several sources of data in order to inform decision-making. We set out to evaluate a new interactive data integration platform called T3™ made available for pediatric intensive care. Three primary functions are supported: tracking of physiologic signals, displaying trajectory, and triggering decisions, by highlighting data or estimating risk of patient instability. We designed a human factors study to identify interface usability issues, to measure ease of use, and to describe interface features that may enable or hinder clinical tasks.

Methods

Twenty-two participants, consisting of bedside intensive care physicians, nurses, and respiratory therapists, tested the T3™ interface in a simulation laboratory setting. Twenty tasks were performed with a true-to-setting, fully functional, prototype, populated with physiological and therapeutic intervention patient data. Primary data visualization was time series and secondary visualizations were: 1) shading out-of-target values, 2) mini-trends with exaggerated maxima and minima (sparklines), and 3) bar graph of a 16-parameter indicator. Task completion was video recorded and assessed using a use error rating scale. Usability issues were classified in the context of task and type of clinician. A severity rating scale was used to rate potential clinical impact of usability issues.

Results

Time series supported tracking a single parameter but partially supported determining patient trajectory using multiple parameters. Visual pattern overload was observed with multiple parameter data streams. Automated data processing using shading and sparklines was often ignored but the 16-parameter data reduction algorithm, displayed as a persistent bar graph, was visually intuitive. However, by selecting or automatically processing data, triggering aids distorted the raw data that clinicians use regularly. Consequently, clinicians could not rely on new data representations because they did not know how they were established or derived.

Conclusions

Usability issues, observed through contextual use, provided directions for tangible design improvements of data integration software that may lessen use errors and promote safe use. Data-driven decision making can benefit from iterative interface redesign involving clinician-users in simulated environments. This study is a first step in understanding how software can support clinicians’ decision making with integrated continuous monitoring data. Importantly, testing of similar platforms by all the different disciplines who may become clinician users is a fundamental step necessary to understand the impact on clinical outcomes of decision aids.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-017-0520-7) contains supplementary material, which is available to authorized users.

Amplitude Integrated Electroencephalography Compared With Conventional Video EEG for Neonatal Seizure Detection: A Diagnostic Accuracy Study

This diagnostic accuracy study compared the accuracy of seizure detection by amplitude-integrated electroencephalography with the criterion standard conventional video EEG in term and near-term infants at risk of seizures. Simultaneous recording of amplitude-integrated EEG (2-channel amplitude-integrated EEG with raw trace) and video EEG was done for 24 hours for each infant. Amplitude-integrated EEG was interpreted by a neonatologist; video EEG was interpreted by a neurologist independently. Thirty-five infants were included in the analysis. In the 7 infants with seizures on video EEG, there were 169 seizure episodes on video EEG, of which only 57 were identified by amplitude-integrated EEG. Amplitude-integrated EEG had a sensitivity of 33.7% for individual seizure detection. Amplitude-integrated EEG had an 86% sensitivity for detection of babies with seizures; however, it was nonspecific, in that 50% of infants with seizures detected by amplitude-integrated EEG did not have true seizures by video EEG. In conclusion, our study suggests that amplitude-integrated EEG is a poor screening tool for neonatal seizures.

Intermittent auscultation of the fetal heart rate during labor: an opportunity for shared decision making

Electronic fetal heart rate monitoring is the most common form of intrapartal fetal assessment in the United States. Intermittent auscultation of the fetal heart rate is an acceptable option for low-risk laboring women, yet it is underutilized in the hospital setting. Several expert organizations have proposed the use of intermittent auscultation as a means of promoting physiologic childbirth. Within a shared decision-making model, the low-risk pregnant woman should be presented with current evidence about options for fetal heart rate assessment during labor.

Impact of amplitude-integrated electroencephalograms on clinical care for neonates with seizures

Amplitude-integrated electroencephalography (aEEG) was recently introduced into neonatal intensive care in the United States. We evaluated whether aEEG has changed clinical care for neonates with seizures. This study included all 202 neonates treated for seizures at our hospital from 2002-2007. Neonates monitored with aEEG (n = 67) were compared with contemporary control neonates who were not monitored, despite the availability of aEEG (n = 57), and a historic control group of neonates treated for seizures before our neonatal intensive care unit initiated aEEG (n = 78). Eighty-two percent of those receiving phenobarbital (137/167) continued treatment after discharge, with no difference among groups. Adjusted for gestational age and length of stay, no difference among groups was evident in number of neuroimaging studies or number of antiepileptic drugs per patient. Fewer patients undergoing aEEG, compared with contemporary (16/67 vs 29/57, respectively, P = 0.001) or historic (n = 38/78, P = 0.002) controls, were diagnosed clinically with seizures without electrographic confirmation. We conclude that aEEG did not increase neuroimaging tests, and did not alter antiepileptic drug use. However, diagnostic precision regarding neonatal seizures improved with aEEG because fewer neonates were treated for seizures based solely on clinical findings, without electrographic confirmation.

Electrode challenges in amplitude-integrated electroencephalography (aEEG): research application of a novel noninvasive measure of brain function in preterm infants

Continuous real-time brain function monitoring of preterm infants offers a novel way to evaluate neurological development in neonatal intensive care. Direct measurement of brain function is difficult and complicated by vulnerabilities of the preterm infant population. This study illustrates the feasibility of using noninvasive hydrogel electrodes with amplitude-integrated electroencephalography (aEEG) as a simplified brain monitor in preterm infants. This article presents a systematic exploration of factors influencing the accuracy of aEEG measurement, especially skin preparation procedures and skin condition after electrode placement. The authors conducted aEEG recordings on 16 medically stable preterm infants at 31-36 weeks postmenstrual age in the neonatal intensive care unit between feedings and caregiving for approximately 3 hr. The authors systematically performed several strategies to improve electrode placement procedures and reduce skin impedance, including (a) examination of possible influences of environmental electrical equipment, (b) comparison of different hydrogel electrode types, (c) modification of skin preparation procedures, and (d) assessment of impacts of different skin conditions. The authors achieved improvements in the impedance value, length of uninterrupted recording, and percentage of the recording duration with measured impedance <20 kΩ (recommended acceptable limit). There was no report of skin irritation during or after the recording. The aEEG measurement at the bedside using hydrogel electrodes is noninvasive and feasible for reliable brain monitoring in preterm infants. This study demonstrated the importance of establishing systematic methods to ensure the accuracy and feasibility of physiologic measurements for nurse researchers.

Electronic fetal monitoring: past, present, and future

Electronic fetal monitoring (EFM) using cardiotocography is a common tool used during labor and delivery for assessment of fetal well-being. It has largely replaced the use of intermittent auscultation and fetal scalp pH sampling. However, data suggesting improved clinical outcomes with the use of EFM are sparse. In this review, the history of EFM is revisited from its inception in the 1960s to current practice, interpretations, and future research goals.

Near infrared spectroscopy (NIRS) should not be standard of care for postoperative management

Neurologic dysfunction is a problem in patients with congenital heart disease. Near infrared spectroscopy (NIRS) may provide a real-time window into cerebral oxygenation. Enthusiasm for NIRS has increased in hopes of reducing neurologic dysfunction. However, potential gains need to be evaluated relative to cost and potential detriment of intervention before routine implementation. Responding to data in ways that seem intuitively beneficial can be risky when the long-term impact is unknown. Many centers, and even entire countries, have adopted NIRS as standard of care. Available data suggest that multimodality monitoring, including NIRS, may be a useful adjunct. However, the current literature on the use of NIRS alone does not demonstrate improvement in neurologic outcome. Data correlating NIRS findings with indirect measures of neurologic outcome or mortality are limited. Although NIRS has promise for measuring regional tissue oxygen saturation, the lack of data demonstrating improved outcomes limits the support for wide-spread implementation.

Real-time detection, quantification, warning, and control of epileptic seizures: the foundations for a scientific epileptology

Substantive advances in clinical epileptology may be realized through the judicious use of real-time automated seizure detection, quantification, warning, and delivery of therapy in subjects with pharmacoresistant seizures. Materialization of these objectives is likely to elevate epileptology to the level of a mature clinical science.

Methods, procedures, and contextual characteristics of health technology assessment and health policy decision making: comparison of health technology assessment agencies in Germany, United Kingdom, France, and Sweden

OBJECTIVES

The objectives of this study were (i) to develop a systematic framework for describing and comparing different features of health technology assessment (HTA) agencies, (ii) to identify and describe similarities and differences between the agencies, and (iii) to draw conclusions both for producers and users of HTA in research, policy, and practice.

METHODS

We performed a systematic literature search, added information from HTA agencies, and developed a conceptual framework comprising eight main domains: organization, scope, processes, methods, dissemination, decision, implementation, and impact. We grouped relevant items of these domains in an evidence table and chose five HTA agencies to test our framework: DAHTA@DIMDI, HAS, IQWiG, NICE, and SBU. Item and domain similarity was assessed using the percentage of identical characteristics in pairwise comparisons across agencies. RESULTS were interpreted across agencies by demonstrating similarities and differences.

RESULTS

Based on 306 included documents, we identified 90 characteristics of eight main domains appropriate for our framework. After applying the framework to the five agencies, we were able to show 40 percent similarities in "dissemination," 38 percent in "scope," 35 percent in "organization," 29 percent in "methods," 26 percent in "processes," 23 percent in "impact," 19 percent in "decision," and 17 percent in "implementation."

CONCLUSION

We found considerably more differences than similarities of HTA features across agencies and countries. Our framework and comparison provides insights and clarification into the need for harmonization. Our findings could serve as descriptive database facilitating communication between producers and users.

A pilot study of continuous limited-channel aEEG in term infants with encephalopathy

OBJECTIVE

To evaluate the accuracy, feasibility, and impact of limited-channel amplitude integrated electroencephalogram (aEEG) monitoring in encephalopathic infants.

STUDY DESIGN

Encephalopathic infants were placed on limited-channel aEEG with a software-based seizure event detector for 72 hours. A 12-hour epoch of conventional EEG-video (cEEG) was simultaneously collected. Infants were randomly assigned to monitoring that was blinded or visible to the clinical team. If a seizure detection event occurred in the visible group, the clinical team interpreted whether the event was a seizure, based on review of the limited-channel aEEG. EEG data were reviewed independently offline.

RESULTS

In more than 68 hours per infant of limited-channel aEEG monitoring, 1116 seizures occurred (>90% clinically silent), with 615 detected by the seizure event detector (55%). Detection improved with increasing duration of seizures (73% >30 seconds, 87% >60 seconds). Bedside physicians were able to accurately use this algorithm to differentiate true seizures from false-positives. The visible group had a 52% reduction in seizure burden (P = .114) compared with the blinded group.

CONCLUSIONS

Monitoring for seizures with limited-channel aEEG can be accurately interpreted, compares favorably with cEEG, and is associated with a trend toward reduced seizure burden.

Effects of algorithm for diagnosis of active labour: cluster randomised trial

OBJECTIVE

To compare the effectiveness of an algorithm for diagnosis of active labour in primiparous women with standard care in terms of maternal and neonatal outcomes.

DESIGN

Cluster randomised trial.

SETTING

Maternity units in Scotland with at least 800 annual births.

PARTICIPANTS

4503 women giving birth for the first time, in 14 maternity units. Seven experimental clusters collected data from a baseline sample of 1029 women and a post-implementation sample of 896 women. The seven control clusters had a baseline sample of 1291 women and a post-implementation sample of 1287 women.

INTERVENTION

Use of an algorithm by midwives to assist their diagnosis of active labour, compared with standard care. Main outcomes Primary outcome: use of oxytocin for augmentation of labour.

SECONDARY OUTCOMES

medical interventions in labour, admission management, and birth outcome.

RESULTS

No significant difference was found between groups in percentage use of oxytocin for augmentation of labour (experimental minus control, difference=0.3, 95% confidence interval -9.2 to 9.8; P=0.9) or in the use of medical interventions in labour. Women in the algorithm group were more likely to be discharged from the labour suite after their first labour assessment (difference=-19.2, -29.9 to -8.6; P=0.002) and to have more pre-labour admissions (0.29, 0.04 to 0.55; P=0.03).

CONCLUSIONS

Use of an algorithm to assist midwives with the diagnosis of active labour in primiparous women did not result in a reduction in oxytocin use or in medical intervention in spontaneous labour. Significantly more women in the experimental group were discharged home after their first labour ward assessment.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN00522952.

Fetal health assessment using prenatal diagnostic techniques

PURPOSE OF REVIEW

The assessment of fetal health has occupied our professional attention for many years. As the development of technologies for prenatal diagnostic techniques has progressed, applications of such technologies have aided in the overall assessment of fetal well-being.

RECENT FINDINGS

Fetal heart-rate monitoring remains the main form of fetal assessment for high-risk pregnancies. The additional assessments afforded by the analysis of ST and T-wave changes of the fetal electrocardiogram hold promise for improving the predictive value of fetal heart-rate assessments. Ultrasound has been invaluable for assessment of fetal anatomy, and the use of Doppler ultrasound has given insight into fetal cardiovascular responses to such conditions as intrauterine growth restriction and fetal anemia caused by red blood cell alloimmunization.

SUMMARY

As prenatal diagnostic techniques evolve, their application to the assessment of fetal well-being offers insight into pathophysiologic mechanisms of fetal disease, innovative tools to assess fetal health, and fertile ground for future investigation.