Blockchain Papers

Anwar Ali Sathio, Shafiq Ahmed Awan, Ali Orangzeb Panhwar, Ali Aamir · 6 authors

During the COVID-19 pandemic, finding effective methods to prevent the spread of infectious diseases has become critical. One important measure for reducing the transmission of airborne viruses is wearing face masks but enforcing mask-wearing regulations can be difficult in many settings. Real-time and accurate monitoring of mask usage is needed to address this challenge. To do so, we propose a method for mask detection using a convolutional neural network (CNN) and blockchain technology. Our system involves training a CNN model on a dataset of images of people with and without masks and then deploying it on IoT-enabled devices for real-time monitoring. The use of blockchain technology ensures the security and privacy of the data and enables the efficient sharing of resources among network participants. Our proposed system achieved 99% accuracy through CNN training and was transformed into a blockchain-enabled network mechanism with QR validation of every node for authentication. This approach has the potential to be an effective tool for promoting compliance with mask-wearing regulations and reducing the risk of infection. We present a framework for implementing this technique and discuss its potential benefits and challenges

Lianna Zhao, Pietro Ferraro, Robert Shorten

As Covid-19 remains a cause of concern, especially due to its mutations, wearing masks correctly and efficiently remains a priority in order to limit the spread of the disease. In this paper we present a wearable smart-mask prototype using concepts from Internet of Things, Control Theory and Distributed Ledger Technologies. Its purpose is to encourage people to comply with social distancing norms, through the use of incentives. The smart mask is designed to monitor Carbon Dioxide and Total Volatile Organic Compounds concentrations. The detected data is appended to a DAG-based DLT, named the IOTA Tangle. The IOTA Tangle ensures that the data is secure and immutable and acts as a communication backbone for the incentive mechanism. A hardware-in-the-loop simulation, based on indoor positioning, is developed to validate the effectiveness of the designed prototype.

Sara C. Auld, Mark Caridi-Scheible

On March 6, 2020, the first patient diagnosed with coronavirus disease 2019 (COVID-19) at our institution was admitted to the Emory Serious Communicable Disease Unit (SCDU), which was initially established for the care of patients with Ebola and other special pathogens. The demand for ICU beds quickly outstripped the SCDU capacity: within days, we converted ordinary ICUs to receive the influx of COVID patients. Our teams struggled with fear, anxiety, and uncertainty about our safety and that of our families. We struggled much more wondering about the best care for our patients. Our institutional guidelines initially recommended against the use of both noninvasive positive pressure ventilation (NIPPV) and high-flow nasal oxygen, also referred to as heated high-flow nasal cannula and high-flow nasal cannula. This recommendation emerged from a desire to avoid unnecessary staff exposure to aerosolized viral particles. Global guidance in March 2020 similarly cautioned against high-flow nasal oxygen, out of concern for limited efficacy and high failure rates (1). During those early weeks, patients under our care who remained hypoxemic or tachypneic despite a 100% nonrebreather mask were promptly intubated. As believers in the robust data supporting the use of high-flow nasal oxygen who have been using it as part of our armamentarium to care for patients in the last several years (2,3), we could not dismiss our nagging doubt that we may have been doing a disservice to our patients by withholding this modality. Upon further review of evidence demonstrating minimal additional air dispersion as compared with traditional face masks (4), our institutional guidelines were relaxed on March 25, 2020, to allow for the use of high-flow nasal oxygen. It was at this time that we initially were assigned to review the article by Xia et al (5), published in this issue of Critical Care Medicine. They reported their experience caring for 43 patients with COVID-19 who were treated with high-flow nasal oxygen at three tertiary-care hospitals in Wuhan, China, in the earliest days of the outbreak. Just under half of the patients in their cohort failed high-flow nasal oxygen, requiring escalation to either noninvasive or invasive mechanical ventilation. Patients who failed were older, more commonly male, and had a lower oxygen saturation (Spo2) at admission. They were also more likely to have an increase in their respiratory rate (RR) and a decrease in their ratio of Spo2/Fio2 to RR (ROX) index after initiation of high-flow nasal oxygen. As has been reported in other settings (6), patients with failure of high-flow nasal oxygen had a high mortality rate (65%), whereas no patients died among those who did not require escalation of their respiratory support. Although this was not a randomized trial of high-flow nasal oxygen use, it offers some reassurance to providers that there is a role for this modality in the treatment of COVID-19 and identifies clinical risk factors for treatment failure. The early experience of Xia et al (5) from Wuhan felt like a lifeline in March when the manuscript first reached our hands. Several months later, many of us have cared for our own patients with COVID-19 and these early data no longer feel novel. Yet, it is important that they are published and read. In reviewing and publishing this report, the editors have faced the “challenge of discerning signal amidst noise,” steadily walking the fine line between expediting critical reporting and ensuring a thorough and comprehensive review process (7). Surprisingly, there are few data to guide our use of high-flow nasal oxygen in COVID-19. As of July 9, 2020, a search of the terms “high-flow nasal oxygen” and “high-flow nasal cannula” on LitCovid, a curated hub of articles related to COVID-19 in PubMed, revealed 37 articles written in English, out of more than 30,603 total articles. Thirteen of those articles were reviews or guidelines, three reported on the use of high-flow nasal oxygen in periprocedural settings, 10 were observational studies that reported the use of high-flow nasal oxygen in their cohorts but did not explicitly focus on the modality, eight were small case series of fewer than 10 patients—leaving just three articles reporting on patient outcomes in the context of high-flow nasal oxygen use, two of which examined the use of high-flow nasal oxygen in conjunction with awake prone positioning (8–10). We found an additional preprint manuscript reporting, similar to Xia et al (5), that the ROX index was predictive of failure of high-flow nasal oxygen and the need for invasive mechanical ventilation, with greater mortality in the group that progressed to invasive mechanical ventilation (11). The role for high-flow nasal oxygen in critically ill patients with COVID-19 remains unclear. Although several reports have found that patients who received high-flow nasal oxygen had higher mortality than those who did not, these observational studies cannot account for confounding by indication, whereby the sickest patients would have been those most likely to receive high-flow nasal oxygen in the first place (9,12). The same uncertainty holds for NIPPV. Although there are hospitals that have used NIPPV in the care of patients with COVID-19 (13,14) (including a hospital in Singapore where 20 healthcare workers wore a simple surgical mask while caring for an NIPPV patient who was later found to have COVID-19—and none became ill [15]), our institutional guidelines still recommend against noninvasive ventilation because of concern for aerosol generation with leakage around the face mask. Anecdote is not evidence. Observations are not proof. The patient phenotypes and clinical trajectories are changing. Yet the continuing flow of COVID-19 patients demands that we choose treatment in the face of distressing uncertainty. So what can we do? We start with what we know—or at least what we think we know—about best practices for viral pneumonia, acute respiratory distress syndrome, and general critical care. Inevitably, some of our choices will eventually be proven “wrong.” It is for precisely this reason that reports such as that of Xia et al (5)—and of our own (16)—must be written, reviewed, and published. We started our COVID-19 response by consolidating current best practices in non-COVID critical care and management of respiratory failure into pragmatic guidelines. In ordinary circumstances, we would wait for evidence to accumulate and then modify our practice. History tells us that circumspection is ordinarily best: the history of critical care is littered with good intentions that were ineffective or frankly harmful (17). Prudence asserts equipoise, awaiting evidence that is large-scale, rigorous, and undeniable. The onward global march of COVID-19 denies us this equipoise. The number of infected patients’ lives at stake grows ominously with every passing day. This is not business as usual. We cannot wait. They cannot wait. How has our healthcare system moved forward? We have paid close attention to every patient’s evolution, assembled subject matter experts, formed working groups, shared and analyzed internal data, reviewed the emerging (albeit limited and imperfect) literature, and week by week (sometimes day by day) integrated that new knowledge into our institutional guidelines. When new avenues of uncertainty arose, from how to handle higher than normal rates of ventilator dyssynchronies to unprecedented rates of filter clotting for patients on continuous renal replacement therapy, we pivoted our efforts to assess, evaluate, and respond. We formed a microcosm, sharing observations, reviewing experience, and challenging our own logic and outcomes. We collated ideas and data, digested them, put them up for debate, and attempted to place them in perspective as we made changes in practice. Absent the sort of evidence that comes from randomized, controlled trials, we did the best we could with what we had. Observational comparative studies like the one of high-flow nasal oxygen by Xia et al (5) are reassuring. Each provides additional data in what remains a largely data-free zone, supporting cautious, ongoing changes in our practice. These small adjustments are slow moves toward perfect care. Increments are preferred to big changes in these parlous times. We understood that the report by Xia et al (5) was not a perfect study, that there was selection bias for administration of high-flow nasal oxygen, that the sample size was somewhat limited, among other potential critiques. Yet the study by Xia et al (5) informed our own decision to incorporate high-flow nasal oxygen into our care. Although the study by Xia et al (5) did not provide a definitive answer to high-flow nasal oxygen use, it allowed us to take one more step toward rigorous practice. With publication of their peer-reviewed revised report, Xia et al (5) now create more confidence for readers that high-flow nasal oxygen is an appropriate choice for some patients with COVID-19. Only 19 weeks ago, we admitted our first COVID-19 patient. We have just admitted our 580th. She will receive more informed care that is shaped by local and global experience. Like Xia et al (5), we have written, submitted, revised, and ultimately published in Critical Care Medicine. By continuing to submit our reports of experiences to peer-review, we—and the authors of the other 30,602 papers—join an invisible college. We do so in the hope of informing the best care today and of delivering even better care tomorrow.

Jeannine W.C. Blake, Karen K. Giuliano

In late 2019 the novel coronavirus disease 2019 (COVID-19) emerged in China, causing severe respiratory illness with persistent person-to-person transmission.1–3 The first diagnosed case in the United States was reported in late January, sparking an initial US public health response that included restricted travel, traveler screening, and required quarantine.1 Because of the growing number of cases, the World Health Organization (WHO) declared a global health emergency on January 30, 2020; on March 11, 2020, the WHO issued a pandemic declaration.4,5 With the disease showing a high transmission rate, atypical symptoms, high rates of mortality, and documented transmission from patient to health care worker, fear grew as countries hurried to prepare.3When a previously unknown pathogen causes an epidemic rate of infection, the success of national health systems relies on reserves of health care supplies and their appropriate allocation.4 Effective distribution, training, and use of personal protective equipment (PPE) is key to preventing spread between patients and health care workers.4 In the setting of COVID-19, PPE that was once taken for granted as a disposable commodity quickly became a treasured resource to maintain the personal health and safety of health care workers.4Patients who contract COVID-19 experience a wide spectrum of symptom severity that requires care ranging from at-home symptom management to inpatient intensive care.6 The COVID-19 pandemic introduced a need to increase hospital intensive care capacity rapidly in order to be able to provide adequate care for the patients presenting with this disease.2 Although SARS-CoV-2, the virus that causes COVID-19, is primarily transmitted via droplets, aerosol-generating procedures can cause the virus to remain in the air for up to 3 hours and be infective through simple inhalation.7,8 Aerosol-generating procedures performed on patients positive for COVID-19 present an elevated infection risk for health care workers.5,8 Most studies suggest that aerosol-generating procedures include preintubation ventilation, intubation, tracheostomy, open-airway suctioning, cardiopulmonary resuscitation, and noninvasive ventilation.8In order to provide the complex care required by critically ill patients infected with the highly contagious SARS-CoV-2, frontline clinicians have had to implement practice changes to address patient care needs while simultaneously conserving PPE and reducing personal exposure risk. One of the resultant practice changes was to move medical devices, most commonly intravenous (IV) infusion pumps, away from the bedside and into the anterooms or hallways outside of patient rooms. This article aims to provide nurses with the information needed to support clinical decision-making during IV infusion therapy when IV infusion devices are located away from the patient bedside.Adversity drives people to change habits, adjust protocols, and innovate. In the case of COVID-19, the scarcity of PPE pushed health care workers to conserve and make do with what was available. As a result, health care workers were quickly required to balance unimaginable clinical demands for the sickest patients while also preserving personal safety.In intensive care units (ICUs), where the most-critical patients go for care, aerosol-generating procedures are required frequently and, in some cases, continuously. To mitigate the risk of exposure and effectively manage the use and conservation of PPE, the doors to patient rooms must be kept closed, and nurses and other clinicians must limit contact frequency and time in COVID-19 isolation rooms. With the doors closed and PPE required to enter, nurses are unable to enter into patient rooms quickly or easily to manage the multiple lines and infusions required to care for critically ill patients. For very sick patients, even a brief pause in a life-sustaining infusion from an occlusion, air in the line, or the completion of a medication bag can have dire consequences. Because infusion pumps cannot be controlled without direct device interaction, the use of longer-than-usual extension tubing allows for placement and operation of the pumps outside of patient rooms. This practice has been rapidly adopted for care of critically ill patients with COVID-19 and is permitted by the US Food and Drug Administration (FDA) for the duration of this public health emergency under Emergency Use Authorization.9 One goal of this FDA policy is to “help foster technologies that maintain a safer physical distance between the health care provider and patient affected by COVID-19.”9 A modification that the FDA determines would not create undue risk is “remote monitoring and/or manual control of infusion pumps to manage the care of a patient without physically entering a patient’s room.”9The complex care of critically ill patients often requires the simultaneous administration of multiple IV medications using large-volume IV smart pumps (IVSPs). Under normal circumstances, most IVSPs are located at the bedside only a few feet from the patient, where the nurse can see the patient and the pump when administering and adjusting medications. Frequent nursing intervention is necessary to manage concurrent IV medication administration, including infusion titrations, bolus/loading of medication doses, and intermittent medication dosing. Nursing intervention is also necessary to ensure that the correct volume of each individual infusion is completely delivered through the lengthy extension tubing. Managing IVSPs outside the rooms of patients with COVID-19 may also entail infusing multiple compatible medications together to reduce the use of extension tubing and the potential need to attend to frequent nuisance alarms or other tasks necessary to ensure continuous flow. Even when IVSPs are located at the bedside, IV infusion is associated with high rates of adverse drug events and medication errors, many of which can be life threatening.10 Remote IV infusion also makes it more difficult to verify patient identity during dual nurse medication checks. Operation of the IVSP in these circumstances is intricate, requires high levels of cognitive attention, and can be error prone.10,11 Nurses must recognize the potential for error associated with IV infusion under normal circumstances and keep in mind the added risk when moving the IVSPs farther from the patient, especially when both cannot be seen concurrently.Moving IVSPs outside of patient rooms requires modifications to allow the IV tubing to reach the patient; the Figure includes images of real-world use and modifications. Various methods for increasing the length of IV tubing are now being used so patients can continue to receive their medications even while the IVSPs are placed outside the room at distances of 15 feet or more. Placing the pumps outside the rooms improves nursing workflow when managing patients with COVID-19 in isolation, allows for easier interaction with the IVSP, and helps reduce risk of exposure for the nurses. Although this practice can be effective in helping to manage competing patient care demands, it is important for nurses to understand the safety implications in order to ensure that medications are still being delivered as expected.BD Alaris, Baxter Sigma, B. Braun Space Series, and ICU Medical Plum Series are the 4 most commonly used IVSPs in US acute care. The BD Alaris, Baxter Sigma, and B. Braun IVSPs use peristaltic pump technology to infuse fluid, whereas the ICU Medical Plum Series pumps use cassette-based volumetric technology. The Ivenix IVSP, which is not yet in clinical use but has recently received FDA approval, also uses cassette-based volumetric technology. A peristaltic pump uses rollers to propel fluid forward by pinching down on the length of tubing.12,13 Cassette-based pumps contain a flow regulator and a set of valves to administer fluids properly.13,14 Refer to the Table for additional definitions and technology features.With peristaltic IVSPs, flow rate accuracy of the pumping segment is impacted by variations in system resistance in the form of intake and outlet pressures.14 When intake pressure decreases and/or outlet pressure increases during IV medication administration, decreases in both flow rate and flow rate accuracy will occur.14 Most troubling is that the IVSP will continue to display the intended flow rate, making these errors extremely difficult to detect. When volumetric delivery is provided by cassette-based systems (eg, ICU Medical Plum Series or Ivenix IVSPs) the IV infusion is delivered at the programmed rate regardless of system resistance.14In addition to changes in system resistance, increasing the tubing length between the IVSP and patient presents additional challenges that must be considered. There is a significant increase in tubing dead volume, increased priming requirements, and elevated risk for air in line and medication adhering to the tubing because of increased tubing surface area. All of these factors can lead to portions of medication doses being left nonadministered or underinfused, which presents various safety concerns for the patient. Overinfusion may also be a concern in the setting of large amounts of medication left in the dead volume and then subsequently flushed into the patient at a higher-than-intended flow rate. A discussion of clinical implications, ways to mitigate effects, and dosing considerations is provided in the Table.New practice norms will no doubt continue to develop to address the complex care requirements for patients with COVID-19. The remote use of IVSPs addresses many salient clinical and workflow issues. As the primary users of IVSPs, nurses must be aware of the impact of this practice on the accuracy of IV medication administration and the increased potential for error. The most important aspects of IV medication administration should be patient safety, delivery of medication dosing as intended, and achievement of the desired therapeutic effect and/or measurable patient outcome. Improved understanding of the impact of remote IVSP system set-up can help the health care team make more informed decisions for individual patients and situations. With education and continued vigilance regarding the implications these changes can have, nurses can take steps to decrease risk of flow inaccuracy and other complications to support the safest and most accurate remote IVSP medication administration practices.The authors wish to thank Michelle Mandrack, MSN, RN, Director of Consulting Services for the Institute for Safe Medication Practices, for her generosity and expertise in providing a review of this brief report. Also thanks to to Robert Butterfield of RDB Consulting for his ongoing willingness to share his expertise.