• IDS071 - Neurocritical care in Intensive Care Units in Canada

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    A rap­pe­ler pour tout usage - To quote for any use : ZAGHDOUDI Lina, « Neu­ro­cri­ti­cal care in Inten­sive Care Units in Cana­da », Uni­ver­si­té de Tech­no­lo­gie de Com­piègne (France), Mas­ter Ingé­nie­rie de la San­té, Par­cours Tech­no­lo­gies Bio­mé­di­cales et Ter­ri­toires de San­té (TBTS) et Dis­po­si­tifs Médi­caux et Affaires Régle­men­taires (DMAR), Mémoire de stage, juillet 2020, https://travaux.master.utc.fr/formations-master/ingenierie-de-la-sante/ids071/

    Résumé

    Les fac­teurs humains ou l'ergonomie est l'étude de la façon dont les humains se com­portent phy­si­que­ment et psy­cho­lo­gi­que­ment par rap­port aux envi­ron­ne­ments, aux pro­duits ou aux services.

    La concep­tion d'interfaces est une dis­ci­pline en évo­lu­tion. L'interface de concep­tion éco­lo­gique (EID) com­bine des concepts d'humains et d'environnement, et le concept d'affichage.

    L'analyse cog­ni­tive du tra­vail (CWA) est un cadre for­ma­tif basé sur des contraintes pour ana­ly­ser des sys­tèmes socio­tech­niques com­plexes tels que les uni­tés de soins inten­sifs. Le cadre CWA aide à déve­lop­per des outils de sup­port tels que, par exemple, une hié­rar­chie de l'abstraction (AH).

    Dans ce rap­port de stage, nous ver­rons ici com­ment la CWA est appli­quée aux soins neu­ro­cri­tiques dans l'unité de soins inten­sifs à tra­vers la concep­tion d'une inter­face sui­vant l’EID.

    Abstract

    Human Fac­tors or Ergo­no­mics is the stu­dy of how humans behave phy­si­cal­ly and psy­cho­lo­gi­cal­ly in rela­tion to envi­ron­ments, pro­ducts, or services. 

    Inter­face Desi­gn is an evol­ving dis­ci­pline. Eco­lo­gi­cal Desi­gn Inter­face (EID) com­bines concepts of Humans and envi­ron­ment, and the concept of Display. 

    Cog­ni­tive Work Ana­ly­sis (CWA) is a for­ma­tive, constraint-based fra­me­work for ana­ly­zing com­plex socio­tech­ni­cal sys­tems such as Inten­sive Care Units. The CWA fra­me­work helps to deve­lop sup­port tools such as an Abs­trac­tion Hie­rar­chy (AH).

    This inter­n­ship report focuses on how CWA can be applied to neu­ro­cri­ti­cal care in the inten­sive care unit using EID.

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    IDS071 - ZAGHDOUDI - Inter­n­ship report

    Neu­ro­cri­ti­cal care in Inten­sive Care Units in Canada

    Internship Report :
    Neurocritical care in Intensive Care Units

    Acknowledgment

    Over all, I would like to thank, pro­fes­sor Sofiane Bou­daoud, pro­fes­sor Isa­belle Claude and the edu­ca­tio­nal team of Healthcare’s Engi­nee­ring, inclu­ding Pro­fes­sor Dan Istrate at the Uni­ver­si­ty of Com­piegne, for giving me the great oppor­tu­ni­ty to do my inter­n­ship in the scien­ti­fic research area at a pres­ti­gious uni­ver­si­ty such as the Uni­ver­si­ty of Water­loo. In addi­tion, I am gra­te­ful to each and eve­ryone for giving me basic engi­nee­ring know­ledge in the Heal­th­care field.

    I would espe­cial­ly like to thank Pro­fes­sor Cathe­rine Burns, my inter­n­ship tutor, for her wel­come at the AIDL team, for assis­ting me from the moment pre­ce­ding the start of the inter­n­ship and for sup­por­ting and encou­ra­ging me over time for the work I have done. 

    I would like to thank per­so­nal­ly Ece Uere­ten, a PhD student who works with me on neu­ro­cri­ti­cal care. Wor­king with her was a great plea­sure for me and her sup­port made me pro­gress without having any difficulties.

    My spe­cial thanks are for the Secre­ta­riat of my master’s degree, the Inter­na­tio­nal Rela­tions Depart­ment of the UTC, the IVGS depart­ment, the HR depart­ment of UW and Fran Han­ni­gan, Vicky Law­rence, Audray Slo­bo­da, Char­lotte Amstrong, for hel­ping me with all the admi­nis­tra­tive pro­ce­dures during my internship. 

    I also owe a great debt of gra­ti­tude to Kirs­ten Ander­son, Ryan Ten­nant, Ola­mide Ola­toye, Murat Dik­men, Ram­tin Lot­fa­ba­di and Fan He, mem­bers of my team, have always been kind, help­ful and patient to help me and assist me to car­ry out the impor­tant tasks throu­ghout the inter­n­ship period. 

    Spe­cial thanks for my com­rades, Phi­lippe Por­tailler, Kaw­tar Ghiatt, Mariam Laghi Mra­bat and Cla­ra Magnier for giving me their feed­backs of their expe­riences at UW, for not only advi­sing me but also hel­ping me with all of the obs­tacles that I had to face coming to Canada. 

    I also thank my fami­ly and my friends for sup­por­ting and encou­ra­ging me along my jour­ney away from them. Without their sup­port I would not have been as moti­va­ted as I am now.

    Abbreviations

    • AH : Abs­trac­tion Hierarchy 
    • AIDL : Advan­ced Inter­face Desi­gn Lab 
    • CBB : Centre for Bioen­gi­nee­ring and Biotechnology 
    • CPP : Cere­bral Per­fu­sion Pressure
    • CSF : Cere­bros­pi­nal fluid 
    • CWA : Cog­ni­tive Work Analysis 
    • ConTask : Control Task (Ana­ly­sis)
    • EEG : Elec­tro Ence­pha­lo Gram 
    • EID : Eco­lo­gi­cal Inter­face Design 
    • GCS : Glas­gow Coma Scale 
    • HF : Human Factors 
    • HFES : Human Fac­tors and Ergo­no­mics Society 
    • ICU : Inten­sive Care Unit 
    • ICP : Intra Cra­nial Pressure 
    • IH : Intra­cra­nial hypertension 
    • MAP : Mean Arte­rial Pressure 
    • SARS : Severe Acute Res­pi­ra­to­ry Syndrome 
    • SHAP : SHa­pley Addi­tive exPlanations 
    • SYDE : SYs­tem Desi­gn Engineering 
    • UW : Uni­ver­si­ty of Waterloo 
    • UXD : User Expe­rience Design 
    • WDA : Work Domain Analysis 
    • WFH : Work From Home 

    Introduction

    The world has known the big­gest pan­de­mic in 2020 due to Covid-19. Accor­ding to the World Health Orga­ni­za­tion, a pan­de­mic is defi­ned as “an epi­de­mic occur­ring world­wide, or over a very wide area, cros­sing inter­na­tio­nal boun­da­ries and usual­ly affec­ting a large num­ber of people”[1] [2]. By epi­de­mic, we mean “a wides­pread occur­rence of an infec­tious disease in a com­mu­ni­ty at a par­ti­cu­lar time”[3].  

    Covid-19 is a new disease which has simi­lar symp­toms to com­mon cold such as fever, dry cough, and tired­ness. It spreads through close contact with an infec­ted per­son. This coro­na­vi­rus disease is cau­sed by a virus cal­led SARS-CoV-2. Coro­na­vi­ruses are part of a large fami­ly of viruses that can cause ill­ness in ani­mals or humans. The spread of this new infec­tious disease began in Wuhan, Chi­na, in Decem­ber 2019 and has rea­ched today 216 coun­tries, cau­sing 495 760 confir­med deaths and more than 9 843 073 confir­med cases on June 27th 2020 [4]–[6]. 

    Anyone can catch this disease without or with mild symp­toms in most cases. Howe­ver, Covid-19 can also evolve into severe res­pi­ra­to­ry ill­nesses, like pneu­mo­nia, with an occur­rence of 1 infec­ted per­son out of 5 [4]. Two cate­go­ries of people are most like­ly to be affec­ted by these severe symp­toms, the elder­ly, and those with under­lying condi­tions such as high blood pres­sure, heart and lung pro­blems, dia­betes or can­cer. These per­sons need a hos­pi­tal treat­ment and patient care in the ICU [7]. 

    This has shown the impor­tance of having func­tio­nal and effi­cient ICU units in order to improve the qua­li­ty of care given by phy­si­cians and nurses. Thus, it would be inter­es­ting to think about how the Eco­lo­gi­cal Desi­gn Inter­face (EID) and Cog­ni­tive Work Ana­ly­sis (CWA) methods, could improve the qua­li­ty of care.

    I. Internship environment

    1.      The University of Waterloo

    Uni­ver­si­ty of Water­loo, with its lea­ding “spi­rit of the why not”, is a public research uni­ver­si­ty crea­ted in 1957 by busi­ness lea­ders to address indus­try needs. Its par­ti­cu­la­ri­ty is that the inven­tor owner­ship of intel­lec­tual pro­per­ty, so it is an incen­tive way to attract lea­ding and entre­pre­neu­rial resear­chers. It’s the lar­gest post-secon­da­ry pro­gram in the world with the co-op Education. 

    • UW has rea­ched the first rank of Com­pre­hen­sive Research for 12 years conse­cu­tive years accor­ding the research info source 2019 [8], [9].
    • It is also the most inno­va­tive uni­ver­si­ty in Cana­da for 28 years [9], [10].
    • And the first in the world for student-employer connec­tions [9], [11].

    Uni­ver­si­ty of Water­loo is com­po­sed by dif­ferent schools such as Public Health and Health Sys­tems, Accoun­ting and Finance, Archi­tec­ture, Plan­ning, Com­pu­ter Science, Opto­me­try and Vision Science, Phar­ma­cy, but also by dif­ferent facul­ties : Applied Health Sciences, Arts, Engi­nee­ring, Envi­ron­ment, Mathe­ma­tics and Science. 

    2.     The Faculty of Engineering

    It’s Canada’s Lar­gest Engi­nee­ring School with more than 8000 under­gra­duate stu­dents, 13% inter­na­tio­nal stu­dents and about 2000 gra­duate students. 

    The Facul­ty of Engi­nee­ring is com­po­sed by 8 fol­lo­wing departments : 

    • Elec­tri­cal and com­pu­ter engineering
    • Mecha­ni­cal and mecha­tro­nics engineering
    • Sys­tems Desi­gn Engineering
    • Mana­ge­ment Sciences
    • Che­mi­cal engineering
    • Civil and Envi­ron­men­tal engineering
    • School of archi­tec­ture inclu­ding inte­gra­ted design
    • Conrad School of Entre­pre­neur­ship and Business

    They offer, among the men­tio­ned depart­ments, 15 bache­lor degree pro­grams and 37 gra­duate degree programs.

    Figure 1 - Water­loo Engi­nee­ring : E7 Buil­ding - Source : Author

    Here you can find the Water­loo Engi­nee­ring Inte­gra­tion Com­plex in the cam­pus in Figure 2. That aims to be intel­li­gent, connec­ted, digi­tal and phy­si­cal. The E7 Inte­gra­tion Hub is in Figure 1.

    Figure 2 - Water­loo Engi­nee­ring Inte­gra­tion Com­plex - Source : UW

    3.     The System Design Engineering department

    The depart­ment of  SYDE was esta­bli­shed 40 years ago and until today it is still pro­vi­ding the most flexible pro­grams and various areas of research such as envi­ron­men­tal socioe­co­no­mic and poli­ti­cal aspects. Star­ted in 1969, the depart­ment was consi­de­red unique due to the inter­dis­ci­pli­na­ry pro­grams with lea­ding and deve­lo­ping topics. The dis­tinc­tive nature of the offe­red pro­grams within the depart­ment emer­ged from the topics cove­red in the cur­ri­cu­lum. Topics cove­red include poli­ti­cal, envi­ron­men­tal, eco­no­mic, social and tech­ni­cal aspects of engineering.

    4.     The Centre for Bioengineering and Biotechnology

    In 2011, the UW esta­bli­shed the centre CBB. Cathe­rine Burns, my inter­n­ship super­vi­sor, was the foun­ding Exe­cu­tive Direc­tor (ED) until May 2020. Since its esta­blish­ment, CBB focu­sed on faci­li­ta­ting tac­ti­cal mul­ti­dis­ci­pli­na­ry research that connects tech­no­lo­gy to bios­ciences, health sciences and envi­ron­men­tal sciences. Moreo­ver, CBB stri­ved to cover indus­trial chal­lenges by hol­ding events with com­pa­nies, dis­cus­sions and aca­de­mic semi­nars and work­shops. Finan­cial­ly, CBB uses inde­pendent fun­ding sys­tem to sup­ports resear­chers by applying to grants and see­king alter­na­tive fun­ding opportunities. 

    Location

    The Centre is loca­ted at 200 Uni­ver­si­ty Ave West, Water­loo, ON N2L 3G1 | East Cam­pus 4 Buil­ding, Room 2001, in Figure 3.

    Figure 3 - East Cam­pus 4 Buil­ding - Source : Author

    The Staff and Leadership Organization 

    Since May 2020, Karim S. Karim became the new Exe­cu­tive Direc­tor of the CBB [12].
    The CBB team is also com­po­sed by : 

    • Car­ly Turn­bull, the pro­ject co-ordi­na­tor, inter­im mana­ger, pro­gram Deve­lop­ment and Partnerships
    • Char­lotte Arm­strong, the admi­nis­tra­tive assistant
    • Colin Rus­sell, Mana­ger, Pro­gram Deve­lop­ment and Partnerships
    • Cathe­rine Burns, the foun­der and for­mer CBB Exe­cu­tive Director

    The pro­duct is know­ledge trans­fer and partnerships.

    Budget

    The Centre’s bud­get is not part of the public domain, but finan­cial sta­te­ments about the Uni­ver­si­ty of Water­loo can be found here.

    5.     The Advanced Interface Design Lab

    At UW, each facul­ty and depart­ment relate to labo­ra­to­ries. The AIDL is atta­ched to SYDE. Cathe­rine Burns, my super­vi­sor, is the direc­tor of this lab. 

    The AIDL, focus on col­la­bo­ra­tive pro­cesses bet­ween tech­no­lo­gy and human users with the goal of deve­lo­ping advan­ced inter­faces in the fol­lo­wing domains :

    • Defence and Aviation
    • Finan­cial Trading
    • Heal­th­care
    • Auto­ma­ted Vehicles
    • Human Inter­ac­tion with Arti­fi­cial Intelligence 
    • Other Pro­jects in Inter­face Desi­gn, Col­la­bo­ra­tion, and Visualization

    6.     My role in this internship : research assistant

    During my inter­n­ship, I was assi­gned the posi­tion of a research assis­tant. I wor­ked on an ICU neu­ro­cri­ti­cal care pro­ject with a Ph.D. student, Ece Uere­ten. Aside from my main pro­ject, I par­ti­ci­pa­ted in a secon­da­ry pro­ject cove­ring Arti­fi­cial Intel­li­gence in Finance. I cove­red the visua­li­sa­tion of SHAP[1] for a peer to peer len­ding web­site mana­ged by Murat Dikmen. 

    In both pro­jects, work was done in groups which shar­pe­ned my team­work skills. Team mee­tings were done eve­ry week to pro­vide updates about the pro­gress of the pro­ject and to show the pro­fes­sio­nal deve­lop­ment acqui­red by team mem­bers. During each mee­ting, mem­bers would present chal­lenges they faced and the skills they lear­ned while wor­king on the assi­gned pro­jects. Moreo­ver, the mee­tings were used to dis­cuss future steps and tasks for each member. 

    My role as a research assis­tant was affec­ted by Covid-19 thus res­tric­ting my res­pon­si­bi­li­ties to main­ly conduc­ting lite­ra­ture reviews, reques­ting sup­plies neces­sa­ry for the pro­ject, atten­ding online pro­ject mee­tings, atten­ding an inter­na­tio­nal confe­rence HFES sym­po­sium, and sum­ma­ri­zing pro­ject results through presentations. 

    II. Neurocritical care in ICU

    Neu­ro­cri­ti­cal care is a medi­cal area that deals with the treat­ment of serious diseases in the ner­vous sys­tem and iden­ti­fies, pre­vents and treats them. Neu­ro-ICU is the place where the patients are admit­ted and taken care of. 

    1.      Intensive Care Units in Canada

    The inten­sive cri­ti­cal care unit pro­vides inten­sive care to seve­re­ly ill patients. Accor­ding to a report, in 2013–2014, 11% of the more than 2 mil­lion adult hos­pi­tal stays in Cana­da are spent in an ICU (out­side Que­bec) [13].

    The ave­rage dai­ly cost of an ICU stay is esti­ma­ted to be as high as 3 times the ave­rage cost of a day’s stay in a gene­ral ward. This is because ICU stays are more resource-inten­sive in terms of per­son­nel to equip­ment and medi­ca­tion. For these rea­sons, it is impor­tant to bet­ter unders­tand the use of this constrai­ned resource with res­pect to ope­ra­ting pat­terns, patient flow, trends in admis­sions, patient popu­la­tions and pro­cess of care for those trea­ted in ICUs [13].

    There are three dif­ferent types of ICUs : 

    • The gene­ral ICUs 
    • The spe­cia­li­zed ICUs : for example, neu­ro-ICU
    • The pae­dia­tric ICUs

    None­the­less, it could also be a com­bi­na­tion of the any of the above types. 

    In ICUs, a lot of medi­cal devices are connec­ted to the patients. There is a lot of data obtai­ned from patients through moni­tors, ven­ti­la­tors, EEG etc. Nurses per­form their care over­sight using a flow­sheet aspre­sen­ted in Figure 5. They note down data rela­ted to car­dio­vas­cu­lar, res­pi­ra­to­ry, neu­ro­lo­gic, nur­sing care, nur­sing assess­ment, cli­ni­cal notes and fluid balance. Although this flow­sheet is tho­rough it pre­sents limi­ta­tion such as the mul­ti­tude of variable para­me­ters that need to be taken into account. Ano­ther limi­ta­tion is the lack of conti­nuous tra­cking of a patient's vitals. As a result, phy­si­cians do not get the com­plete pic­ture of the patient's his­to­ry. The patient's life can be at stake for a few minutes or even seconds for patients in neu­ro­cri­ti­cal care. The main issue is to track data conti­nuous­ly and show data on one screen. It will aid phy­si­cians in sto­ring those data.

    Figure 5 - Extract of the flow­sheet used by nurses and phy­si­cians in ICU at hos­pi­tal X - Source : Hos­pi­tal X

    As it is shown in Figure 6, the ICU is a com­plex dyna­mic socio-tech­ni­cal envi­ron­ment. Nume­rous inter­ac­tions bet­ween patients and care­gi­vers take place, as well as inter­ac­tions of the patients with sup­port staff such as phar­ma­cists and tech­ni­cians. Care­gi­vers are chan­ging. Simi­lar­ly, the patient’s condi­tions change as well. For example, a nurse takes care of the patient and take notes in the flow­sheet. Then, the phy­si­cian threa­tens the disease of the patient in cri­ti­cal condi­tions. After­wards, the patient is connec­ted to seve­ral medi­cal devices. All these inter­ac­tions should be taken into account in our EID.

    Figure 6 - An unders­tan­ding of ICU envi­ron­ment as a com­plex dyna­mic socio­tech­ni­cal - Source : Author

    Thus, we are inves­ti­ga­ting whe­ther inte­gra­ting the infor­ma­tion from a range of medi­cal devices into an inte­gra­ted dis­play in Neu­ro-ICU using EID would be effi­cient. This inte­gra­ted dis­play could be dyna­mic or sta­tic. This EID should faci­li­tate deci­sion-making for heal­th­care personnel.

    2.     EID and CWA modelling

    Ecological Design Interface

    The word eco­lo­gi­cal deals with the rela­tion­ship bet­ween humans and the envi­ron­ment. Inter­face desi­gn relates to the dis­play. EID is known for visua­li­zing func­tio­nal rela­tion­ships in a “quick glance” with lit­tle cog­ni­tive efforts. The moti­va­tion for EID ori­gi­na­ted from pro­blems ari­sing in the inter­face desi­gn of com­plex socio-tech­ni­cal sys­tems. It could be applied to neu­ro­cri­ti­cal care in ICU. 

    Why choose EID ins­tead of UXD ? UXD is a user-cen­te­red win­dows-based inter­face whe­reas EID takes a wider account of the envi­ron­ment. It bridges bet­ween humans and the program/environment. An unders­tan­ding of human concep­tion, cog­ni­tion, and beha­viour is cri­ti­cal to desi­gning inter­faces. That much can be lear­ned by get­ting feed­back from actual users of the inter­face, at the ear­ly desi­gn stages, and then through tes­ting various points in the desi­gn [14].

    EID approach is used : when asking users is not pos­sible, when we want users to become experts and when we want to handle the unex­pec­ted [14].

    In com­plex sys­tems, it is use­ful to unders­tand how the sys­tem works, before begin­ning the desi­gn [14]. There are two key concepts in EID from cog­ni­tive engi­nee­ring research : the Abs­trac­tion Hie­rar­chy (AH) and the Skills, Rules, Know­ledge (SRK) fra­me­work. That is why the CWA approach was our first step.

    Cognitive Work Analysis

    As pre­vious­ly men­tio­ned, ICU is a com­plex dyna­mic socio-tech­ni­cal sys­tem the­re­fore, to unders­tand how ICU works and its constraints, we used CWA model­ling. It allo­wed us to unders­tand phy­si­cians but also to focus on the workload. 

    The word cog­ni­tive is asso­cia­ted with human fac­tors or ergo­no­mics. The word work is rela­ted to a world, not a task. Ana­ly­sis refers to a model­ling tool. It is used to unders­tand the world in a for­ma­tive way [15]. Tech­no­lo­gy may change. Users may change. Tasks may change. The infor­ma­tion sys­tem should over­come the fluctuation.

    Figure 7 - Dif­ferent steps of CWA - Source : AIDL

    This model­ling could be applied to the neu­ro-ICU. It requires 5 steps as shown in Figure 7. 

    The CWA fra­me­work includes five dif­ferent phases : the work domain ana­ly­sis (WDA) through the Abs­trac­tion Hie­rar­chy (AH), the Control task (or acti­vi­ty) ana­ly­sis which leads us to the deci­sion lad­der, the stra­te­gies ana­ly­sis, the social orga­ni­za­tion and co-ope­ra­tion ana­ly­sis, and the wor­ker com­pe­ten­cies ana­ly­sis.

    CWA will enable us to unders­tand how the ICUs envi­ron­ment works and the dif­ferent flows and para­me­ters to take into account for the inter­face desi­gn. We will focus on the first point. The AH is the key tool in per­for­ming WDA and thus EID [14].

    Work Domain Analysis (WDA) & Abstraction Hierarchy (AH)

    As a first level of the CWA, WDA requires a des­crip­tion of domain through the AH as a first step of the desi­gning pro­ject. In other words, we are defi­ning the sys­tem of inter­est. This des­crip­tion is context inde­pendent. The ana­lyses, and resul­tant dia­grams, are not spe­ci­fic to any tech­no­lo­gy ; rather they represent the entire domain[15], [16].

    The AH is a “tree­like struc­ture with mul­tiple levels and each level are dif­ferent from others and are orde­red along a dimension”[14]. Each level has a means-ends link that can be ans­we­red by “how” and “why”.

    Figure 8 - The five levels of the AH and asso­cia­ted ques­tions - Adap­ted from the book EID

    There are 5 steps, repre­sen­ted in Figure 8 : the func­tio­nal pur­pose, the abs­tract func­tion, the gene­ra­li­zed func­tion, the phy­si­cal func­tion and the phy­si­cal forms. For each step, a ques­tion is to be answered. 

    My col­la­bo­ra­tor, Ece, as a first step of the EID and through her obser­va­tion at Hos­pi­tal X, car­ried out pre­vious work on the AH, in Figure 9. It focuses on the neu­ro-sys­tem and cog­ni­tion as shown in Figure 9.

    Figure 9 - AH : Neu­ro­cri­ti­cal care in ICU - Source : Ece Uereten

    I contri­bu­ted to this lat­ter AH by focu­sing more on the qua­li­ty of care and staff issues. As shown in Figure 10, an ans­wer to the first ques­tion, what pro­blem do we want to solve in ICU, would be to improve patient care, patient condi­tions and main­tain patient safe­ty. For each level, the AH is pro­vi­ding an ans­wer to the ques­tion of each level of the AH. 

    Figure 10 - AH : Neu­ro­cri­ti­cal care in ICU - Source : Author

    The qua­li­ty of care is defi­ned as the per­cei­ved qua­li­ty, the effi­cien­cy and the effi­ca­cy of care. The per­cei­ved qua­li­ty is, here, the level of qua­li­ty of the care ser­vice as per­cei­ved by the patient in a more or less sub­jec­tive way. By effi­ca­cy, we mean the abi­li­ty to reach a goal of treat­ment by the phy­si­cian, for example, whe­reas effi­cien­cy refers to the abi­li­ty to reach this goal of treat­ment with the mini­mum waste of resources. 

    By their capa­bi­li­ty, know­ledge or com­pe­tences, the qua­li­ty of care can be affec­ted by the care­gi­vers, and also by the fatigue, burn out or ful­fillment at work.

    Later, we mer­ged both our AH into one des­cri­bing wide­ly the envi­ron­ment in Figure 11.

    Figure 11 - mer­ged AH : Neu­ro­cri­ti­cal care in ICU - Source : Ece Uere­ten & Author
    List of parameters

    With the help of the AHs (Figure 10 and Figure 9), my col­la­bo­ra­tor, the brains­tor­ming tool and the flow­sheets for each level, we have lis­ted all of the para­me­ters and variables that could arise in Figure 12.

    Figure 12 - List of the para­me­ters for each level of the AHs - source : Author

    This list of para­me­ters has been detai­led in Appen­dix 1. For each para­me­ter, we pro­vi­ded a defi­ni­tion, its units and range. 

    Focus on neuro-parameters

    Three neu­ro­lo­gic variables are impor­tant in neu­ro­cri­ti­cal care and used in neu­ro-ICU : GCS, ICP and EEG. 

    Glasgow Coma Scale (GCS)

    This is a neu­ro­lo­gi­cal scale that aims to pro­vide a reliable and objec­tive way of recor­ding the level of conscious­ness of a patient. The score lies bet­ween 3 to 15. Three ele­ments are consi­de­red : Eye res­ponse (5 grades), Ver­bal res­ponse (5 grades) and Motor res­ponse (6 grades).

    Intra-Cranial Pressure (ICP)

    This is an inva­sive para­me­ter. It repre­sents the pres­sure applied by fluids such as CSF inside the skull and on the brain tis­sue. The CPP is the dif­fe­rence bet­ween the MAP and the ICP. Nor­mal ICP lies bet­ween 5 to 10 mmHg [17]. IH, IICP or rai­sed ICP is the most com­mon cli­ni­cal condi­tion that requires treat­ment to reduce ICP.

    Electroencephalogram (EEG)

    This is a non-inva­sive para­me­ter. It is the recor­ding or mea­su­re­ment of cere­bral bioe­lec­tric acti­vi­ty using elec­trodes pla­ced on the scalp. It aims to moni­tor seda­tion or diag­no­sis of sei­zure acti­vi­ty. There exist 3 types of exa­mi­na­tions : stan­dard (short term), Hol­ter (long term) and ence­pha­lic death. EEG is cha­rac­te­ri­zed by : Ampli­tude, Fre­quen­cy, Spa­tial dis­tri­bu­tion and Wave­form (mono­pha­sic, bipha­sic or poly­pha­sic). There are 4 cate­go­ries of fre­quen­cies : del­ta (<3.5Hz), the­ta (4 to 7.5 Hz), alpha (8 to 13 Hz) and beta (>13 Hz). 

    For each of these para­me­ters, we tried to find out which com­pa­nies sell these types of moni­tors and the avai­lable desi­gn screen types.

    A first draft of the EID on Figma

    After the results were obtai­ned in this list of para­me­ters and also from the obser­va­tions my col­la­bo­ra­tor made during her time in the hos­pi­tal, a first draft of the desi­gn was esta­bli­shed on Fig­ma, as shown in Figure 13.

    Fig­ma is a free col­la­bo­ra­tive inter­face desi­gn tool. Thanks to the UW, a free edu­ca­tion ver­sion was avai­lable enabling us to work in team.

    Figure 13 - EID front page - vital sign para­me­ters - Source : Ece Uere­ten & Author

    In order to take into account all per­sons like­ly to use this inter­face, a grays­cale will be used. This is done spe­ci­fi­cal­ly because there may be people with colour blind­ness within the nur­sing staff.

    Figure 14 - EID front page - blood work - Source : Ece Uere­ten & Author

    In Figure 14, the blood work para­me­ters are pre­sen­ted as an example. In all screens, some impor­tant para­me­ters are shown such as time, date, iden­ti­fi­ca­tion of the patient. 

    Feedback from the users : Personas and Scenarios

    The next step was to unders­tand the use cases. For that, we nee­ded to unders­tand cli­ni­cians bet­ter. Since we could not inter­view nurses and phy­si­cians due to the cir­cum­stances, we had to find ano­ther way to create sce­na­rios and per­so­nas. We crea­ted per­so­nas to unders­tand cli­ni­cians' pers­pec­tives and tasks/challenges. We resear­ched on typi­cal ICU sce­na­rios to pre­pare for com­pa­ri­son and tal­ked to a phy­si­cian wor­king at hos­pi­tal X about them.

    Personas

    The goal here is to create reliable and rea­lis­tic repre­sen­ta­tions of our key audience seg­ments for refe­rence. The per­so­nas would be the cli­ni­cians that we are consi­de­ring in our AH. We had to unders­tand their pers­pec­tives and many examples were found online. Thanks to an open­source web­site, we got some per­so­nas which are lis­ted in the Annexe II : Pri­ma­ry Care Phy­si­cian, Hos­pi­tal Nurse, Medi­cal Assis­tant, Hos­pi­tal Phar­ma­cist, and an example in Figure 15.

    Figure 15 - Example of per­so­nas - source : EHRA

    A com­plete sce­na­rio would look like the whole pro­cess of a patient coming into the ICU with x pro­blem. This would be some­thing we give to our par­ti­ci­pants, so they can set all neces­sa­ry para­me­ters on the inter­face to treat the patient.

    We crea­ted a list of sce­na­rios. For each sys­tem, we have dif­ferent cases with out­come variables, pro­cess variables and variables. The dif­ferent men­tio­ned sys­tems are neu­ro­lo­gic, pul­mo­na­ry, car­dio­vas­cu­lar, renal-fluid-elec­tro­lytes, gas­tro-intes­ti­nal-meta­bo­lic-nutri­tion and hematologic/infectious disease. 

    After a dis­cus­sion with the phy­si­cian, we obtai­ned a list of the most cri­ti­cal case sce­na­rios encoun­te­red in neu­ro-ICU. These are sub­arach­noid hemor­rhage, intra­ce­re­bral hemor­rhage, acute ische­mic stroke, trau­ma­tic brain inju­ry, spi­nal cord inju­ry and sta­tus epi­lep­ti­cus. We also obtai­ned more rele­vant sce­na­rios cases through simu­la­tion trai­ning data­bases. These sce­na­rios cases would help to improve our EID.

    3.     Usability study

    To have a bet­ter unders­tan­ding of the boun­da­ries of the existent soft­ware, a usa­bi­li­ty stu­dy will be done at hos­pi­tal X in the fall or win­ter term. 

    Hos­pi­tal X is cur­rent­ly using the soft­ware A of Com­pa­ny A as a bed­side moni­tor. We found ano­ther new soft­ware B com­mer­cia­li­zed by Com­pa­ny B. This soft­ware only col­lects, visua­lizes, and stores ICU data in near real-time. It does not make any diag­no­sis. Soft­ware B can track data from soft­ware A through ser­vers and uses the HL7[2] stan­dard to communicate. 

    With my col­la­bo­ra­tor, we com­pa­red both tech­ni­cal para­me­ters and func­tio­nal para­me­ters as well as the desi­gn dif­fe­rences in both dis­plays. My col­la­bo­ra­tor has atten­ded a demo of the new soft­ware B. Some of the limits of these two soft­ware are data sto­rage, data tra­cking, visua­li­za­tion and alarms.

    For example, we found out that real dis­play size is typi­cal­ly bet­ween about 15” and 19”. At this moment, we adjus­ted the size of our EID draft. 

    The aim of this usa­bi­li­ty stu­dy is to com­pare the cur­rent ICU soft­ware A to the new soft­ware B. The fin­dings of this stu­dy and the limits will help us in our EID in neu­ro­cri­ti­cal care.

    III. Personal feedback and career professional assessment of this internship

    1.      Personal feedback

    This was my first expe­rience in a non-Euro­pean coun­try. It was very exci­ting and inter­es­ting to dis­co­ver the North Ame­ri­can culture and espe­cial­ly Cana­dian one. It allo­wed me to improve my com­mu­ni­ca­tion skills in English. This inter­n­ship also gave me the oppor­tu­ni­ty to attend an inter­na­tio­nal sym­po­sium on Human Fac­tors and Ergo­no­mics in Health care from May 18th to 21th 2020, which was done vir­tual­ly due to the pan­de­mic cir­cum­stances. It is wor­thy of men­tio­ning that I also par­ti­ci­pa­ted in the Fluxible online event, which was a Cana­dian UX Fes­ti­val, on June 4th.

    Moreo­ver, I dis­co­ve­red the field of research, which I was appre­hen­sive of pre­vious­ly. In par­ti­cu­lar, I was intro­du­ced to the field of desi­gn, in which I had no expe­rience and know­ledge prior to this internship. 

    Auto­no­my, free­dom of plan­ning, the plea­sure of inves­ti­ga­ting in the health care field were the keys words that I retai­ned from this expe­rience. Team­work allo­wed me to work in com­ple­men­ta­ri­ty with my col­leagues, each with dif­ferent and com­ple­men­ta­ry backgrounds.

    In addi­tion, we had to adapt our­selves to the chan­ging sani­ta­ry requi­re­ments and Work from Home (WFH). Even though we could not inter­view the health per­son­nel because they were nee­ded most in the ICU, my research work was not affec­ted. Inter­na­tio­nal soli­da­ri­ty lin­ked to the pan­de­mic made it easier for us to occa­sio­nal­ly get free valuable online infor­ma­tion about com­pa­nies and medi­cal devices. Wor­king from home requi­red us to have a balance bet­ween our per­so­nal and pri­vate life but also to have an effi­cient sche­dule allo­wing consistency.

    Many thanks are due to our super­vi­sor, Mrs. Burns, who orga­ni­zed week­ly mee­tings and fos­te­red effec­tive com­mu­ni­ca­tion with the mem­bers of the labo­ra­to­ry with the tools avai­lable. Fur­ther­more, the UTC set up a sup­port unit for iso­la­ted stu­dents during lock-down.

    Des­pite the qua­ran­tine, the first two months allo­wed me to meet and keep in touch with many stu­dents from UW. It also made me aware of how lucky I was to live in France and to have access to the uni­ver­si­ty for free. We do not bur­den of stu­dy loan which some­thing I am gra­te­ful for. I am also gra­te­ful for the Era­mus+ pro­gram other­wise I wouldn’t have been able to embark on this journey.

    2.     Career objectives

    Since my bachelor’s degree, I have had three dif­ferent expe­riences in dif­ferent set­tings : hos­pi­tal, company/association and labo­ra­to­ry, which gives me a more com­plete vision of the types of trades in health engi­nee­ring. This research inter­n­ship ope­ned me to the idea of fin­ding a job in this field. Two aspects of bio­me­di­cal engi­nee­ring I mis­sed were the contact with other people, espe­cial­ly the medi­cal staff, and contact with medi­cal devices. The job of an appli­ca­tion engi­neer com­bines both. Also, it requires a lot of tra­vel and I love to tra­vel. Moni­to­ring and car­dio­vas­cu­lar are the areas in which I am par­ti­cu­lar­ly interested.

    Conclusion

    In neu­ro­cri­ti­cal care, patients in ICU are in cri­ti­cal and sen­si­tive states. As we have seen in Europe and also in Ame­ri­ca, the over­load of ICUs during the pan­de­mic was unex­pec­ted. In these cases, it is impor­tant for care­gi­vers to make the best deci­sions during treat­ment as qui­ck­ly as possible. 

    Through CWA model­ling, our AH was able to lead us to the first draft of our EID. The second step of this pro­ject will be to apply the sce­na­rios on this EID consi­de­ring the second step of the CWA model­ling : The Control Task Ana­ly­sis, which is com­ple­men­ta­ry to EID. This aims to take into account the deci­sion lad­der of the medi­cal staff to help the phy­si­cian with the diag­no­sis. A small mis­take can jeo­par­dize patient safe­ty. The soo­ner we can diag­nose the patho­lo­gy, the bet­ter the treat­ment plan would be mea­ning enabling a bet­ter qua­li­ty of care. 

    Bibliographic references

    [1]   Heath Kel­ly, ‘The clas­si­cal defi­ni­tion of a pan­de­mic is not elu­sive’, WHO, doi : 10.2471/BLT.11.088815.

    [2]  Jamie Ducharme, ‘World Health Orga­ni­za­tion Declares COVID-19 a “Pan­de­mic.” Here’s What That Means’, Time, Mar. 11, 2020.

    [3]  Oxford Dic­tio­na­ry, ‘Defi­ni­tion of Epi­de­mic’, https://www.lexico.com/. Acces­sed : Jun. 28, 2020. [Online]. Avai­lable : https://www.lexico.com/en/definition/epidemic.

    [4]  World Health Orga­ni­za­tion, ‘Tech­ni­cal gui­dance : Naming the coro­na­vi­rus disease (COVID-19) and the virus that causes it’. Acces­sed : Jun. 28, 2020. [Online]. Avai­lable : https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/naming-the-coronavirus-disease-(covid-2019)-and-the-virus-that-causes-it.

    [5]  World Health Orga­ni­za­tion, ‘Coro­na­vi­rus disease (COVID-19) pan­de­mic’, https://www.who.int/. https://www.who.int/emergencies/diseases/novel-coronavirus-2019 (acces­sed Jun. 28, 2020).

    [6]  World Health Orga­ni­za­tion, ‘Q&A on coro­na­vi­ruses (COVID-19)’, https://www.who.int/, Apr. 17, 2020. https://www.who.int/news-room/q-a-detail/q-a-coronaviruses (acces­sed Jun. 28, 2020).

    [7]  Celiac Disease Foun­da­tion, ‘Celiac Disease and COVID-19’, Celiac Disease Foun­da­tion. https://celiac.org/celiac-disease-and-covid-19/ (acces­sed Jun. 28, 2020).

    [8]  Research Info­source Inc., ‘Canada’s Top 50 Research Uni­ver­si­ties 2019’, 2019. https://researchinfosource.com/top-50-research-universities/2019/top-research-universities-by-tier-corp (acces­sed Jun. 28, 2020).

    [9]  ‘UW, Uni­ver­si­ty of Water­loo’, Uni­ver­si­ty of Water­loo, Nov. 03, 2016. https://uwaterloo.ca/content/home (acces­sed Jun. 28, 2020).

    [10] Macleans.ca, ‘Canada’s best uni­ver­si­ties by repu­ta­tion : Ran­kings 2020’, https://www.macleans.ca/, Oct. 03, 2019. https://www.macleans.ca/education/canadas-top-school-by-reputation-2020/ (acces­sed Jun. 28, 2020).

    [11] ‘QS Gra­duate Employa­bi­li­ty Ran­kings 2019’, Top Uni­ver­si­ties, Feb. 01, 2017. https://www.topuniversities.com/university-rankings/employability-rankings/2019 (acces­sed Jun. 28, 2020).

    [12] ‘Centre for Bioen­gi­nee­ring and Bio­tech­no­lo­gy, CBB Team’, Centre for Bioen­gi­nee­ring and Bio­tech­no­lo­gy, Jun. 18, 2015. https://uwaterloo.ca/bioengineering-biotechnology/about/people/cbb-team (acces­sed Jun. 28, 2020).

    [13] CIHI, Cana­dian Ins­ti­tute for Health Infor­ma­tion, ‘Care in Cana­dian ICUs’, Aug. 2016. Acces­sed : Jun. 28, 2020. [Online]. Avai­lable : https://secure.cihi.ca/free_products/ICU_Report_EN.pdf.

    [14] Cathe­rine M. Burns and John R. Haj­du­kie­wicz, Eco­lo­gi­cal Inter­face Desi­gn. CRC Press, 2004.

    [15] K. J. Vicente, Cog­ni­tive Work Ana­ly­sis : Toward Safe, Pro­duc­tive, and Heal­thy Com­pu­ter-Based Work. CRC Press, 1999.

    [16] J. Ras­mus­sen, ‘The role of hie­rar­chi­cal know­ledge repre­sen­ta­tion in deci­sion­ma­king and sys­tem mana­ge­ment’, IEEE Trans. Syst. Man Cybern., vol. SMC-15, no. 2, pp. 234–243, Mar. 1985, doi : 10.1109/TSMC.1985.6313353.

    [17] C. A. Mount and J. M Das, ‘Cere­bral Per­fu­sion Pres­sure’, in Stat­Pearls, Trea­sure Island (FL): Stat­Pearls Publi­shing, 2020.

    [18] ASTM Inter­na­tio­nal, ‘Annex B of ASTM Stan­dard F2761-09 : Cli­ni­cal Context and Cli­ni­cal Sce­na­rios’. 2013, Acces­sed : Jun. 28, 2020. [Online]. Avai­lable : http://www.mdpnp.org/uploads/Clinical_Scenario_and_CConOps_definitions_and_framework.pdf.

    Annexes

    Annex I - List of parameters

    List of Parameters Defi­ni­tion Units Range
    Time of treatment The time bet­ween the first and the last treat­ment order.  Seconds, Minutes, Hours, Days, Months, Years  Not deter­mi­nable (depends on the patient) [0:∞[
    Length of stay The time bet­ween patient arri­val and discharge of the ICU.  (Seconds), Minutes, Hours, Days, Months, Years   Not deter­mi­nable (depends on the patient) [0:∞[
    Read­mis­sions The num­ber of times being admit­ted to an ICU again.  0, 1, 2, 3, … (posi­tive integer)  Not deter­mi­nable (depends on the patient) [0:∞[
    Patient reco­ve­ry Which cri­te­ria include the patient recovery ?  % [0:100]
    Mor­ta­li­ty rate  The rela­tion bet­ween alive and dead patients in the num­ber of deaths in ICU.  % [0:100]
    Com­fort in the ICU To be defi­ned with cri­te­ria : Type/size of room­Type of bed­Hos­pi­tal meal­Single or sha­red room  % [0:100]  
    Seve­ri­ty rate The amount of affec­ted organs by disease.  % [0:100]
    Pain scale
    NRS : Nume­ric Rating Scale   0 : No pain 10 : Worst pain possible  [0:10]
    CPOT : Cri­ti­cal Care Pain Obser­va­tion Tool   3 : No pain 12 : Maxi­mum Pain  [3:12]
    GCS : Glas­gow Coma Scale  Neuro  3 : No pain 15 : Maxi­mum Pain  [3:15]  
    Res­pi­ra­to­ry parameters
    Time of ventilation The time bet­ween star­ting and stop­ping the mecha­ni­cal ven­ti­la­tion on the patient.  Seconds, Minutes, Hours  [0:∞[  
    Ven­ti­la­tion support The amount of how much the patient is sup­por­ted by mecha­ni­cal ventilation.  % 0 : the patient breathes by him-/her­self 100 : ven­ti­la­tor sup­ple­ments res­pi­ra­to­ry function  [0:100]
    Ven­ti­la­tor changes The amount of how many times the patient cir­cuit is chan­ged to a dif­ferent setting.  0, 1, 2, 3, … (posi­tive integer)  Not deter­mi­nable (depends on the patient) [0:∞[
    Res­pi­ra­to­ry rate (f) The num­ber of breaths per minute or, more for­mal­ly, the num­ber of move­ments indi­ca­tive of ins­pi­ra­tion and expi­ra­tion per unit time.  b/m 10-20 
    Tidal volume (Vt) The volume of air moved into and out of the lungs during each ven­ti­la­tion cycle.  Ml/kg 5-15 
    Oxy­gen concen­tra­tion (FiO2) The per­cen­tage or concen­tra­tion of oxy­gen that a per­son inhales.  % b/w 21-90 
    I:E ratio The ratio of ins­pi­ra­to­ry time : expi­ra­to­ry time.  1:2
    Flow rate or peak ins­pi­ra­to­ry flow rate The maxi­mum flow at which a set tidal volume breath is deli­ve­red by the ventilator.  L/min 40-100 
    Sensitivity/trigger Deter­mines how much effort the patient has to exert before his ins­pi­ra­tion is aug­men­ted by the ventilator.  cmH2O  0.5-1.5
    Pres­sure Limit   cmH2O  10-25 
    PEEP Abbre­via­tion for posi­tive end-expi­ra­to­ry pres­sure. A method of ven­ti­la­tion in which air­way pres­sure is main­tai­ned above atmos­phe­ric pres­sure at the end of exha­la­tion by means of a mecha­ni­cal impe­dance, usual­ly a valve, within the circuit.  cmH2O  5-10 
    Other para­me­ters VC NIF Cuff pres­sure Extu­ba­ted VENT ETT/Trach size Taped Air Entry Adven­ti­tious Sounds Ini­tials RN/RT, Mode, PS/PC Level, Rate Set­ting and Patient, Vt Set­ting and Patient, VE Total, Peak Flow, Wave­form, PAW (Peak and Mean), CPAP, I time, FIO2/NO, SaO2/ETCO2, pH, PCO2, PO2, TCO2, SO2, ABG’s time, DB+C/Incentive, Secre­tions, Suc­tion-Oral, EET/Trach, PZA (Art, PA, CVP), Time of res­pi­ra­to­ry (These depend on the ventilator).             Cm Nume­ric Scale(Air Entry) Scale Scale                0, 1, 2, 3 +, ++, +++                                     1 2 3 M P B 
    Moni­to­ring parameters
    Moni­to­ring systems Num­ber of dif­ferent type of monitors.  0, 1, 2, 3, … (posi­tive integer)  ND 
    Moni­tor interfaces Num­ber of dif­ferent moni­tor screens.  0, 1, 2, 3, … (posi­tive integer)  ND 
    Body tem­pe­ra­ture The tem­pe­ra­ture mea­su­red on a patient’s body.  °K or °C 98.6°F or 37°C
    Cardiac/ECG Heart Rate, Wave­form, Dias­to­lic BP, Sys­to­lic BP, Mean BP  Beats per minute (bpm)   mmHg mmHg  from 60 to 100   lower than 80 (60) 120-129 (110) (76,67)
    Hemo­dy­na­mics   PAP Pul­mo­na­ry Arte­ry Pres­sure RAP Right Atrial Pres­sure /CVP LAP Left Atrial Pres­sure /PCWP SVR Sys­te­mic Vas­cu­lar Resis­tance /PVR MAP Mean Arte­rial Pressure  mmHg mmHg mmHg dynes · sec/cm5 mmHg  15 – 25 2-6 6-12 800 – 1200 70 – 105 
    ICP Moni­to­ring (EVD) MAP Mean Arte­rial Pres­sure ICP Intra Cra­nial Pres­sure CPP Cra­nial Per­fu­sion Pres­sure CSF Drai­ned CC : Cere­bro Spi­nal Drai­ned Level  mmHg mmHg mmHg Cubic Cen­ti­mer Cubic Centimer  MAP = CPP – ICP = 70 – 10 = 60 5 to 15 (10) 60-80 (70)  
    EEG Ampli­tude, Fre­quen­cy,       Spa­tial dis­tri­bu­tion Waveform  µV Hz  about 100 on the scalp del­ta (<3.5Hz) the­ta (4 to 7.5 Hz) alpha (8 to 13 Hz) beta (>13 Hz) mono­pha­sic, bipha­sic or polyphasic 
    SpO2 Rate R/IR Per­cen­tage of oxy­gen Saturation  % >95
    EtCO2   mmHg  35-45 
    Blood test parameters
    Blood tests Num­ber of sample tubes requi­red for the tests.  0, 1, 2, 3, … (posi­tive integer)   
    Type of blood test  Che­mis­try : Glu, Na, K, Cl, Bicar­bo­nate, Urea, Crea­ti­nine, Ca, Mg, P, AST, ALD, ALP, LD, Bili­ru­bin, Albu­min, Pro­tein, Amy­lase, Tro­po­nin, Lac­tate, CK, Crea­ti­nine Kinase Hema­to­lo­gy : Hb, Leu­co­cytes, Pla­te­lest, Hema­to­crit, Neu­tro­phils, Lym­pho­cytes, Pro Time, INR, aPTT  concen­tra­tion mg/dL mEq/L mmol/L mEq/L mmol/L mg/dL mg/dL mg/dL mmol/L or mg/dL mg/dl U/L ng/dL U/L U/L mg/dL g/dL g/dL U/L ng/mL mmol/L SI units/L   mmol/L mmol/L /L mg/Dl mmol/L /L   https://webpath.med.utah.edu/EXAM/labref.htm [70:100] [135 :145] [3.6:5.2] [98:106] [23:29] [6:20] [0.9:1.3] ♂ [0.6:1.1] ♀ fr 18:60 yo [8.6:10.2] 0.6-1.1 or 1.46–2.68 3.4 to 4.5 14 - 59 2 - 9 50-100 300 - 600 less than 0.3 3.5 - 5.2 6.3 - 8.2 40-140   <0.4 0.5-1 ♂ 55-170 ♀30-135   ♂8.7-11.2 ♀7.4-9.9 135 – 145 150-400 x 10^9 6 and 20  135 – 145  1.0-4.0 X 109   https://mcc.ca/objectives/normal-values/
    Phar­ma­co­lo­gy parameters
    Medi­ca­tion amount and types Num­ber of dif­ferent types of medi­ca­tion and names  0, 1, 2, 3, … (posi­tive inte­ger) and name  [0:∞[
    Maxi­mal concen­tra­tion (Cmax or Tmax) Cₘₐₓ is the maxi­mum serum concen­tra­tion that a drug achieves in a spe­ci­fied com­part­ment or test area of the body after the drug has been admi­nis­te­red and before the admi­nis­tra­tion of a second dose.  Unit of concentration  Drug-depended 
    Area under the concentration–time curve (AUC, 0–10 h)    The area under the curve (AUC) is the defi­nite inte­gral of a curve that des­cribes the varia­tion of a drug concen­tra­tion in blood plas­ma as a func­tion of time.  Unit of concentration  Drug-depended 
    Half-life (t1/2) The time it takes for the concen­tra­tion of the drug in the plas­ma or the total amount in the body to be redu­ced by 50%.  Units of time  Drug-depended 
    Eli­mi­na­tion rate constant (Ke) It is a value that des­cribes the rate at which a drug is remo­ved from the system.  Units of concentration  Drug-depended 
    Total body clea­rance (CL) The total body clea­rance (ClT) is the sum of the renal clea­rance (see the record on Renal drug excre­tion), hepa­tic clea­rance, and clea­rance due to any other routes of eli­mi­na­tion (res­pi­ra­to­ry, fecal, sali­va­ry, etc.). Clea­rance is a mea­sure of the effi­cien­cy of the body to eli­mi­nate the drug.  Unit of concentration  Drug-depended 
    Dose of medication Amount of medi­ca­tion taken at one time.  ml  Drug-depended 
    Dosage of medication Fre­quen­cy of doses over spe­ci­fic per­iod of time.  0, 1, 2, 3, … (posi­tive integer)  [0:∞[
    Side-effects of medication Enter the obser­ved and diag­no­sed side-effects of given medication.    Drug-depended 
    Drips/Drugs   mL/h Drug-depend 
    Loca­tion and amount of drain Loca­tion of drain on patient’s body and the amount of drains used.  Areal des­crip­tion of body   0, 1, 2, 3, … (posi­tive integer)  Depends on the patient’s conditions 
    Dia­ly­sis parameters
    Fre­quen­cy of dialysis  Each time that we change the dia­ly­sis circuit.  0, 1, 2, 3, … (posi­tive integer)  Not deter­mi­nable (depends on the patient) [0:∞[
    Total dura­tion of dialysis Tem­po­ral des­crip­tion of the dura­tion of dia­ly­sis appli­ca­tion on patient.  Seconds, Minutes, Hours, Days  (Depends on the patient) [0:∞[
    URR Urea reduc­tion ratio  % >65
    Kt/V Ano­ther way of mea­su­ring dia­ly­sis ade­qua­cy K stands for the dia­ly­zer clea­rance, the rate at which blood passes through the dia­ly­zer, expres­sed in mil­li­li­ters per minute (mL/min)t stands for timeKt, the top part of the frac­tion, is clea­rance mul­ti­plied by time, repre­sen­ting the volume of fluid com­ple­te­ly clea­red of urea during a single treat­mentV, the bot­tom part of the frac­tion, is the volume of water a patient's body contains    Below 1.2
    Other Neu­ro­lo­gic parameters
    Pupil size Dia­me­ter mea­su­red of pupils with variance of light brightness.  mm  from 2 to 4 mm in dia­me­ter in bright light to 4 to 8 mm in the dark 
    Reac­ti­vi­ty of pupil Pupil’s accom­mo­da­tion to light changes.  Binary  Yes or No 
    Limb move­ment Abi­li­ty to move limbs.  Left or Right, Scale for Legs and Arms  Yes or No, 0, 1, 2, 3, 4, 5 Pos­tu­ring F/E
    Patient stats
    Damage (type, loca­tion, amount)   Obser­ved and diag­no­sed patient’s body damage type, loca­tion and the amount of damages.  Text   
    Disease (type and state) Diag­no­sed disease type and state of disease.  Text   
    Patient type Des­crip­tion of patient (pedia­tric, adult).  adult, pediatric   
    Patient condi­tions Des­crip­tion of diag­no­sed conditions.  Text   
    Patient iden­ti­ty Name, age, patient ID.  Text, num­ber, number  Text, [0:120[, [0:∞[
    Patient his­to­ry Avai­lable infor­ma­tion on patient’s his­to­ry from GP, other hos­pi­tals and treatments.  Text   
    Ima­ging setting
    Radio­lo­gy (DICOM?) Images taken (Scans etc.)  Image file   
    Notes and Assessment
    Cli­ni­cal notes Notes taken by phy­si­cians to keep track of the requi­re­ments for fur­ther treatment.  Text   
    Nur­sing Assessment Patient assess­ment taken by nurses.  Text   
    Staff para­me­ters
    Medi­cal staff (in ICU) Num­ber of nurses, the­ra­pists, phy­si­cians, radiologists, ...  0, 1, 2, 3, … (posi­tive integer)  ND 
    Sup­port staff (in ICU) Num­ber of phar­ma­cists, tech­ni­cians, engi­neers etc.  0, 1, 2, 3, … (posi­tive integer)  ND 
    Years of experience  Time that shows how long a staff mem­ber has wor­ked in a specific/related field.  0, 1, 2, 3, … (posi­tive integer)   
    Type of diploma Gra­dua­ted degree of staff.  Nurse, phar­ma­cist, physicians   
    Impor­tant parameters
    Date Day of the year.  Year/Month/Day  
    Time Clock time.  Hours, Minutes, Seconds   

    Refe­rences :

    Ven­ti­la­tor Para­me­ters : https://www.slideshare.net/sanilmlore/mechanical-ventilation-29439357

    Hemo­dy­na­mics : http://www.lidco.com/education/normal-hemodynamic-parameters/

    Dia­lyses part : https://www.niddk.nih.gov/health-information/professionals/clinical-tools-patient-management/kidney-disease/identify-manage-patients/manage-ckd/hemodialysis-dose-adequacy

    Annex II - List of personas

    PERSONAS Pri­ma­ry Care Physician https://www.ehra.org/resource-library/personas/sharon-benton-md-primary-care-physician Hos­pi­tal Nurse https://www.ehra.org/resource-library/personas/carolyn-coolridge-rn-hospital-nurse   Medi­cal Assistant https://www.ehra.org/resource-library/personas/mary-michaels-medical-assistant Hos­pi­tal Pharmacist https://www.ehealthireland.ie/Strategic-Programmes/Electronic-Health-Record-EHR-/Final-Persona-Scenario-files/Acute-HSP-Hospital-Pharmacist-Charlene-Hunter-v1-0.pdf
    Name  Sha­ron Ben­ton, MD  Caro­lyn Cool­ridge, RN  Mary Michaels  Char­lene Hunter 
    Short pre­sen­ta­tion about them  42 years old ; Mar­ried, two kids ; Typi­cal­ly works 60 hours/week 45 years old ; mar­ried, three chil­dren ; BSN degree ; Works four 10-hour shifts per week, plus occa­sio­nal wee­kend overtime.  Age 35 ; Mar­ried, two chil­dren ; Associate's degree, heal­th­care admi­nis­tra­tion ; Works full-time, Mon­day – Friday  40 years mar­ried with 2 young chil­dren MSc in Pharmacy 
    Tasks        Log into HER­Take in charge new drug pres­crip­tion­Need to check medi­ca­tion his­to­ry Inpa­tient pres­crip­tion char­tRe­view the record of the patient Com­mu­ni­cate with the medi­cal team through HER for recom­men­da­tion­Com­plete phar­ma­co­lo­gi­cal review 
    Short-term goals  share infor­ma­tion about my patients with other pro­vi­ders effi­cient­ly and easi­lys­pend less time com­ple­ting admi­nis­tra­tive or dupli­ca­tive tasks­com­mu­ni­cate effec­ti­ve­ly with patients pay edu­ca­tio­nal debt and sup­port family.a bet­ter work-life balance  Ensure that all patients receive their medi­ca­tions and other treat­ments on timeE­du­cate patients on a heal­thy life­style and observe the patient put­ting the edu­ca­tion into action­Make sure each patient and fami­ly feels like they are get­ting the care and atten­tion they need.Organize the day to finish shift on time.Complete all tasks. Ensure patients are dischar­ged in a time­ly man­ner see and com­mu­ni­cate easi­ly each patient’s plan of care  Make a patient feel bet­ter today­Get all the patients out on time today­Do­cu­ment the most accu­rate patient infor­ma­tion Help patients access the right infor­ma­tion about their treat­ment plans­Get addi­tio­nal EHR[3] trai­ning to increase work­flow efficiency.  Coun­sel the patients on the safe use of pres­cri­bed pro­ducts Par­ti­ci­pate in depart­men­tal audits 
    Long-term goals  pro­vide high-qua­li­ty care for patients consis­tent­ly, see impro­ve­ments in their out­comes, and help them stay heal­thy. Iden­ti­fy new reve­nue oppor­tu­ni­ties at the prac­tice and par­ti­ci­pate in an advan­ced care team solu­tion Iden­ti­fy more ways that tech­no­lo­gy can be used in the prac­tice to save time or improve pro­cesses, work­flows and tasks.Become a total­ly paper­less medi­cal prac­tice in the next two years.  Become pro­fi­cient in cus­to­mi­za­tion and opti­mi­za­tion of EHR to improve dai­ly workflow.Seamlessly cap­ture data during rou­tine pro­vi­sion of care Stay up-to-date on conti­nuing edu­ca­tion requi­red to main­tain RN licen­sure eve­ry two years.Develop and imple­ment a trai­ning pro­gram for new gra­duates and other nurses new to our unit to help them get up to speed more qui­ck­ly and efficiently.  Go back to school to become a nur­se­Create an envi­ron­ment that makes our office run more smooth­ly and makes patients feel more comfortable. 
    Typi­cal problems  Spend 2–4 hours eve­ry day after work com­ple­ting EHR tasksThe prac­tice can­not keep exam rooms full, because of com­ple­ting the post-visit qua­li­ty repor­ting tasks requi­red for each patient.Daily frus­tra­tions when inter­ac­ting with the EHR sys­tem because of many clicks requi­red for fre­quent­ly used work­flows, navi­ga­tion is dif­fi­cult, and the sys­tem does not orga­nize the data in an effi­cient way Prior autho­ri­za­tion and other payer-impo­sed road­blocks contri­bute to inef­fi­cient care deli­ve­ry for both cli­ni­cians and patients.Patients with mul­tiple chro­nic condi­tions can be very dif­fi­cult to care for.  Staf­fing shor­tages can put nurses at grea­ter risk for patient safe­ty issues.Unable to locate patient records in one place.High per­cen­tage of nur­sing bur­nout, with nurses lea­ving the patient care work­force in favor of non-direct patient care types of nursing.Unable to speak to some patients without inter­pre­ter due to lan­guage barrier.Difficulty com­mu­ni­ca­ting with heal­th­care team effi­cient­ly  Spend a lot of time recor­ding large amounts of infor­ma­tion and com­ple­ting documentation.Common tasks can be labo­rious (too much clicking).The doc­tor keeps recon­ci­ling the meds incor­rect­ly, fur­ther leng­the­ning the time requi­red to discharge patients.Rarely doing one task at a time and constant­ly inter­rup­ted. pres­sure and fati­gue­no consis­ten­cy. Misuse from other nurses of HER (com­ple­ting the same info in a dif­ferent part)Complex tasks­Me­di­ca­tion mana­ge­ment Can’t easi­ly see what is mis­sing or what hasn’t been done, par­ti­cu­lar­ly around documentation.Lack of invest­ment in dai­ly patient because of dis­sa­tis­fac­tion of jobInjuries  Don’t feel effi­cient with this EHR­Must cater to each doctor’s work habits and docu­men­ta­tion styles.Possibilities for errors.Interruptions and distractions.Inexperienced staff/high turnover.Wear too many hats.Spend a lot of time with tasks that should be faster/easier. Frus­tra­tion because of the lack of com­pu­ters on the ward­sNot having enough time to pro­vide safe and effec­tive cover on the wards as well as under­take her dis­pen­sa­ry duties 

    [1] The SHAP is a method used to explain indi­vi­dual pre­dic­tions based on the game theo­re­ti­cal­ly opti­mal sha­pley values. It was intro­du­ced by Lund­berg and Lee in 2016. 

    [2] HL7 is an inter­na­tio­nal stan­dard that is used to trans­fer data bet­ween soft­ware appli­ca­tions. It is used by dif­ferent heal­th­care providers.

    [3] E.H.R.: Elec­tro­nic Health Record 

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