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Found 68 results
  1. Content Article
    When critically ill premature infants require transfer by ambulance to another hospital, they frequently require mechanical ventilation. This observational study investigated acceleration during emergency transfers and looked at whether they result from changes in ambulance speed and direction, or from vibration due to road conditions. It aimed to assess how these forces impact on performance of neonatal ventilators and on patient-ventilator interactions. The authors found that infants are exposed to significant acceleration and vibration during emergency transport. Although these forces do not interfere with overall maintenance of ventilator parameters, they make the pressure-volume loops more irregular.
  2. Content Article
    This National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report highlights the results of a study into quality of care received by people aged 0-24 receiving long-term ventilation (LTV). It aimed to identify remediable factors in the care provided to children and young people who were receiving, or had received, LTV.
  3. Content Article
    This toolkit has been produced by the National Tracheostomy Safety Project in collaboration with the Academic Health Science Networks in response to the COVID-19 pandemic, to support healthcare staff who are looking after this very vulnerable group of patients. Primarily it is for those working in hospitals. However, much of the material is also applicable to primary and community care settings. Wherever it is used, the toolkit’s key objective is the same: to ensure that healthcare staff caring for patients with tracheostomies in these challenging circumstances are able to do so safely. 
  4. Content Article
    The British Thoracic Society has published the results of their 2019 national audit of acute non-Invasive ventilation (NIV) in adult patients in NHS hospitals.   Data were collected in 2019, before the pandemic, and the audit did not look at things such as pandemic preparedness or numbers of NIV hardware available, but at the quality of the service provided. The audit analysed data provided from over 150 hospitals, for a total of over 3500 patient records, and looked for adherence to our quality standards in the provision of the service.
  5. Content Article
    In March 2020 Philips Health Systems released an FSN concerning V60 ventilators. This FSN concerned a hardware fault in the device, which can result in an unexpected shutdown. There are two ways in which this shutdown can occur: The first will sound a warning to alert the user that the machine is shutting down. This will let the user know they need to switch to an alternative source of ventilation. There is a risk that the patient will be unventilated while this second source of ventilation is prepared. The second failure mode will cause the device to shut down with no warning to the user. If a device fails in use and does not alarm, the patient will not be adequately ventilated and there is a potential risk of brain damage or death, depending on how long it takes clinicians to become aware of the situation and respond. There has been a significant delay of replacement parts arriving in the United Kingdom, resulting in an increased risk of this failure occurring. The MHRA has decided to update the guidance issued in the Medical Device Alert published in June. The MHRA will continue to work with the manufacturer to improve the delivery time for replacement components.
  6. Content Article
    Acute respiratory distress syndrome (ARDS) and respiratory failure are characterised by hypoxemia (i.e., low levels of blood oxygen). Infections such as influenza and COVID-19 can lead to ARDS or respiratory failure. Treatment is through supportive measures. In severe cases, patients receive oxygen through a ventilator and, when appropriate, are placed in a prone position for an extended period. A retrospective review of events submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) identified 98 prone position–related events in patients with ARDS, respiratory failure, distress, and pneumonia from 1 January 2010, through 30 June 2020; 30 events were associated with COVID-19. Skin integrity injuries accounted for 83.7% (82 of 98) of the events. The remaining events, 16.3% (16 of 98), involved unplanned extubations, cardiac arrests, displaced lines, enteral feedings, medication errors, a dental issue, and posterior ischemic optic neuropathy.
  7. Content Article
    The University of California, Irvine, health sciences researchers have created a machine-learning model to predict the probability that a COVID-19 patient will need a ventilator or ICU care. The tool is free and available online for any healthcare organisation to use. "The goal is to give an earlier alert to clinicians to identify patients who may be vulnerable at the onset," said Daniel S. Chow, an assistant professor in residence in radiological sciences and first author of the study, published in PLOS ONE. The tool predicts whether a patient's condition will worsen within 72 hours. Coupled with decision-making specific to the healthcare setting in which the tool is used, the model uses a patient's medical history to determine who can be sent home and who will need critical care. The study found that at UCI Health, the tool's predictions were accurate about 95% of the time.
  8. Content Article
    Hospital-acquired pneumonia, whether device associated or not, is the number one hospital-acquired infection in the United States and a major threat to the safety of patients. This blog by Patient Safety Movement discusses how engaging nurses in quality improvement around mouth care reduces ventilator acquired pneumonias.
  9. Content Article
    This document should be used to guide clinicians on the appropriate use of continuous positive airway pressure (CPAP), non-invasive ventilation (NIV), here referring to bilevel positive airway pressure (BiPAP) and high flow nasal oxygen (HFNO, such as OptiflowTM) in patients with confirmed or suspected COVID-19. Published evidence, clinical guidelines and personal communications with colleagues in China and Italy have informed this document. The guidance is not designed to be prescriptive but to provide a useful aid to use alongside clinical judgement. It can be adjusted to suit individual clinical environments. Decisions relating to the escalation of ventilatory support (whether as a trial of treatment, as a ceiling of care, or as a possible bridge to ongoing invasive ventilation) need to be made early and by experienced clinical decision-makers. 
  10. Content Article
    In response to the ongoing coronavirus situation, the Government has put a call out for businesses who can provide support in the supply of ventilators and ventilator components for the healthcare system.[1] This has been met with a positive reaction from industry, with firms such as Dyson, Smiths Group and an industrial consortium (including Rolls-Royce, Airbus, McLaren, Thales, BAE Systems and Ford) responding to this.[2] Patient Safety Learning has been engaging with key leaders in Parliament, the healthcare system and international colleagues on matters in relation to patient safety during the pandemic. With forthcoming introduction of thousands of new ventilators, we have been collaborating with human factors/ergonomics experts and colleagues regarding the design and development of these.  It’s important that we have ventilators. It’s important that they’re safe. 
  11. Content Article
    This is a specification of the minimally (and some preferred options) clinically acceptable ventilator to be used in UK hospitals during the current SARS-CoV2 outbreak. It sets out the clinical requirements based on the consensus of what is ‘minimally acceptable’ performance in the opinion of the anaesthesia and intensive care medicine professionals and medical device regulators.
  12. Content Article
    In this blog, Claire discusses the use of NEWS2 in coronavirus patients and the importance of recognising, tracking and alerting the appropriate team that your patient has an increasing oxygen demand to ensure that the risk of more people being exposed to the virus is minimal.
  13. Content Article
    Dr Gordon Caldwell, a consultant physician, questions whether he should be ventilated if gets the coronavirus. Gordon is a 64 year old in good health. But in his blog he asks us to consider whether this would be a wise action and whether more harm than good would come from ventilating him. The process of ventilation may be the most important and dangerous fomite for the current generation of healthcare staff, but by jumping to “do it all” and “have a go” we may be shooting the human race in the foot; however well intentioned the motivation. Read Gordon's full blog in the attachment below.
  14. Content Article
    The purpose of this document is to provide designers and manufacturers of ventilators with overarching advice and guidance on the key themes for consideration and specific Human Factors and Ergonomic (HFE) issues in a period of “crisis management” requiring rapid design and production.
  15. Content Article
    This document designed by the Patient Safety Movement is a dynamic document that gives a summary of therapies given to COVID patients in the US.
  16. Content Article
    This article, published by the American Association for Respiratory Care, discusses a Ventilator Training Alliance (VTA) that has been formed by several of the world’s ventilator manufacturers. The VTA has partnered with Allego to create a mobile app that frontline medical providers can use to access a centralised repository of ventilator training resources. To download the Ventilator Training Alliance knowledge hub app and to watch a video of it in action, please follow the link.
  17. Content Article
    On 30 March, in response to the UK Government asking for business to provide thousands of ventilators to help tackle the Covid-19 pandemic, Patient Safety Learning published a blog with recommendations to ensure that ventilators are ‘safe in use’ (this means making sure they are as intuitive and easy to use for frontline staff as possible, reducing the potential for error).[1] In that blog, we outlined how we had brought together human factors/ergonomics and clinical experts to discuss the design, development and use of the equipment.
  18. Content Article
    Blog published in the Guardian from an NHS respiratory consultant.
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