Publications by authors named "Sadiq Said"

7 Publications

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Voice alerting as a medical alarm modality for next-generation patient monitoring: a randomised international multicentre trial.

Br J Anaesth 2021 Aug 25. Epub 2021 Aug 25.

Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland.

Background: Acoustic alarms in medical devices are vital for patient safety. State-of-the-art patient monitoring alarms are indistinguishable and contribute to alarm fatigue. There are two promising new sound modalities for vital sign alarms. Auditory icons convey alarms as brief metaphorical sounds, and voice alerts transmit information using a clear-spoken language. We compared how reliably healthcare professionals identified alarms using these two modalities.

Methods: This investigator-initiated computer-based multicentre simulation study included 28 anaesthesia providers who were asked to identify vital sign alarms in randomised order, once with voice alerts and once with auditory icons. We further assessed time to decision, diagnostic confidence, and perceived helpfulness. We analysed the results using mixed models, adjusted for possible confounders.

Results: We assessed 14 alarms for each modality, resulting in 392 comparisons across all participants. Compared with auditory icons, healthcare providers had 58 times higher odds of correctly identifying alarms using voice alerts (odds ratio 58.0; 95% confidence interval [CI]: 25.1-133.6; P<0.001), made their decisions about 14 s faster (coefficient -13.9; 95% CI: -15.8 to -12.1 s; P<0.001), perceived higher diagnostic confidence (100% [392 of 392] vs 43% [169 of 392; P<0.001]), and rated voice alerts as more helpful (odds ratio 138.2; 95% CI: 64.9-294.1; P<0.001). The participants were able to identify significantly higher proportions of alarms with voice alerts (98.5%; P<0.001) and auditory icons (54.1%; P<0.001) compared with state-of-the-art alarms (17.9%).

Conclusions: Voice alerts were superior to auditory icons, and both were superior to current state-of-the-art auditory alarms. These findings demonstrate the potential that voice alerts hold for patient monitoring.
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August 2021

Avatar-based patient monitoring in critical anaesthesia events: a randomised high-fidelity simulation study.

Br J Anaesth 2021 May 8;126(5):1046-1054. Epub 2021 Apr 8.

Institute of Anaesthesiology, University and University Hospital Zurich, Zurich, Switzerland. Electronic address:

Background: Failures in situation awareness cause two-thirds of anaesthesia complications. Avatar-based patient monitoring may promote situation awareness in critical situations.

Methods: We conducted a prospective, randomised, high-fidelity simulation study powered for non-inferiority. We used video analysis to grade anaesthesia teams managing three 10 min emergency scenarios using three randomly assigned monitoring modalities: only conventional, only avatar, and split-screen showing both modalities side by side. The primary outcome was time to performance of critical tasks. Secondary outcomes were time to verbalisation of vital sign deviations and the correct cause of the emergency, perceived workload, and usability. We used mixed Cox and linear regression models adjusted for various potential confounders. The non-inferiority margin was 10%, or hazard ratio (HR) 0.9.

Results: We analysed 52 teams performing 154 simulations. For performance of critical tasks during a scenario, split-screen was non-inferior to conventional (HR=1.13; 95% confidence interval [CI], 0.96-1.33; not significant in test for superiority); the result for avatar was inconclusive (HR=0.98; 95% CI, 0.83-1.15). Avatar was associated with a higher probability for verbalisation of the cause of the emergency (HR=1.78; 95% CI, 1.13-2.81; P=0.012). We found no evidence for a monitor effect on perceived workload. Perceived usability was lower for avatar (coefficient=-23.0; 95% CI, -27.2 to -18.8; P<0.0001) and split-screen (-6.7; 95% CI, -10.9 to -2.4; P=0.002) compared with conventional.

Conclusions: This study showed non-inferiority of split-screen compared with conventional monitoring for performance of critical tasks during anaesthesia crisis situations. The patient avatar improved verbalisation of the correct cause of the emergency. These results should be interpreted considering participants' minimal avatar but extensive conventional monitoring experience.
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May 2021

Effects of an Animated Blood Clot Technology (Visual Clot) on the Decision-Making of Users Inexperienced in Viscoelastic Testing: Multicenter Trial.

J Med Internet Res 2021 May 3;23(5):e27124. Epub 2021 May 3.

Institute of Anesthesiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.

Background: Viscoelastic test-guided coagulation management has become increasingly important in assessing hemostasis. We developed Visual Clot, an animated, 3D blood clot that illustrates raw rotational thromboelastometry (ROTEM) parameters in a user-centered and situation awareness-oriented method.

Objective: This study aimed to evaluate the applicability of Visual Clot by examining its effects on users that are novices in viscoelastic-guided resuscitation.

Methods: We conducted an investigator-initiated, international, multicenter study between September 16, 2020, and October 6, 2020, in 5 tertiary care hospitals in central Europe. We randomly recruited medical students and inexperienced resident physicians without significant prior exposure to viscoelastic testing. The 7 participants per center managed 9 different ROTEM outputs twice, once as standard ROTEM tracings and once as the corresponding Visual Clot. We randomly presented the 18 viscoelastic cases and asked the participants for their therapeutic decisions. We assessed the performance, diagnostic confidence, and perceived workload in managing the tasks using mixed statistical models and adjusted for possible confounding factors.

Results: Analyzing a total of 630 results, we found that the participants solved more cases correctly (odds ratio [OR] 33.66, 95% CI 21.13-53.64; P<.001), exhibited more diagnostic confidence (OR 206.2, 95% CI 93.5-454.75; P<.001), and perceived less workload (coefficient -41.63; 95% CI -43.91 to -39.36; P<.001) using Visual Clot compared to using standard ROTEM tracings.

Conclusions: This study emphasizes the practical benefit of presenting viscoelastic test results in a user-centered way. Visual Clot may allow inexperienced users to be involved in the decision-making process to treat bleeding-associated coagulopathy. The increased diagnostic confidence, diagnostic certainty, reduced workload, and positive user feedback associated with this visualization may promote the further adoption of viscoelastic methods in diverse health care settings.
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May 2021

Physicians' perceptions regarding acute bleeding management: an international mixed qualitative quantitative study.

BMC Anesthesiol 2021 02 10;21(1):43. Epub 2021 Feb 10.

Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.

Background: Acute bleeding is an omnipresent challenge for all physicians. Uncontrolled hemorrhage is the most common preventable cause of death after trauma worldwide. In different surgical disciplines, hemorrhage represents an independent risk factor for increased postoperative morbimortality, directly affecting patients' outcomes. This study asked anesthesiologists about their personal perceived challenges when treating bleeding patients.

Methods: This investigator-initiated, prospective, international, dual-center, mixed qualitative and quantitative study interrogated anesthesiologists about what they found easy and what difficult in treating acutely bleeding patients. Following the template approach for qualitative research, we identified major and minor topics through free inductive coding and word count. In a second step, we derived ten statements from the participants' answers. Using a field survey, we then asked the participants to rate their level of agreement with the derived statements. We analyzed the answers using one sample Wilcoxon test and the Mann-Whitney test.

Results: We included a total of 84 physicians in the qualitative interrogations and a different group of 42 anesthesiologists in the quantitative part. We identified 11 major topics and 19 associated subtopics. The main topics and the degree of agreement (here as agree or strongly agree) were as follows: "Complexity of the topic" (52.4% agreed to find the topic complex), "Cognitive aids" (92.9% agreed to find them helpful), "Time management" (64.3% agreed to feeling time pressure), "Human factors" (95.2% agreed that human factors are essential), "Resources" (95.2% agreed that resources are essential), "Experience" and "Low frequency of cases" (57.1% agreed to lack practice), "Diagnostic methods" (31.0% agreed that the interpretation of test results is difficult), "Anticoagulation" (85.7% agreed to it being difficult), "Treatment" (81.0% agreed to knowing the first therapeutic steps), and "Nothing".

Conclusions: Anesthesiologists in two large tertiary care facilities in different parts of the world found coagulation management, especially in anticoagulated patients, complex. We identified the delayed diagnostic test results and their interpretation as challenges. Resources, treatment protocols and human factors such as team communication were perceived to facilitate management. Future studies should explore the challenges in smaller hospitals and other parts of the world and test new technologies addressing the identified difficulties.
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February 2021

Physicians' Perceptions of a Situation Awareness-Oriented Visualization Technology for Viscoelastic Blood Coagulation Management (Visual Clot): Mixed Methods Study.

JMIR Serious Games 2020 Dec 4;8(4):e19036. Epub 2020 Dec 4.

Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zürich, Switzerland.

Background: Viscoelastic tests enable a time-efficient analysis of coagulation properties. An important limitation of viscoelastic tests is the complicated presentation of their results in the form of abstract graphs with a multitude of numbers. We developed Visual Clot to simplify the interpretation of presented clotting information. This visualization technology applies user-centered design principles to create an animated model of a blood clot during the hemostatic cascade. In a previous simulation study, we found Visual Clot to double diagnostic accuracy, reduce time to decision making and perceived workload, and improve care providers' confidence.

Objective: This study aimed to investigate the opinions of physicians on Visual Clot technology. It further aimed to assess its strengths, limitations, and clinical applicability as a support tool for coagulation management.

Methods: This was a researcher-initiated, international, double-center, mixed qualitative-quantitative study that included the anesthesiologists and intensive care physicians who participated in the previous Visual Clot study. After the participants solved six coagulation scenarios using Visual Clot, we questioned them about the perceived pros and cons of this new tool. Employing qualitative research methods, we identified recurring answer patterns, and derived major topics and subthemes through inductive coding. Based on them, we defined six statements. The study participants later rated their agreement to these statements on five-point Likert scales in an online survey, which represented the quantitative part of this study.

Results: A total of 60 physicians participated in the primary Visual Clot study. Among these, 36 gave an interview and 42 completed the online survey. In total, eight different major topics were derived from the interview field note responses. The three most common topics were "positive design features" (29/36, 81%), "facilitates decision making" (17/36, 47%), and "quantification not made" (17/36, 47%). In the online survey, 93% (39/42) agreed to the statement that Visual Clot is intuitive and easy to learn. Moreover, 90% (38/42) of the participants agreed that they would like the standard result and Visual Clot displayed on the screen side by side. Furthermore, 86% (36/42) indicated that Visual Clot allows them to deal with complex coagulation situations more quickly.

Conclusions: A group of anesthesia and intensive care physicians from two university hospitals in central Europe considered Visual Clot technology to be intuitive, easy to learn, and useful for decision making in situations of active bleeding. From the responses of these possible future users, Visual Clot appears to constitute an efficient and well-accepted way to streamline the decision-making process in viscoelastic test-based coagulation management.
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December 2020

Validation of the Raw National Aeronautics and Space Administration Task Load Index (NASA-TLX) Questionnaire to Assess Perceived Workload in Patient Monitoring Tasks: Pooled Analysis Study Using Mixed Models.

J Med Internet Res 2020 09 7;22(9):e19472. Epub 2020 Sep 7.

Department of Anesthesiology, University Hospital Zurich, Zurich, Switzerland.

Background: Patient monitoring is indispensable in any operating room to follow the patient's current health state based on measured physiological parameters. Reducing workload helps to free cognitive resources and thus influences human performance, which ultimately improves the quality of care. Among the many methods available to assess perceived workload, the National Aeronautics and Space Administration Task Load Index (NASA-TLX) provides the most widely accepted tool. However, only few studies have investigated the validity of the NASA-TLX in the health care sector.

Objective: This study aimed to validate a modified version of the raw NASA-TLX in patient monitoring tasks by investigating its correspondence with expected lower and higher workload situations and its robustness against nonworkload-related covariates. This defines criterion validity.

Methods: In this pooled analysis, we evaluated raw NASA-TLX scores collected after performing patient monitoring tasks in four different investigator-initiated, computer-based, prospective, multicenter studies. All of them were conducted in three hospitals with a high standard of care in central Europe. In these already published studies, we compared conventional patient monitoring with two newly developed situation awareness-oriented monitoring technologies called Visual Patient and Visual Clot. The participants were resident and staff anesthesia and intensive care physicians, and nurse anesthetists with completed specialization qualification. We analyzed the raw NASA-TLX scores by fitting mixed linear regression models and univariate models with different covariates.

Results: We assessed a total of 1160 raw NASA-TLX questionnaires after performing specific patient monitoring tasks. Good test performance and higher self-rated diagnostic confidence correlated significantly with lower raw NASA-TLX scores and the subscores (all P<.001). Staff physicians rated significantly lower workload scores than residents (P=.001), whereas nurse anesthetists did not show any difference in the same comparison (P=.83). Standardized distraction resulted in higher rated total raw NASA-TLX scores (P<.001) and subscores. There was no gender difference regarding perceived workload (P=.26). The new visualization technologies Visual Patient and Visual Clot resulted in significantly lower total raw NASA-TLX scores and all subscores, including high self-rated performance, when compared with conventional monitoring (all P<.001).

Conclusions: This study validated a modified raw NASA-TLX questionnaire for patient monitoring tasks. The scores obtained correctly represented the assumed influences of the examined covariates on the perceived workload. We reported high criterion validity. The NASA-TLX questionnaire appears to be a reliable tool for measuring subjective workload. Further research should focus on its applicability in a clinical setting.
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September 2020

Situation Awareness-Oriented Patient Monitoring with Visual Patient Technology: A Qualitative Review of the Primary Research.

Sensors (Basel) 2020 Apr 9;20(7). Epub 2020 Apr 9.

Institute of Anesthesiology, University and University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland.

Visual Patient technology is a situation awareness-oriented visualization technology that translates numerical and waveform patient monitoring data into a new user-centered visual language. Vital sign values are converted into colors, shapes, and rhythmic movements-a language humans can easily perceive and interpret-on a patient avatar model in real time. In this review, we summarize the current state of the research on the Visual Patient, including the technology, its history, and its scientific context. We also provide a summary of our primary research and a brief overview of research work on similar user-centered visualizations in medicine. In several computer-based studies under various experimental conditions, Visual Patient transferred more information per unit time, increased perceived diagnostic certainty, and lowered perceived workload. Eye tracking showed the technology worked because of the way it synthesizes and transforms vital sign information into new and logical forms corresponding to the real phenomena. The technology could be particularly useful for improving situation awareness in settings with high cognitive demand or when users must make quick decisions. This comprehensive review of Visual Patient research is the foundation for an evaluation of the technology in clinical applications, starting with a high-fidelity simulation study in early 2020.
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April 2020