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I am an NHS anaesthetist at Brighton and Sussex University Hospitals NHS Trust, on maternity leave (with three children under the age of 4 years), and currently stuck abroad in the US. Unable to be patient-facing during the COVID-19 pandemic, I have had to re-evaluate my initial plans to return to work. I have felt desperate to do something to help, and while keeping up with the news I was inspired by an article I read about a critically ill intensive care patient who was terrified when he couldn’t understand what the healthcare team were saying to him through their PPE (face masks, visors, hoods, etc). PPE creates a barrier to communication. So much is lost through this barrier. Not only verbal communication, but also non-verbal cues, which form the basis of the majority of communication – the ability to lip read for those that rely on it and the human connection behind the mask. As such, there is a significant risk of miscommunication of vital information between the patient and healthcare provider, presenting a considerable patient safety issue. What started out as a simple thought, “would healthcare staff be able to write down what they need to say on a piece of paper and show it to the patient?”, within 72 hours turned into an A–Z index of digital flashcards covering a wide range of topics, and www.cardmedic.com was launched. A free online resource for all to use, CARDMEDICTM launched on 1 April 2020. Prior to being shared on national news platforms, the site already had over 8000 users in 50 countries across 6 continents in just over 3 weeks, including across Europe, Australia, New Zealand, United States, Canada, Asia and Africa. It was shared by the Defence Medical Services to over 70 senior clinicians across all specialties in multiple Trusts across the UK. Since being featured in The Guardian and various other media outlets, the site has now had over 10,000 visits and 60,000 page views in less than 8 hours! I have been inundated with support, positive feedback and offers of help ranging from translation to illustrations and more. CARDMEDICTM is simple to use. Healthcare providers can access www.cardmedic.com/flashcards either on their institution’s or their patient’s smart phone, tablet or desktop. Choose the flashcard you would like to talk to the patient about and display it on the screen to the patient. Just ensure the website is displayed in the relevant language, there are 10 to choose from at the moment (thanks to Weglot) – this option is currently at the bottom right hand side of the page. If your patient is too unwell or unable to read, or partially sighted or blind, there is also a read-aloud option (thanks to SiteSpeaker) – choose the blue “play” button at the top right of the screen. Devices can be placed in freezer bags that are compatible with gloves and can be disposed of between patients, although we are aware of the environmental impact of this. Alternatively, some places have devices that they disinfect by wiping clean between patients. For those who prefer a paper-based approach, the cards can be printed and laminated; write-on, wipe-off. We are working on making these available as downloadable PDFs. With the re-deployment of vast numbers of healthcare and allied healthcare professionals, together with those returning to practice, there are a large number working outside their usual realm of clinical practice. This presented a further issue; staff may feel uncertain of how to talk to patients about certain aspects of their care in simple language if it is an area they are not familiar with working. The flashcards can also act as a reminder or prompt in these circumstances and another layer of maintaining patient safety. We have also just launched a free app on 25 April, compatible with android and iOS/Apple, improving accessibility for those with difficult internet access and ease of access for all..A huge thanks to Phil at A Million Monkeys for working tirelessly over the last couple of weeks on this. The app should not only improve accessibility for those in areas with little or no internet access, but also provide an immediately available source of flashcards that will be continually updated, without having to repeatedly download new versions from the app store. Based upon my training in anaesthetics and, as a part of this, experience in critical care, I wrote the majority of the CARDMEDICTM content. I have had significant contribution both in terms of content and resources from specialist colleagues in critical care nursing, end of life and palliative care, radiography, DNAR, obstetrics, midwifery, speech and language therapists and learning disability nurses, with more to come. Whilst what we have prepared is not professing to be a “gold standard” in communication, it is based upon a wealth of combined experience, knowledge and an acceptable standard in clinical practice. There is much planned in way of development, in part shaped by the feedback we have received. For example, we are collaborating with Signly on integrating British Sign Language videos and also working on integrating illustrations to improve accessibility for users. I am delighted to have Scarlett Brandley, a Leeds University Medical School student, spending her elective with me working on it. Some incredible suggestions have also been put forward about using it in refugee camps in Greece, Iran and Afghanistan. CARDMEDICTM has been developed through a combination of extreme generosity of colleagues, friends, family, contacts, word of mouth and Twitter, as well as very much burning the candle at both ends seven days a week. When I started this, I thought I would share the site with a few friends and colleagues and it would hopefully help make a difference to a few patients. I never envisaged it would have grown so rapidly and at such pace. I am so overwhelmed by the time, advice, services donated free of charge from so many different people – organisations, colleagues, friends and family. There are too many people to thank here! To mention a few – Patient Safety Learning have been championing it and have been a great source of support. My friends and colleagues at Brighton and Sussex University Hospitals NHS Trust and the University of Brighton have been incredibly supportive and proactive – I am very grateful. The Department for International Trade has been fantastic and introduced me to so many different contacts across a wide range of organisations, including Grow Global and Signly. A Million Monkeys has worked tirelessly on developing the app. The Defence Medical Services have shared it across the UK. The Academic Health Sciences Network (AHSN) have also been a really useful resource, especially with advice on possible funding streams. Dr Andy Tagg at Don’t Forget the Bubbles in Australia has been brilliant and we are looking forward to working together, along with Jane Stokes, to translate it into a further 15–20 languages. Having never been on Twitter before, the networking opportunities have been phenomenal and so many people have come forward too, to offer their time and expertise with various clinical sections of the site. I could go on! I am humbled to think my idea could have such far reaching purpose and value as this. It has been and continues to be, an enormous team effort to pull this together. We have applied for government funding and are yet to hear back. If this doesn’t come through, I am going to take the anaesthetics department at Brighton and Sussex University Hospitals NHS Trust up on their incredible offer of financial start-up support to aid further development, as well as a private donor up on their unbelievably generous offer to pay for the app development. All else has been without funding. It is so important for this to remain free for the end users: the patients and the staff. We are constantly looking to develop and improve. It is essential this works on the frontline and we are very grateful for your thoughts and feedback. If you have a moment, please either contact us via the website (www.cardmedic.com/contact) or via Twitter (@cardmedic).

This website provides nformation, guidance and resources supporting the understanding and management of coronavirus (COVID-19), iincluding: airway management for adults and children obstetric management critical care management cross skilling podcasts and webinars PPE drug management.

Implications While this study shows that those referring patients to ICU could benefit from greater support, the decision support tool trialled in this study would need some adaptation to fit the time-pressured realities of the users. The process did seem to help clinicians articulate and communicate their reasoning for admission. Perhaps, as the authors say, if the tool were to be integrated into existing systems the perceived additional workload may be diminished. Another not insignificant finding is that although clinicians stated they valued patient’s wishes, in some cases there was a lack of patient and family involvement.