{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T15:27:42Z","timestamp":1787671662718,"version":"build-2736575974"},"reference-count":39,"publisher":"BMJ","issue":"8","license":[{"start":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T00:00:00Z","timestamp":1787616000000},"content-version":"unspecified","delay-in-days":24,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/100004320","name":"Philips","doi-asserted-by":"publisher","award":["Exhibit B -USZ-0007"],"award-info":[{"award-number":["Exhibit B -USZ-0007"]}],"id":[{"id":"10.13039\/100004320","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100004320","name":"Philips","doi-asserted-by":"publisher","award":["Exhibit B -USZ-0010"],"award-info":[{"award-number":["Exhibit B -USZ-0010"]}],"id":[{"id":"10.13039\/100004320","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100004320","name":"Philips","doi-asserted-by":"publisher","award":["SRA_233936\/WCM-0001."],"award-info":[{"award-number":["SRA_233936\/WCM-0001."]}],"id":[{"id":"10.13039\/100004320","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2026,8,4]]},"published-print":{"date-parts":[[2026,8]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Perioperative monitoring requires clinicians to integrate multiple physiological data streams while managing interruptions and audible alarms. The Visual Patient Avatar (VPA) is an avatar-based monitor visualisation that integrates vital signs and sensor states into an animated virtual patient. This protocol evaluates whether VPA implementation is associated with objective changes in monitoring and alarm outcomes during routine perioperative care.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods and analysis<\/jats:title>\n                    <jats:p>This investigator-initiated, dual-centre, quasi-experimental pre-post observational study uses routine perioperative monitoring and alarm data from NewYork-Presbyterian\/Weill Cornell, USA and University Hospital Zurich, Switzerland. It includes approximately 58\u2009000 anaesthesia cases (16\u2009000 and 42 000, respectively); adult and paediatric cases will be analysed separately. Data span pre-implementation, adaptation and post implementation phases; technical deployment intervals are excluded. Each anaesthesia case is one unit of analysis. The primary outcome is the duration of vital-sign deviation per 60\u2009min of valid measurement. Secondary outcomes are a time-based area under the curve metric and audible alarm burden (count, time and reaction time). Multivariable models will adjust for patient, procedure and care-context covariates. Analyses will be performed separately by centre.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Ethics and dissemination<\/jats:title>\n                    <jats:p>The Weill Cornell Medicine Institutional Review Board approved the study and granted a waiver of informed consent (IRB No. 22-05024803). At University Hospital Zurich, only cases from patients with written general consent for research use of routinely collected health data were included. The Cantonal Ethics Committee Zurich issued a declaration of non-jurisdiction (BASEC Req-2021-00756; 6 July 2021), and the University Hospital Zurich Data Governance Board approved data export and anonymisation (DGR0000504; 31 January 2025). A data-sharing agreement was established on 11 April 2023. Data-collection windows are complete; extraction, linkage and quality control are ongoing, and no comparative outcome analyses have been performed. Findings will be disseminated through peer-reviewed publications and conferences.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2026-121099","type":"journal-article","created":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T14:46:14Z","timestamp":1787669174000},"page":"e121099","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Effects of the Visual Patient Avatar on vital sign deviations and audible alarm burden in perioperative care: a dual-centre, quasi-experimental pre-post large-scale observational study protocol (NewYork-Presbyterian\/Weill Cornell and University Hospital Zurich)"],"prefix":"10.1136","volume":"16","author":[{"given":"Silis Y","family":"Jiang","sequence":"first","affiliation":[{"name":"Department of Anaesthesiology, Weill Cornell Medicine, New York, New York, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tadzio R","family":"Roche","sequence":"additional","affiliation":[{"name":"Institute of Anaesthesiology and Perioperative Medicine, University Hospital Zurich, Z\u00fcrich, Switzerland"},{"name":"University of Zurich, Z\u00fcrich, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Krzysztof","family":"Cybulski","sequence":"additional","affiliation":[{"name":"Seminar for Statistics, ETH Zurich, Z\u00fcrich, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gaspar","family":"Dugac","sequence":"additional","affiliation":[{"name":"Seminar for Statistics, ETH Zurich, Z\u00fcrich, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8508-1222","authenticated-orcid":false,"given":"Lukas","family":"Meier","sequence":"additional","affiliation":[{"name":"Mathematics, ETH Zurich, Z\u00fcrich, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Virginia E","family":"Tangel","sequence":"additional","affiliation":[{"name":"Department of Anaesthesiology, Weill Cornell Medicine, New York, New York, USA"},{"name":"Department of Anaesthesiology, University Medical Centre Groningen, Groningen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Max","family":"Ebensperger","sequence":"additional","affiliation":[{"name":"Technical University of Munich, Munich, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andreas","family":"Maskos","sequence":"additional","affiliation":[{"name":"Institute of Anaesthesiology and Perioperative Medicine, University Hospital Zurich, Z\u00fcrich, Switzerland"},{"name":"University of Zurich, Z\u00fcrich, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael","family":"Tucci","sequence":"additional","affiliation":[{"name":"Institute of Anaesthesiology and Perioperative Medicine, University Hospital Zurich, Z\u00fcrich, Switzerland"},{"name":"University of Zurich, Z\u00fcrich, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christoph B","family":"N\u00f6thiger","sequence":"additional","affiliation":[{"name":"Institute of Anaesthesiology and Perioperative Medicine, University Hospital Zurich, Z\u00fcrich, Switzerland"},{"name":"University of Zurich, Z\u00fcrich, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Markus","family":"Kalisch","sequence":"additional","affiliation":[{"name":"Seminar for Statistics, ETH Zurich, Z\u00fcrich, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zachary A","family":"Turnbull","sequence":"additional","affiliation":[{"name":"Department of Anaesthesiology, Weill Cornell Medicine, New York, New York, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3677-3705","authenticated-orcid":false,"given":"David W","family":"Tscholl","sequence":"additional","affiliation":[{"name":"Institute of Anaesthesiology and Perioperative Medicine, University Hospital Zurich, Z\u00fcrich, Switzerland"},{"name":"University of Zurich, Z\u00fcrich, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,8,25]]},"reference":[{"key":"2026082507351088000_16.8.e121099.1","doi-asserted-by":"publisher","DOI":"10.1213\/ane.0000000000002927"},{"key":"2026082507351088000_16.8.e121099.2","doi-asserted-by":"publisher","DOI":"10.1111\/anae.15501"},{"key":"2026082507351088000_16.8.e121099.3","unstructured":"American Society of Anesthesiologists . Standards for basic anesthetic monitoring. Schaumburg, IL, Available: https:\/\/www.asahq.org\/standards-and-practice-parameters\/standards-for-basic-anesthetic-monitoring"},{"key":"2026082507351088000_16.8.e121099.4","doi-asserted-by":"publisher","DOI":"10.1097\/ALN.0b013e318280a40f"},{"key":"2026082507351088000_16.8.e121099.5","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1518\/001872006776412270","article-title":"The right picture is worth a thousand numbers: data displays in anesthesia","volume":"48","author":"Drews","year":"2006","journal-title":"Hum Factors"},{"key":"2026082507351088000_16.8.e121099.6","doi-asserted-by":"crossref","DOI":"10.1186\/s12871-019-0757-z","article-title":"It\u2019s not you, it\u2019s the design - common problems with patient monitoring reported by anesthesiologists: a mixed qualitative and quantitative study","volume":"19","author":"Tscholl","year":"2019","journal-title":"BMC Anesthesiol"},{"key":"2026082507351088000_16.8.e121099.7","doi-asserted-by":"publisher","DOI":"10.1213\/ANE.0b013e3181e627d4"},{"key":"2026082507351088000_16.8.e121099.8","doi-asserted-by":"crossref","DOI":"10.3390\/s20072112","article-title":"Situation awareness-oriented patient monitoring with visual patient technology: a qualitative review of the primary research","volume":"20","author":"Tscholl","year":"2020","journal-title":"Sensors (Basel)"},{"key":"2026082507351088000_16.8.e121099.9","doi-asserted-by":"crossref","DOI":"10.1186\/s12911-020-1032-4","article-title":"Avatar-based versus conventional vital sign display in a central monitor for monitoring multiple patients: a multicenter computer-based laboratory study","volume":"20","author":"Garot","year":"2020","journal-title":"BMC Med Inform Decis Mak"},{"key":"2026082507351088000_16.8.e121099.10","doi-asserted-by":"crossref","first-page":"1369","DOI":"10.1007\/s10877-019-00429-2","article-title":"Effects of a standardized distraction on caregivers\u2019 perceptive performance with avatar-based and conventional patient monitoring: a multicenter comparative study","volume":"34","author":"Pfarr","year":"2020","journal-title":"J Clin Monit Comput"},{"key":"2026082507351088000_16.8.e121099.11","doi-asserted-by":"publisher","DOI":"10.1016\/j.bja.2018.04.024"},{"key":"2026082507351088000_16.8.e121099.12","doi-asserted-by":"crossref","first-page":"1046","DOI":"10.1016\/j.bja.2021.01.015","article-title":"Avatar-based patient monitoring in critical anaesthesia events: a randomised high-fidelity simulation study","volume":"126","author":"Roche","year":"2021","journal-title":"Br J Anaesth"},{"key":"2026082507351088000_16.8.e121099.13","doi-asserted-by":"publisher","DOI":"10.1097\/NCI.0b013e3182a903f9"},{"key":"2026082507351088000_16.8.e121099.14","doi-asserted-by":"crossref","DOI":"10.3390\/ijerph17228409","article-title":"Impact of alarm fatigue on the work of nurses in an intensive care environment\u2014a systematic review","volume":"17","author":"Lewandowska","year":"2020","journal-title":"Int J Environ Res Public Health"},{"key":"2026082507351088000_16.8.e121099.15","doi-asserted-by":"crossref","first-page":"52","DOI":"10.1177\/0310057X20968840","article-title":"Reducing medical device alarms by an order of magnitude: a human factors approach","volume":"49","author":"Koomen","year":"2021","journal-title":"Anaesth Intensive Care"},{"key":"2026082507351088000_16.8.e121099.16","doi-asserted-by":"publisher","DOI":"10.1016\/j.bja.2018.04.036"},{"key":"2026082507351088000_16.8.e121099.17","doi-asserted-by":"crossref","first-page":"565","DOI":"10.1007\/s10877-024-01161-2","article-title":"Haemodynamic monitoring during noncardiac surgery: past, present, and future","volume":"38","author":"Kouz","year":"2024","journal-title":"J Clin Monit Comput"},{"key":"2026082507351088000_16.8.e121099.18","doi-asserted-by":"crossref","DOI":"10.3390\/ijerph18168749","article-title":"Perioperative hypothermia\u2014a narrative review","volume":"18","author":"Rauch","year":"2021","journal-title":"Int J Environ Res Public Health"},{"key":"2026082507351088000_16.8.e121099.19","unstructured":"Koninklijke Philips NV . Visual patient avatar\u2014a new way to see your patient\u2019s vitals takes shape, 2025. Available: https:\/\/www.usa.philips.com\/healthcare\/technology\/visual-patient-avatar"},{"key":"2026082507351088000_16.8.e121099.20","doi-asserted-by":"crossref","DOI":"10.1186\/s13054-023-04544-0","article-title":"Human-centered visualization technologies for patient monitoring are the future: a narrative review","volume":"27","author":"Gasciauskaite","year":"2023","journal-title":"Crit Care"},{"key":"2026082507351088000_16.8.e121099.21","doi-asserted-by":"crossref","first-page":"1065","DOI":"10.1007\/s10877-024-01239-x","article-title":"Avatar-based versus conventional patient monitoring with distant vision: a computer-based simulation study","volume":"39","author":"Milovanovic","year":"2025","journal-title":"J Clin Monit Comput"},{"key":"2026082507351088000_16.8.e121099.22","doi-asserted-by":"crossref","unstructured":"Endsley MR , Jones DG . Designing for situation awareness: an approach to user-centered design.3rd edn. Boca Raton, FL: CRC Press, 2025.","DOI":"10.1201\/9781003388234-2"},{"key":"2026082507351088000_16.8.e121099.23","doi-asserted-by":"crossref","DOI":"10.5662\/wjm.v15.i3.100459","article-title":"Visual avatar to increase situational awareness in anaesthesia: systematic review of recent evidence","volume":"15","author":"Tramontana","year":"2025","journal-title":"World J Methodol"},{"key":"2026082507351088000_16.8.e121099.24","doi-asserted-by":"crossref","DOI":"10.2196\/15052","article-title":"Novel interface designs for patient monitoring applications in critical care medicine: human factors review","volume":"7","author":"Andrade","year":"2020","journal-title":"JMIR Hum Factors"},{"key":"2026082507351088000_16.8.e121099.25","doi-asserted-by":"publisher","DOI":"10.1177\/0018720813499367"},{"key":"2026082507351088000_16.8.e121099.26","doi-asserted-by":"publisher","DOI":"10.1016\/j.jbi.2004.11.003"},{"key":"2026082507351088000_16.8.e121099.27","doi-asserted-by":"publisher","DOI":"10.1023\/A:1007395901610"},{"key":"2026082507351088000_16.8.e121099.28","doi-asserted-by":"crossref","DOI":"10.1186\/s12871-018-0650-1","article-title":"User perceptions of avatar-based patient monitoring: a mixed qualitative and quantitative study","volume":"18","author":"Tscholl","year":"2018","journal-title":"BMC Anesthesiol"},{"key":"2026082507351088000_16.8.e121099.29","doi-asserted-by":"crossref","DOI":"10.2196\/13041","article-title":"Avatar-based patient monitoring with peripheral vision: a multicenter comparative eye-tracking study","volume":"21","author":"Pfarr","year":"2019","journal-title":"J Med Internet Res"},{"key":"2026082507351088000_16.8.e121099.30","doi-asserted-by":"crossref","DOI":"10.2196\/15070","article-title":"The mechanisms responsible for improved information transfer in avatar-based patient monitoring: multicenter comparative eye-tracking study","volume":"22","author":"Tscholl","year":"2020","journal-title":"J Med Internet Res"},{"key":"2026082507351088000_16.8.e121099.31","doi-asserted-by":"crossref","DOI":"10.3390\/diagnostics12020555","article-title":"Improving visual-patient-avatar design prior to its clinical release: a mixed qualitative and quantitative study","volume":"12","author":"Wetli","year":"2022","journal-title":"Diagnostics (Basel)"},{"key":"2026082507351088000_16.8.e121099.32","article-title":"Pediatric anesthesia providers\u2019 perspective on the real-life implementation of the Philips Visual Patient Avatar: a qualitative study","volume":"10","author":"Lunkiewicz","year":"2023","journal-title":"Children (Basel)"},{"key":"2026082507351088000_16.8.e121099.33","doi-asserted-by":"crossref","DOI":"10.3390\/bioengineering11040323","article-title":"Qualitative exploration of anesthesia providers\u2019 perceptions regarding Philips Visual Patient Avatar in clinical practice","volume":"11","author":"Hunn","year":"2024","journal-title":"Bioengineering (Basel)"},{"key":"2026082507351088000_16.8.e121099.34","doi-asserted-by":"crossref","DOI":"10.1038\/s41598-024-72338-7","article-title":"Survey-based qualitative exploration of user perspectives on the philips visual patient avatar in clinical situation management","volume":"14","author":"Radaviciute","year":"2024","journal-title":"Sci Rep"},{"key":"2026082507351088000_16.8.e121099.35","doi-asserted-by":"publisher","DOI":"10.2105\/AJPH.94.3.361"},{"key":"2026082507351088000_16.8.e121099.36","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1001885","article-title":"The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement","volume":"12","author":"Benchimol","year":"2015","journal-title":"PLoS Med"},{"key":"2026082507351088000_16.8.e121099.37","doi-asserted-by":"crossref","first-page":"585","DOI":"10.1016\/j.bja.2023.01.024","article-title":"Age-dependent changes in arterial blood pressure in neonates during the first week of life: reference values and development of a model","volume":"130","author":"van Zadelhoff","year":"2023","journal-title":"Br J Anaesth"},{"key":"2026082507351088000_16.8.e121099.38","doi-asserted-by":"crossref","first-page":"904","DOI":"10.1097\/ALN.0000000000001310","article-title":"Reference values for noninvasive blood pressure in children during anesthesia: a multicentered retrospective observational cohort study","volume":"125","author":"de Graaff","year":"2016","journal-title":"Anesthesiology"},{"key":"2026082507351088000_16.8.e121099.39","doi-asserted-by":"crossref","DOI":"10.1186\/s12874-017-0442-1","article-title":"When and how should multiple imputation be used for handling missing data in randomised clinical trials - a practical guide with flowcharts","volume":"17","author":"Jakobsen","year":"2017","journal-title":"BMC Med Res Methodol"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2026-121099","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T14:46:18Z","timestamp":1787669178000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2026-121099"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8]]},"references-count":39,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,8,25]]},"published-print":{"date-parts":[[2026,8]]}},"alternative-id":["10.1136\/bmjopen-2026-121099"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2026-121099","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8]]}}}