V 2.6.2 Clinical Realism, Stability

This is a rolling pre-release for the upcoming version 2.7 with major improvements including:

• Applicable waveforms drawn accounting for systolic versus diastole
  • Creates realistic waveforms in both bradycardic and tachycardic situations
  • Reduces improper drawing (pulsatility during diastole or diastolic function during extreme tachycardia)
• Performance improvements in drawing algorithm, especially effects bradycardias
  • Removed inefficiencies that caused memory overflows on some machines
  • Equal performance at reduced memory use
• Drastically reduced build and installation file size

V 2.6 Clinical Realism, Stability, Enhancements

This update includes a number of improvements to clinical realism and program stability:

Enhancements

• Keyboard shortcuts added for all windows
  • Hints visible in dropdown menu items (e.g. Ctrl+N for new simulation, Ctrl+S to save simulation)
  • Added "Toggle Fullscreen" option; toggles between Fullscreen and Normal window states.
  • Implemented in all devices (e.g. cardiac monitor, defibrillator, etc.)
    • Allows fast changing of color schemes, numerics & tracings shown, etc.

Clinical Realism

• Improved the drawing algorithm for atrial fibrillation for realistic tracings (#189)
• Included Tracing amplitude variations based on diastolic filling time
  • Implemented into SpO2 & ABP for decreased output with tachycardic runs (e.g. in atrial fibrillation)
  • Implemented into CVP as fluid backup with tachycardic runs
• Early beats (SpO2, ABP, etc.) no longer "drop" reading to 0%/0mmHg before imposing next (early) beat (#190)
  • Now early beats now enter the Tracing as an additive replacement, not a complete superimposition
• PA catheter placement in the right atrium now pulls pressure from CVP setting
  • PA pressure values get disabled (greyed out) when the catheter is at the CVP (RA) site
• Multiple improvements to the Intra-Aortic Balloon Pump (IABP) including:
  • Reshaped how the buttons resize automatically (fixes text clipping/overrunning)
  • IABP balloon waveform timing adjusted for adaptability to irregular rhythms (#191)
    • Enhanced and adjusted the physiology model timer that the tracing was triggered by
      • Implemented trigger dynamic delays for enhanced timing accuracy using modeling (#195)
      • Implemented manual inflation timing adjustment via IABP console user interface
    • Proper deflation at the T wave and/or arterial inflection, inflation at dicrotic notch
  • Fixed ABP tracings not being drawn when IABP is running
    • Partly caused by Tracing autoscaling not being triggered properly in edge cases- fixed.
    • Tracing also triggered for ABP rhythm only provided by IABP (e.g. during VF) (#192)

Stability

• Fixed program crashing on window resizing (#127)!
  • This was a longstanding problem that was difficult to identify, track down, and fix!
  • Affected the Cardiac Monitor, Defibrillator, and IABP- all fixed!
• Implementation debugging (#204, #205, #206)
• AvaloniaUI (foundational dependency) upgraded to 10.21 (from 10.18)

V 2.5 Defibrillator Enhancements, Stability

This update is the culmination of many small enhancements and bugfixes implemented since version 2.4. While there is nothing newly groundbreaking, lots of fixes, implementations, and enhancements make version 2.5 a more realistic, stable, and effective simulator. Changes include:

Defibrillator Enhancements

• Options to select maximum defibrillation energy and energy increments
  • Simulates Zoll (200 J) or LifePak (360 J)
  • Can increment at 10 J or 20 J such as to simulate institution preference/settings
• Audio tones for "charging" and "charged" electricity states
  • Audio playback controlled by main window's audio settings (on/off)
  • Audio options for defibrillator now include:
    • "Off": device is muted
    • "Defibrillator": only charging/charged tones will play
    • "Heart Rate/QRS" and "SpO2": both charging/charged tones and QRS/SpO2 tones play
• Color coded indicators for defibrillator state in Dark (colorful) color scheme
  • The "Defibrillator Settings" numeric entirely changes color based on defibrillator state
    • Charging: yellow; Charged: red
    • Analyzing rhythm: yellow-green
    • Pacing enabled: orange
    • All other discharged states return to light blue

General Enhancements

• Numerous Avalonia UI (window manager) package updates merged into this build version
  • Includes numerous bugfixes for compatibility and functionality across supported operating systems
  • Should help with program speed and stability on all platforms

Minor releases since version 2.4.0 include:

• Minor update 2.4.1: bugfixes
  • This update fixes several minor bugs
  • The biggest fix in this update is the ability to open an .ii simulation file by double-clicking on it from the desktop, launching the program directly into the simulation file.
• Minor update 2.4.4: Signing Doses w/ MAR & Bugfixes
  • This update includes the ability to sign off doses of medications on the MAR and add comments
  • This update also includes the ability to edit comments and sign off via the Scenario Editor
  • This update fixes several additional bugs, including a functionality-breaking bug
    • On opening Infirmary with an update available, the program sometimes hangs or crashes- this fixes that problem
• Minor update 2.4.5: QOL Improvements
  • This update fixes several quality-of-life issues improving Tracing responsiveness during vital sign changes
    • Including more responsive Tracings when loading files
  • ECG lead labels are now properly aligned to top-left for realism

V 2.4 Medication Administration Record (MAR)

This is the first release bringing Infirmary Integrated into simulating the electronic health record (EMR). This release includes a moderately-featured electronic Medication Administration Record (MAR) that can display drugs ordered and doses to be given in a layout familiar to anybody that has used an electronic MAR. Doses are plotted on a time-grid and you can navigate forward and backwards in time to see future or past doses. This release also includes the ability to add patient demographic information, so patient identifiers are displayed on the MAR to allow students to complete all the rights of drug administration.

Major features with this release:

• Add simulated patient demographics and drug orders in the Infirmary Integrated Scenario Editor
• View and navigate the MAR in the Infirmary Integrated Simulator by loading a simulation file with the relevant data
• In the Scenario Editor, each Step can have a different date/time set, so simulations can progress over time
• Drug and dose data includes: drug, dose, units, route, frequency (prn, once, repeat), priority (routine, now, stat)
• Administration and Indication fields can receive free-text: can enter hold parameters ("hold for SBP < 100") or infusion instructions ("infuse over 60 minutes")
• Color coding: past-due doses (> 1 hour in the past per simulated time) are marked in red, scheduled doses marked in blue, prn doses marked in green
• Automatic sorting of drug orders: scheduled doses present first, prn orders underneath, and all drugs are sorted alphabetically by name

Features that are not implemented, but are planned for future releases include:

• Signing off drug doses after administering them
• Marking past doses as being given or not given in the Scenario Editor

A simulated fully populated MAR with sample (fake) patient identifiers for students to complete the rights of drug administration:

V 2.3 External Fetal Monitoring (Cardiotocography), Device Audio

This release has been years in the making, with work beginning on the External Fetal Monitoring (EFM, cardiotocography) simulator in 2020, but then being placed on the backburner due to the pandemic and to make way for cross-platform porting... it's finally complete and stable!

External Fetal Monitoring (EFM, Cardiotocography)

New features with the External Fetal Monitor include simulation of:

• Fetal heart rate (FHR)
• Fetal heart rate variability (baseline variability)
• Uterine contractions via "toco": set the frequency and the duration
• Fetal heart rhythms (interval variability) including:
  • Baseline (minimal variability)
  • Accelerations
  • Early Decelerations
  • Late Decelerations
  • Variable Decelerations

All on the background of the standard cardiotocography strip! Just set the variables and let Infirmary's patient modeling do the rest to create your simulation or educational materials (e.g. rhythm strips).

Additional features include:

• Multiple "strip speeds" available on the EFM's menu to fast-forward the simulation: 1:1, 1:10, 1:25 speeds are available.
• Temporal smoothing implemented for obstetric rhythms: when you make changes to the "patient", Infirmary smoothly transitions the changes into the future waveform drawings.

Device Audio (and Alarm improvements)

Improvements have also been made to the Cardiac Monitor, the Defibrillator, and the Intra-Aortic Balloon Pump simulators as well, mainly including audio enhancements!

• Monitoring "beep" implemented for the Cardiac Monitor and the Defibrillator (sometimes called "anesthesia monitoring")
  • Beeps a traditional tone on each heart beat, used to audibly keep track of heart rate and/or pulse oximetry in a busy environment
  • Can set to ECG mode: beeps on each QRS complex
  • Or can set to SpO2 mode: beeps on each SpO2 waveform and the tone changes depending on the SpO2 reading
  • Device alarms still sound in addition to the monitoring beep
• Audio alarm for Intra-Aortic Balloon Pump's augmentation alarm
  • A unique tone unmistakable among the cacophony of potential critical care alarms
• Visual alarm improvement for Intra-Aortic Balloon Pump's augmentation alarm

Screenshots

V 2.2.3: QRS/QT Morphology, Temporal Smoothing, Bugfixes

In this minor release, a few subtle but important changes and fixes were implemented:

QRS/QT Morphology

• QRS interval and QTc interval is now adjustable under "Cardiac Profile"
• As you would expect, on all ECG tracings on all simulation devices, the QRS and ST segments are now drawn to those set intervals
• Allows for advanced simulation of narrow or wide complex morphologies, or abnormally elongated or shortened QTc pathology

Temporal Smoothing

• Changes made to vital signs, etc. (to the underlying digital patient model) are now applied synchronously with the cardiac and respiratory cycles
• Changing cardiac vital signs or rhythms no longer creates artifact or "ectopic"-appearing beats on ECG waveforms
• Changing respiratory vital signs or rhythms no longer creates artifact as well

Bugfixes

Some minor bugfixes were made to the Simulator interface for improved user experience. A bugfix was made to the Scenario Editor that fixed a feature-breaking bug. Specific details are in commit notes and issues logs.

V 2.2 Alarms! Scenario Editor Cross-Platform Port!

Multiple major improvements in this release, starting off with both visual and audio alarms in the Cardiac Monitor simulator. Many healthcare personnel are already overly familiar with alarms, so this probably does not need explaining... but I will:

Alarms (Visual and Audio!)

• Alarm limits able to be enabled, high/low values set, and alarm priority (low, moderate, high) are all adjustable in the Scenario Editor, as well as a default set of alarms (appropriate for adult patients) being enabled by default. Future plans exist for adjusting alarm limits in the simulator, as well as including default limits for other age groups, but this is not currently implemented.
• Alarms are present for all hemodynamic parameters (vital signs and advanced hemodynamics)

When alarms are active and set, if a physiologic parameter falls outside of an enabled alarm limit:

• The number visually flashes in the cardiac monitor. The numbers flash at different speeds based on priority- low priority is slow flashing, high priority is fast flashing.
• An audio alarm is sounded, and the audio alarm is selected based on alarm priority. Low priority alarms have a slow low-frequency beep and longer intermediary pause, high priority alarms have more rapid high-frequency beeping with slower pause.

Note: Audio is played cross-platform using libraries provided by the LibVLC project, a subset of the VLC Media Player. These libraries are bundled into the Windows and MacOS versions of Infirmary Integrated, but require installation of VLC and its libraries on Linux platforms. If the LibVLC libraries are missing, Infirmary Integrated will simply run without audio.

Options/Settings

• Alarms (includes both visual and audio) can be enabled and disabled in the Cardiac Monitor simulator via a newly-created menu option.
• Audio can be enabled or disabled in the main Infirmary Integrated simulator window via a newly-created menu option. This option will be used to silence all audio from all simulated devices, as audio is integrated into other devices in future versions.
• All changes localized into supported languages

Scenario Editor

This release brings back the Infirmary Integrated Scenario Editor as a cross-platform standalone tool used for creating simulation files that can be saved, shared, and then loaded into Infirmary Integrated and run in a stepwise manner. Simulation files created with the Scenario Editor can have multiple "steps" each with their own simulated patient's parameters and vital signs. Steps can "progress" in different ways, depending on which progression is selected in the scenario player (which is part of Infirmary Integrated's simulator). An example case for using simulation files created with the Scenario Editor would be for an educator to simulate a patient in a stable state, progressing to a deteriorating state, then depending on a student's actions or response, could progress to an improved state or a declined state of hemodynamic parameters- all simulated with Infirmary Integrated.

While the Scenario Editor existed before in older releases of Infirmary Integrated, the following new features are part of this major release:

• Cross-platform functionality (runs on Windows, Linux, and MacOS) for both the Simulator and the Scenario Editor.
• Installer packages for Windows, Linux, and MacOS now include the Scenario Editor
• Improved major re-design of the Scenario Editor for ease of use and improved workflow
• Miscellaneous minor quality-of-life improvements and small features added

Additionally, some of the new features in the Scenario Editor blend into the Simulator when loading simulation files, including:

• The ability to choose which devices automatically open when loading a simulation file (e.g. cardiac monitor, 12 lead ECG, etc.)

Stability and Testing

There were also tons of behind-the-scenes improvements made to the entire program suite, including a large effort of modernizing the code that powers Infirmary Integrated. Many advancements in the C# programming language and the frameworks that Infirmary Integrated are built on are now utilized thoroughly. The language and frameworks have had significant changes over the last 5 years, improving overall performance and stability of Infirmary Integrated!

Lastly, immense amounts of testing went into this release, ensuring that all features work as intended! Although all computer programs have "bugs" in them, large amounts of testing went into this release to ensure that all major bugs are fixed and that Infirmary Integration is "production-ready". This is the main reason why the project went from version 2.0 to 2.2: by the time version 2.1's updates were tested as being stable, half of the updates for version 2.2 were already being added!

Bugfixes

Some major bugfixes and issues resolved in this release are:

• #139: Fixed atrial flutter drawing problems (out of phase synchronicity between A/V; A:V ratio)
• Fixed pacemaker spikes from blocking atrial flutter and fibrillation on isoelectric line drawing
• #143: Fixed "Reset Parameters" from unlinking patient model from device simulators (also disabled this button if auto-apply changes are enabled)
• #140, #137

V 2.0.2 Targeting .NET 6.0

This is a minor update release for Infirmary Integrated 2.0 as it now targets (is built on) .NET 6.0.

• Targeting .NET 6.0 changed from .NET 5.0
  • Due to .NET 5.0 support coming to end-of-life by Microsoft

V 2.0 Cross-Platform Port

This is a major release of Infirmary Integrated 2.0 with the following new features:

• Cross-platform support for:

  • Windows
  • Linux
  • MacOS

• Color schemes for every device

  • Light mode
  • Dark mode
  • Some additional modes e.g. Grid mode for ECGs

• Interface Improvements

  • Mirroring now available from menu options
    • Interface is less cluttered
  • "Check For Updates" functionality from Help menu
  • Scenario controls only visible if loading a scenario
    • Interface is less cluttered

• Bugfixes

  • 3rd degree AV block now draws properly
  • Transcutaneous pacemaker doesn't cut off pulsatile rhythms (e.g. SpO2)
  • Transcutaneous pacemaker will only electrically capture if electrical organization is present
    • E.g. cannot capture in ventricular fibrillation, though spikes will still appear

Full Changelog: v1.3.2...v2.0

Edit re: v2.0.1: Extremely minor bugfix made in v2.0.1, repackage made primarily for .deb release package

V 1.3.2 Code Signing, Miscellaneous Bug Fixes

This is a minor release with miscellaneous behind-the-scenes improvements, bug fixes, and stability improvements. The major addition to this release is that the program is now signed by the developer, which reduces the amount of security warnings that Infirmary Integrated will generate by Microsoft Windows.