Changes in intensive care unit nurse task activity after installation of a third-generation intensive care unit information system

The potential of patient-based nurse staffing - a queuing theory application in the neonatal intensive care setting

Faced by a severe shortage of nurses and increasing demand for care, hospitals need to optimally determine their staffing levels. Ideally, nurses should be staffed to those shifts where they generate the highest positive value for the quality of healthcare. This paper develops an approach that identifies the incremental benefit of staffing an additional nurse depending on the patient mix. Based on the reasoning that timely fulfillment of care demand is essential for the healthcare process and its quality in the critical care setting, we propose to measure the incremental benefit of staffing an additional nurse through reductions in time until care arrives (TUCA). We determine TUCA by relying on queuing theory and parametrize the model with real data collected through an observational study. The study indicates that using the TUCA concept and applying queuing theory at the care event level has the potential to improve quality of care for a given nurse capacity by efficiently trading situations of high versus low workload.

The Reduction in Medical Errors on Implementing an Intensive Care Information System in a Setting Where a Hospital Electronic Medical Record System is Already in Use: Retrospective Analysis

Background

Although the various advantages of clinical information systems in intensive care units (ICUs), such as intensive care information systems (ICISs), have been reported, their role in preventing medical errors remains unclear.

Objective

This study aimed to investigate the changes in the incidence and type of errors in the ICU before and after ICIS implementation in a setting where a hospital electronic medical record system is already in use.

Methods

An ICIS was introduced to the general ICU of a university hospital. After a step-by-step implementation lasting 3 months, the ICIS was used for all patients starting from April 2019. We performed a retrospective analysis of the errors in the ICU during the 6-month period before and after ICIS implementation by using data from an incident reporting system, and the number, incidence rate, type, and patient outcome level of errors were determined.

Results

From April 2018 to September 2018, 755 patients were admitted to the ICU, and 719 patients were admitted from April 2019 to September 2019. The number of errors was 153 in the 2018 study period and 71 in the 2019 study period. The error incidence rates in 2018 and 2019 were 54.1 (95% CI 45.9-63.4) and 27.3 (95% CI 21.3-34.4) events per 1000 patient-days, respectively (P<.001). During both periods, there were no significant changes in the composition of the types of errors (P=.16), and the most common type of error was medication error.

Conclusions

ICIS implementation was temporally associated with a 50% reduction in the number and incidence rate of errors in the ICU. Although the most common type of error was medication error in both study periods, ICIS implementation significantly reduced the number and incidence rate of medication errors.

Trial Registration

University Hospital Medical Information Network Clinical Trials Registry UMIN000041471; https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000047345

Electronic Health Record Implementations and Insufficient Training Endanger Nurses' Well-being: Cross-sectional Survey Study

Background

High expectations have been set for the implementations of health information systems (HIS) in health care. However, nurses have been dissatisfied after implementations of HIS. In particular, poorly functioning electronic health records (EHRs) have been found to induce stress and cognitive workload. Moreover, the need to learn new systems may require considerable effort from nurses. Thus, EHR implementations may have an effect on the well-being of nurses.

Objective

This study aimed to examine the associations of EHR-to-EHR implementations and the sufficiency of related training with perceived stress related to information systems (SRIS), time pressure, and cognitive failures among registered nurses. Moreover, we examined the moderating effect of the employment sector (hospital, primary care, social services, and others) on these associations.

Methods

This study was a cross-sectional survey study of 3610 registered Finnish nurses in 2020. EHR implementation was measured by assessing whether the work unit of each respondent had implemented or will implement a new EHR (1) within the last 6 months, (2) within the last 12 months, (3) in the next 12 months, and (4) at no point within the last 12 months or in the forthcoming 12 months. The associations were examined using analyses of covariance adjusted for age, gender, and employment sector.

Results

The highest levels of SRIS (adjusted mean 4.07, SE 0.05) and time pressure (adjusted mean 4.55, SE 0.06) were observed among those who had experienced an EHR implementation within the last 6 months. The lowest levels of SRIS (adjusted mean 3.26, SE 0.04), time pressure (adjusted mean 4.41, SE 0.05), and cognitive failures (adjusted mean 1.84, SE 0.02) were observed among those who did not experience any completed or forthcoming implementations within 12 months. Nurses who perceived that they had received sufficient implementation-related training experienced less SRIS (F₁=153.40, P<.001), time pressure (F₁=80.95, P<.001), and cognitive failures (F₁=34.96, P<.001) than those who had received insufficient training. Recent implementations and insufficient training were especially strongly associated with high levels of SRIS in hospitals.

Conclusions

EHR implementations and insufficient training related to these implementations may endanger the well-being of nurses and even lead to errors. Thus, it is extremely important for organizations to offer comprehensive training before, during, and after implementations. Moreover, easy-to-use systems that allow transition periods, a re-engineering approach, and user involvement may be beneficial to nurses in the implementation process. Training and other improvements would be especially important in hospitals.

Interaction Time with Electronic Health Records: A Systematic Review

BACKGROUND

The amount of time that health care clinicians (physicians and nurses) spend interacting with the electronic health record is not well understood.

OBJECTIVE

This study aimed to evaluate the time that health care providers spend interacting with electronic health records (EHR).

METHODS

Data are retrieved from Ovid MEDLINE(R) and Epub Ahead of Print, In-Process and Other Non-Indexed Citations and Daily, (Ovid) Embase, CINAHL, and SCOPUS.

STUDY ELIGIBILITY CRITERIA

Peer-reviewed studies that describe the use of EHR and include measurement of time either in hours, minutes, or in the percentage of a clinician's workday. Papers were written in English and published between 1990 and 2021.

PARTICIPANTS

All physicians and nurses involved in inpatient and outpatient settings.

STUDY APPRAISAL AND SYNTHESIS METHODS

A narrative synthesis of the results, providing summaries of interaction time with EHR. The studies were rated according to Quality Assessment Tool for Studies with Diverse Designs.

RESULTS

Out of 5,133 de-duplicated references identified through database searching, 18 met inclusion criteria. Most were time-motion studies (50%) that followed by logged-based analysis (44%). Most were conducted in the United States (94%) and examined a clinician workflow in the inpatient settings (83%). The average time was nearly 37% of time of their workday by physicians in both inpatient and outpatient settings and 22% of the workday by nurses in inpatient settings. The studies showed methodological heterogeneity.

CONCLUSION

This systematic review evaluates the time that health care providers spend interacting with EHR. Interaction time with EHR varies depending on clinicians' roles and clinical settings, computer systems, and users' experience. The average time spent by physicians on EHR exceeded one-third of their workday. The finding is a possible indicator that the EHR has room for usability, functionality improvement, and workflow optimization.

Methods used to examine technology in relation to the quality of nursing work in acute care: A systematic integrative review

AIMS AND OBJECTIVES

To systematically locate, assess and synthesise research to describe methods used to examine technology in relation to the quality of nursing work in acute care. Specific objectives were to (a) describe the types of nursing work examined; (b) describe methods used to examine technology in nursing work; (c) identify outcomes used to evaluate technology in relation to the quality of nursing work; and (d) make recommendations for future research.

BACKGROUND

New technologies can offer numerous benefits to nurses; however, it is challenging to evaluate health information technologies in relation to the quality of nurses' complex day-to-day work.

DESIGN

A systematic integrative review using a five-step process.

METHODS

Five databases were searched using search terms "nurs*," "workload," "task," "time." Data screening, extraction and interpretation were conducted independently by at least two authors and agreement verified by discussion. Data extraction followed PRISMA guidelines.

RESULTS

Of the 41 studies included, most (87.8%, n = 36) examined physical dimensions of nursing work; 31.7% (n = 13) organisational dimensions; 17.1% (n = 8) cognitive dimensions; and only 12.2% (n = 5) emotional dimensions. More than half (58.5%, n = 24) examined only one dimension; one captured all four dimensions. Most frequently examined technologies were electronic medical/health records (36.5%) and electronic medication management (19.5%). Direct observation (58.8%, n = 28) and multiple methods (19.5%, n = 8) were the most common methods; nurse tasks, frequency, duration and time distribution were variables most often measured.

CONCLUSIONS

Examinations of technology in nursing work often failed to capture the multiple dimensions of this work nor did they recognise the complexity of day-to-day nursing work in acute care. There is a paucity of literature to inform how and what technology should be measured in relation to the quality of nursing care.

RELEVANCE TO CLINICAL PRACTICE

The outcomes inform useful research methods to comprehensively examine technology to enhance the quality of complex nursing work.

Tracking resident pre-rounding electronic health record usage

PURPOSE

Residents collect information from the electronic health record (EHR) to present during rounds, but this crucial process is understudied. The purpose of this paper is to examine the feasibility of utilizing an EHR embedded time-tracking software to quantify resident pre-round EHR activity and how patient acuity impacts this activity.

DESIGN/METHODOLOGY/APPROACH

This was a retrospective observational study that quantified resident EHR activities (total time spent, tasks performed and patient encounters accessed) during pre-rounds on their pediatric intensive care unit rotation between May 2016 and December 2016. Patient encounters were reviewed to determine resident ownership and critical care resources provided.

FINDINGS

Allo 21 eligible participants were included. In total, 907 patient encounters were included to evaluate patient acuity impact. EHR usage per patient encounter (median in minutes (25th, 75th percentile)) was significantly affected by the critical care resources utilized. Total EHR time: both ventilator and vasoactive support (10.54 (6.68, 17.19)); neither ventilator nor vasoactive support (8.23 (5.07, 12.72)); invasive/noninvasive ventilator support (8.74 (5.69, 13.2)); and vasoactive support (10.37 (7.72, 11.65)), p<0.001. Chart review, order entry and documentation EHR times demonstrated similar trends.

PRACTICAL IMPLICATIONS

Residents spend more time utilizing the EHR to collect data on patients who require significant critical care resources. This information can be useful to determine optimal resident to patient workload. Future research is required to assess this EHR tool's ability to contribute to physician workflow study.

ORIGINALITY/VALUE

EHR embedded time-tracking software can offer insights into resident workflow.

BALANCING DOCUMENTATION AND DIRECT PATIENT CARE ACTIVITIES: A STUDY OF A MATURE ELECTRONIC HEALTH RECORD SYSTEM

US hospitals now fully embrace electronic documentation systems as a way to reduce medical errors and improve patient safety outcomes. Whether spending time on electronic documentation detracts from the time available for direct patient care, however, is still unresolved. There is no knowledge on the permanent effects of documenting electronically and whether it takes away significant time from patient care when the healthcare information system is mature. To understand the time spent on documentation, direct patient care tasks, and other clinical tasks in a mature information system, we conducted an observational and interview study in a midwestern academic hospital. The hospital implemented an electronic medical record system 11 years ago. We observed 22 health care workers across intensive care units, inpatient floors, and an outpatient clinic in the hospital. Results show that healthcare workers spend more time on documentation activities compared to patient care activities. Clinical roles have no influence on the time spent on documentation. This paper describes results on the time spent between documentation and patient care tasks, and discusses implications for future practice.

RELEVANCE TO INDUSTRY

The study applies to healthcare industry that faces immense challenges in balancing documentation activities and patient care activities.

[Comparison of current critical care information systems from the perspective of clinical users : Summary of the results of a German nationwide survey]

BACKGROUND

Critical care information systems (CCIS) are computer-based systems designed to process the growing amount of complex medical data in intensive care units (ICU). Previous studies have shown that CCICs can increase the quality of patient care by reducing errors and improving work efficiency; however, other studies have shown that CCISs can also cause harmful effects by disrupting workflow, facilitating medication errors or increasing charting time. The factors that decide whether a CCIS has a positive or negative impact on patient care are summarized under the term "usability". This article summarizes the results of three previously published papers on this topic.

OBJECTIVE

The aim of the study was to identify which CCIS functions were considered useful by clinical ICU staff and how well these functions are implemented in the CCISs currently used in German ICUs.

MATERIAL AND METHODS

An online survey was performed targeting nurses and physicians working in German ICUs using a previously validated questionnaire. The questionnaire included a list of functions (36 for physicians/31 for nurses) that were preselected by experts based on a comprehensive model of ICU work processes. Each of these functions was rated by the study participants on a Likert scale ranging from 0 (worst rating) to 5 (best rating) with respect to the usefulness to identify which functions of CCIS can truly be considered as useful by clinical ICU staff. Furthermore, the participants rated how well these functions were implemented in the CCIS currently in use on the ICU, also using a Likert scale of 0-5. Further questions were provided to rate specific technical usability aspects of the CCISs currently in use. In addition, to capture possible confounders the questionnaire recorded 18 individual and workspace characteristics which might influence the ratings.

RESULTS

A total of 171 nurses and 741 physicians participated in the survey of which 535 used CCISs. Of the functions 33 were rated as useful for doctors and 28 functions for nurses with median scores between 4 and 5. Participants currently using CCISs gave higher ratings compared to participants not using CCISs. The quality of the functions was rated relatively lower than the usefulness and the availability. Furthermore, currently used CCISs in Germany differ greatly in their technical and task-specific usability. Of the CCISs investigated, the system ICUData had the best overall rating and technical usability followed by the systems ICM and MetaVision. The same three CCIS were rated best in task-specific functions without significant differences between them.

CONCLUSION

Those functions that were identified as useful based on the ratings of clinical ICU staff should be implemented in current CCIS. The list of these functions might be regarded as a first step towards providing a catalog of functional requirements for CCISs. Furthermore, as the results show that the quality of the available functions was rated lower than the availability of the functions, manufacturers should shift more of the effort away from the development of new features and focus on improving the user-friendliness and quality of existing functions.

Interruptions and Delivery of Care in the Intensive Care Unit

OBJECTIVE

This study samples interruption frequency in intensive care unit (ICU) settings to assess the relationship between interruptions and common patient hazards.

BACKGROUND

Task interruptions are accident contributors in numerous industries. Recently, studies on health care interruptions and their impact on patient hazards have received attention.

METHOD

Seven ICUs in four hospitals participated in a 24-month study. Experienced ICU nurses directly observed nursing tasks, interruptions, and patient hazards (delays in care, breaks in device task protocols, and patient safety hazards).

RESULTS

During 1,148 hours of observation, 175 nurses performed 74,733 nursing tasks. Interruptions occurred at a rate of 4.95 per hour, and 8.4% of tasks were interrupted. Interruptions originated mostly from humans (65.9%), alarms (24.1%), and others (10%). A total of 774 patient hazards were observed, with a hazard occurring on average every 89 minutes. Relative to noninterrupted tasks, device alarm interrupted nonstructured tasks were associated with increased rates of delays in care and safety hazards (rate ratio [RR] = 3.19). In contrast, rate of delays in care and safety hazards did not increase during human interrupted tasks (RR = 1.13). Rates of protocol nonadherence varied by device type and were highest during artificial airway, medication administration, chest tube, and supplemental oxygen management.

CONCLUSION

Interruptions in the ICU are frequent and contribute to patient hazards, especially when caused by device alarms during nonstructured tasks. Nonadherence to protocols is common and contributed to patient hazards.

APPLICATION

The findings suggest a need for improvement in task and device design to reduce patient hazards.

Functional requirements of critical care information systems (CCIS) from the users' perspective

INTRODUCTION

Critical care information systems (CCIS) are computer software systems specialized for supporting the data processing tasks of clinical staff in intensive care units (ICUs). Reports on the impact of CCIS vary strongly from large benefits to harmful impact. One factor causing these inconsistent results is a large functional heterogeneity of the currently available systems, as no standards exist. Therefore, the aim of this study was to derive recommendations for a minimum range of functions that CCIS should incorporate from the perspective of clinical users.

MATERIALS AND METHODS

We performed a web-based survey targeting clinical ICU staff in Germany. Participants rated the usefulness of pre-defined CCIS functions (36 for physicians / 31 for nurses) between 0-5. To capture confounders that might influence the ratings, we recorded 18 individual and workplace characteristics.

RESULTS

The 912 participants rated all but three of the investigated functions as useful with median scores of 4-5. A multivariable analysis showed that the ratings were influenced by whether CCIS were used on the participants' wards, by the rating of the function quality of the used CCIS, the years of work experience and whether the participant was a physician or a nurse.

CONCLUSIONS

Clinical ICU staff considers all but three of the here investigated CCIS functions as useful. Even though we identified a variety of factors influencing the usefulness ratings, their influence is rather small and thus does not limit the validity of our findings. Accordingly, we commend the functions identified as useful to be incorporated in CCIS.

Reorganizing Care With the Implementation of Electronic Medical Records: A Time-Motion Study in the PICU

OBJECTIVES

To assess caregivers' patient care time before and after the implementation of a reorganization of care plan with electronic medical records.

DESIGN

A prospective, observational, time-motion study.

SETTING

A level 3 PICU.

PARTICIPANTS

Nurses and orderlies caring for intubated patients during an 8-hour work shift before (2008-2009) and after (2016) implementation of reorganization of care in 2013.

INTERVENTIONS

The reorganization plan included improved telecommunication for healthcare workers, increased tasks delegated to orderlies, and an ICU-specific electronic medical record (Intellispace Critical Care and Anesthesia information system, Philips Healthcare).

MEASUREMENTS AND MAIN RESULTS

Time spent completing various work tasks was recorded by direct observation, and proportion of time in tasks was compared for each study period. A total of 153.7 hours was observed from 22 nurses and 14 orderlies. There was no significant difference in the proportion of nursing patient care time before (68.8% [interquartile range, 48-72%]) and after (55% [interquartile range, 51-57%]) (p = 0.11) the reorganization with electronic medical record. Direct patient care task time for nurses was increased from 27.0% (interquartile range, 30-37%) before to 34.7% (interquartile range, 33-75%) (p = 0.336) after, and indirect patient care tasks decreased from 33.6% (interquartile range, 23-41%) to 18.6% (interquartile range, 16-22%) (p = 0.036). Documentation time significantly increased from 14.5% (interquartile range, 12-22%) to 26.2% (interquartile range, 23-28%) (p = 0.032). Nursing productivity ratio improved from 28.3 to 26.0. A survey revealed that nursing staff was satisfied with the electronic medical record, although there was a concern for the maintenance of oral communication in the unit.

CONCLUSIONS

The reorganization of care with the implementation of an ICU-specific electronic medical record in the PICU did not change total patient care provided but improved nursing productivity, resulting in improved efficiency. Documentation time was significantly increased, and concern over reduced oral communication arose, which should be a focus for future electronic improvement strategies.

Caregivers’ Time Utilization before and after the Introduction of an Electronic Nursing Documentation System in a Residential Aged Care Facility

Background: Despite increasing research on caregivers’ interaction with technology, there has been no attempt to investigate how the introduction of an electronic system in a residential aged care facility (RACF) may affect caregivers’ use of their time.

Objective: To assess how caregivers use their time before and after the introduction of an electronic documentation system in an RACF.

Methods: An observational work sampling study was undertaken with caregivers at two months before, and at 3, 6, 12 and 23 months after the implementation of an electronic documentation system.

Results: During the first 12 months after implementation, the proportion of time spent by personal carers on documentation increased, that on direct care reduced, and the proportion on communication remained unchanged. At 23 months, the proportion on documentation and direct care had returned to pre-implementation levels. The percentage of time spent on these activities by recreational activity officers remained unchanged at most measurement periods after implementation. Changes in proportions of time on other activities were not directly associated with the introduction of the electronic system.

Conclusion: It may take over a year for some caregivers in an RACF to integrate the use of a newly introduced electronic documentation system into their daily work. Organisations implementing such systems should develop strategies that support and accelerate the caregivers’ integration of the new documentation practice into their routine activities. The electronic documentation system may not however, replace the role of verbal communication between caregivers in aged care service.

Nurses’ perceptions about and confidence in using an electronic medical record system

Introduction:

Nurses are among the largest potential users of electronic medical record (EMR) systems in health care settings. Yet little is known about their perceptions and confidence toward using such systems. This study explored nurses’ perceptions toward and confidence in using the EMR system. Predictors for confidence status in using the system among nurses were postulated.

Methods:

A cross-sectional survey design was used. A sample of 169 nurses were recruited from a general governmental university hospital in Muscat, Oman.

Results:

Most of study participants did not have prior experience with EMR systems elsewhere. About half (52.1%) perceived that they were confident in using the system. A logistic regression model showed nurses who (a) had six or more years of experience in using the system, (b) perceived that their suggestions regarding improving the system were taken into consideration by the system managing team, (c) perceived that the changes introduced in the system were important to their work, and (d) perceived that the information retrieved through the system was updated, to be more likely confident in using the system.

Discussion:

When customizing the EMR system, the informatics team that manages the system is invited to more consider suggestions for improvement that are raised by nurses. More training on the system is suggested to increase confidence among nurses who had little experience in using the system. In order to enhance the preparation of future nurses with contemporary technology-driven health care practices, nursing schools officials are encouraged to include general computer information technology training into nursing curricula.

Facilitated Nurse Medication-Related Event Reporting to Improve Medication Management Quality and Safety in Intensive Care Units

BACKGROUND

Medication safety presents an ongoing challenge for nurses working in complex, fast-paced, intensive care unit (ICU) environments. Studying ICU nurse's medication management-especially medication-related events (MREs)-provides an approach to analyze and improve medication safety and quality.

OBJECTIVES

The goal of this study was to explore the utility of facilitated MRE reporting in identifying system deficiencies and the relationship between MREs and nurses' work in the ICUs.

METHODS

We conducted 124 structured 4-hour observations of nurses in three different ICUs. Each observation included measurement of nurse's moment-to-moment activity and self-reports of workload and negative mood. The observer then obtained MRE reports from the nurse using a structured tool. The MREs were analyzed by three experts.

RESULTS

MREs were reported in 35% of observations. The 60 total MREs included four medication errors and seven adverse drug events. Of the 49 remaining MREs, 65% were associated with negative patient impact. Task/process deficiencies were the most common contributory factor for MREs. MRE occurrence was correlated with increased total task volume. MREs also correlated with increased workload, especially during night shifts.

DISCUSSION

Most of these MREs would not be captured by traditional event reporting systems. Facilitated MRE reporting provides a robust information source about potential breakdowns in medication management safety and opportunities for system improvement.

A Time-Motion Study of ICU Workflow and the Impact of Strain

OBJECTIVE

Understanding ICU workflow and how it is impacted by ICU strain is necessary for implementing effective improvements. This study aimed to quantify how ICU physicians spend time and to examine the impact of ICU strain on workflow.

DESIGN

Prospective, observational time-motion study.

SETTING

Five ICUs in two hospitals at an academic medical center.

SUBJECTS

Thirty attending and resident physicians.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

In 137 hours of field observations, the most time-84 hours (62% of total observation time)-was spent on professional communication. Reviewing patient data and documentation occupied a combined 52 hours (38%), whereas direct patient care and education occupied 24 hours (17%) and 13 hours (9%), respectively. The most frequently used tool was the computer, used in tasks that occupied 51 hours (37%). Severity of illness of the ICU on day of observation was the only strain factor that significantly impacted work patterns. In a linear regression model, increase in average ICU Sequential Organ Failure Assessment was associated with more time spent on direct patient care (β = 4.3; 95% CI, 0.9-7.7) and education (β = 3.2; 95% CI, 0.7-5.8), and less time spent on documentation (β = -7.4; 95% CI, -11.6 to -3.2) and on tasks using the computer (β = -7.8; 95% CI, -14.1 to -1.6). These results were more pronounced with a combined strain score that took into account unit census and Sequential Organ Failure Assessment score. After accounting for ICU type (medical vs surgical) and staffing structure (resident staffed vs physician assistant staffed), results changed minimally.

CONCLUSION

Clinicians spend the bulk of their time in the ICU on professional communication and tasks involving computers. With the strain of high severity of illness and a full unit, clinicians reallocate time from documentation to patient care and education. Further efforts are needed to examine system-related aspects of care to understand the impact of workflow and strain on patient care.

Decision Support Tool to Improve Glucose Control Compliance After Cardiac Surgery

Hyperglycemia control is associated with improved outcomes in patients undergoing cardiac surgery. The Surgical Care Improvement Project metric (SCIP-inf-4) was introduced as a performance measure in surgical patients and included hyperglycemia control. Compliance with the SCIP-inf-4 metric remains suboptimal. A novel real-time decision support tool (DST) with guaranteed feedback that is based on the existing electronic medical record system was developed at a tertiary academic center. Implementation of the DST increased the compliance rate with the SCIP-inf-4 from 87.3% to 96.5%. Changes in tested clinical outcomes were not observed with improved metric compliance. This new framework can serve as a backbone for development of quality control processes for other metrics. Further and, ideally, multicenter studies are required to test if implementation of electronic DSTs will translate into improved resource utilization and outcomes for patients.

Investigation of the Usability of Computerized Critical Care Information Systems in Germany

INTRODUCTION

The term "usability" describes how effectively, efficiently, and with what level of user satisfaction an information system can be used to accomplish specific goals. Computerized critical care information systems (CCISs) with high usability increase quality of care and staff satisfaction, while reducing medication errors. Conversely, systems lacking usability can interrupt clinical workflow, facilitate errors, and increase charting time. The aim of this study was to investigate and compare usability across CCIS currently used in Germany.

METHODS

In this study, German intensive care unit (ICU) nurses and physicians completed a specialized, previously validated, web-based questionnaire. The questionnaire assessed CCIS usability based on three rating models: an overall rating of the systems, a model rating technical usability, and a model rating task-specific usability.

RESULTS

We analyzed results from 535 survey participants and compared eight different CCIS commonly used in Germany. Our results showed that usability strongly differs across the compared systems. The system ICUData had the best overall rating and technical usability, followed by the platforms ICM and MetaVision. The same three systems performed best in the rating of task-specific usability without significant differences between each other. Across all systems, overall ratings were more dependent on ease-of-use aspects than on aspects of utility/functionality, and the general scope of the functions offered was rated better than how well the functions are realized.

DISCUSSION

Our results suggest that manufacturers should shift some of their effort away from the development of new features and focus more on improving the ease-of-use and quality of existing features.

Exploring Dental Providers' Workflow in an Electronic Dental Record Environment

BACKGROUND

A workflow is defined as a predefined set of work steps and partial ordering of these steps in any environment to achieve the expected outcome. Few studies have investigated the workflow of providers in a dental office. It is important to understand the interaction of dental providers with the existing technologies at point of care to assess breakdown in the workflow which could contribute to better technology designs.

OBJECTIVE

The study objective was to assess electronic dental record (EDR) workflows using time and motion methodology in order to identify breakdowns and opportunities for process improvement.

METHODS

A time and motion methodology was used to study the human-computer interaction and workflow of dental providers with an EDR in four dental centers at a large healthcare organization. A data collection tool was developed to capture the workflow of dental providers and staff while they interacted with an EDR during initial, planned, and emergency patient visits, and at the front desk. Qualitative and quantitative analysis was conducted on the observational data.

RESULTS

Breakdowns in workflow were identified while posting charges, viewing radiographs, e-prescribing, and interacting with patient scheduler. EDR interaction time was significantly different between dentists and dental assistants (6:20 min vs. 10:57 min, p = 0.013) and between dentists and dental hygienists (6:20 min vs. 9:36 min, p = 0.003).

CONCLUSIONS

On average, a dentist spent far less time than dental assistants and dental hygienists in data recording within the EDR.

Design and validation of a questionnaire to evaluate the usability of computerized critical care information systems

The implementation of computerized critical care information systems (CCIS) can improve the quality of clinical care and staff satisfaction, but also holds risks of disrupting the workflow with consecutive negative impacts. The usability of CCIS is one of the key factors determining their benefits and weaknesses. However, no tailored instrument exists to measure the usability of such systems. Therefore, the aim of this study was to design and validate a questionnaire that measures the usability of CCIS. Following a mixed-method design approach, we developed a questionnaire comprising two evaluation models to assess the usability of CCIS: (1) the task-specific model rates the usability individually for several tasks which CCIS could support and which we derived by analyzing work processes in the ICU; (2) the characteristic-specific model rates the different aspects of the usability, as defined by the international standard "ergonomics of human-system interaction". We tested validity and reliability of the digital version of the questionnaire in a sample population. In the sample population of 535 participants both usability evaluation models showed a strong correlation with the overall rating of the system (multiple correlation coefficients ≥0.80) as well as a very high internal consistency (Cronbach's alpha ≥0.93). The novel questionnaire is a valid and reliable instrument to measure the usability of CCIS and can be used to study the influence of the usability on their implementation benefits and weaknesses.

How Do Residents Spend Their Shift Time? A Time and Motion Study With a Particular Focus on the Use of Computers

PURPOSE

To understand how much time residents spend using computers compared with other activities, and what residents use computers for.

METHOD

This time and motion study was conducted in June and July 2010 at NewYork-Presbyterian/Columbia University Medical Center with seven residents (first-, second-, and third-year) on the general medicine service. An experienced observer shadowed residents during a single day shift, captured all their activities using an iPad application, and took field notes. The activities were captured using a validated taxonomy of clinical activities, expanded to describe computer-based activities with a greater level of detail.

RESULTS

Residents spent 364.5 minutes (50.6%) of their shift time using computers, compared with 67.8 minutes (9.4%) interacting with patients. In addition, they spent 292.3 minutes (40.6%) talking with others in person, 186.0 minutes (25.8%) handling paper notes, 79.7 minutes (11.1%) in rounds, 80.0 minutes (11.1%) walking or waiting, and 54.0 minutes (7.5%) talking on the phone. Residents spent 685 minutes (59.6%) multitasking. Computer-based documentation activities amounted to 189.9 minutes (52.1%) of all computer-based activities time, with 128.7 minutes (35.3%) spent writing notes and 27.3 minutes (7.5%) reading notes composed by others.

CONCLUSIONS

The study showed that residents spent considerably more time interacting with computers (over 50% of their shift time) than in direct contact with patients (less than 10% of their shift time). Some of this may be due to an increasing reliance on computing systems for access to patient data, further exacerbated by inefficiencies in the design of the electronic health record.

How Do Residents Spend Their Time in the Intensive Care Unit?

PURPOSE

To describe the work of residents and the distribution of their time in 6 intensive care units (ICUs) of 2 medical centers (MCs).

METHODS

A total of 242 hours of observation to capture data on tasks performed by residents in 6 ICUs, including adult, pediatric, medical and surgical units, were conducted. For each observation period, the percentages of total time spent on each task and on the aggregated task categories were calculated.

RESULTS

Overall, while in the ICUs, residents spent almost half of their time in clinical review and documentation (19%), conversation with team physicians (16%), conversation attendance (6%) and order management (6%). The 2 MCs differed in the time that residents spent on administrative review and documentation (4% in one MC and 15% in the other). The pediatric ICUs were similar in the 2 MCs, whereas the adult ICUs exhibited differences in the time spent on order management and administrative review and documentation.

CONCLUSIONS

While in the ICUs, residents spent most time performing direct patient care and care coordination activities. The distribution of activities varied across 2 MCs and across ICUs, which highlights the need to consider the local context on residents' work in ICUs.

Changes to Workflow and Process Measures in the PICU During Transition From Semi to Full Electronic Health Record

OBJECTIVES

Studies showing the changes in workflow during transition from semi to full electronic medical records are lacking. This objective study is to identify the changes in workflow in the PICU during transition from semi to full electronic health record.

DESIGN

Prospective observational study. Children's Hospital of Wisconsin Institutional Review Board waived the need for approval so this study was institutional review board exempt. This study measured clinical workflow variables at a 72-bed PICU during different phases of transition to a full electronic health record, which occurred on November 4, 2012. Phases of electronic health record transition were defined as follows: pre-electronic health record (baseline data prior to transition to full electronic health record), transition phase (3 wk after electronic health record), and stabilization (6 mo after electronic health record). Data were analyzed for the three phases using Mann-Whitney U test with a two-sided p value of less than 0.05 considered significant.

SETTING

Seventy-two bed PICU.

PATIENTS

All patients in the PICU were included during the study periods.

MEASUREMENTS AND MAIN RESULTS

Five hundred and sixty-four patients with 2,355 patient days were evaluated in the three phases. Duration of rounds decreased from a median of 9 minutes per patient pre--electronic health record to 7 minutes per patient post electronic health record. Time to final note decreased from 2.06 days pre--electronic health record to 0.5 days post electronic health record. Time to first medication administration after admission also decreased from 33 minutes pre--electronic health record and 7 minutes post electronic health record. Time to Time to medication reconciliation was significantly higher pre-electronic health record than post electronic health record and percent of medication reconciliation completion was significantly lower pre--electronic health record than post electronic health record and percent of medication reconciliation completion was significantly higher pre--electronic health record than. There was no significant change in time between placement of discharge order and physical transfer from the unit [corrected].changes clinical workflow in a PICU with decreased duration of rounds, time to final note, time to medication administration, and time to medication reconciliation completion. There was no change in the duration from medical to physical transfer.

"Nothing About Me Without Me": An Interpretative Review of Patient Accessible Electronic Health Records

Background

Patient accessible electronic health records (PAEHRs) enable patients to access and manage personal clinical information that is made available to them by their health care providers (HCPs). It is thought that the shared management nature of medical record access improves patient outcomes and improves patient satisfaction. However, recent reviews have found that this is not the case. Furthermore, little research has focused on PAEHRs from the HCP viewpoint. HCPs include physicians, nurses, and service providers.

Objective

We provide a systematic review of reviews of the impact of giving patients record access from both a patient and HCP point of view. The review covers a broad range of outcome measures, including patient safety, patient satisfaction, privacy and security, self-efficacy, and health outcome.

Methods

A systematic search was conducted using Web of Science to identify review articles on the impact of PAEHRs. Our search was limited to English-language reviews published between January 2002 and November 2014. A total of 73 citations were retrieved from a series of Boolean search terms including “review*” with “patient access to records”. These reviews went through a novel scoring system analysis whereby we calculated how many positive outcomes were reported per every outcome measure investigated. This provided a way to quantify the impact of PAEHRs.

Results

Ten reviews covering chronic patients (eg, diabetes and hypertension) and primary care patients, as well as HCPs were found but eight were included for the analysis of outcome measures. We found mixed outcomes across both patient and HCP groups, with approximately half of the reviews showing positive changes with record access. Patients believe that record access increases their perception of control; however, outcome measures thought to create psychological concerns (such as patient anxiety as a result of seeing their medical record) are still unanswered. Nurses are more likely than physicians to gain time efficiencies by using a PAEHR system with the main concern from physicians being the security of the PAEHRs.

Conclusions

This review implements a novel scoring system, which shows there is a lack of rigorous empirical testing that separates the effect of record access from other existing disease management programs. Current research is too targeted within certain clinical groups’ needs, and although there are positive signs for the adoption of PAEHRs, there is currently insufficient evidence about the effect of PAEHRs on health outcomes for patients or HCPs.

The relationship between interruption content and interrupted task severity in intensive care nursing: an observational study

BACKGROUND

In a previous study, we observed that the majority of interruptions experienced by nurses in a cardiovascular intensive care unit (CVICU) carried information directly related to their patient or other aspects of work affecting other patients or indirectly affecting their patient. Further, the proportion of interruptions with personal content was significantly higher during low-severity (in case of an error as defined by nurses) tasks compared to medium- and high-severity tasks suggesting that other personnel may have evaluated the criticality of the nurses' tasks before interrupting. However, this earlier study only collected data when an interruption happened and thus could not investigate interruption rate as a function of primary task type and severity while controlling for primary task duration as an exposure variable.

OBJECTIVES

We addressed this methodological limitation in a second observational study that was conducted to further study interruptions and also to evaluate an interruption mitigation tool. The data from the baseline condition (i.e., no tool) is analyzed in this paper to validate the results of our previous study and to report interruption rates observed during tasks of varying severities (low, medium, high), with a particular focus on comparing different interruption contents.

DESIGN AND SETTING

The study was conducted in a 24-bed closed CVICU at a Canadian hospital, during day shifts.

PARTICIPANTS

The baseline condition involved thirteen nurses.

METHODS

Over a 3-week period, three researchers observed these nurses 46-120 min each, with an average of 89 min. Data were collected in real time, using a tablet computer and software designed for this purpose. The rate of interruptions with different content was compared across varying task severity levels as defined by CVICU nurses.

RESULTS

Nurses spent about 50% of their time conducting medium-severity tasks (e.g., documentation), 35% conducting high-severity tasks (e.g., procedure), and 14% conducting low-severity tasks (e.g., general care). The rate of interruptions with personal content observed during low-severity tasks was 1.97 (95% confidence interval, CI: 1.04, 3.74) and 3.23 (95% CI: 1.51, 6.89) times the rate of interruptions with personal content observed during high- and medium-severity tasks, respectively.

CONCLUSIONS

Interrupters might have evaluated task severity before interrupting. Increasing the transparency of the nature and severity of the task being performed may help others further modulate when and how they interrupt a nurse. Overall, rather than try to eliminate all interruptions, mitigation strategies should consider the relevance of interruptions to a task or patient as well as their urgency.

Evaluation methods used on health information systems (HISs) in Iran and the effects of HISs on Iranian healthcare: a systematic review

OBJECTIVES

The most important goal of a health information system (HIS) is improvement of quality, effectiveness and efficiency of health services. To achieve this goal, health care systems should be evaluated continuously. The aim of this paper was to study the impacts of HISs in Iran and the methods used for their evaluation.

METHODS

We systematically searched all English and Persian papers evaluating health information systems in Iran that were indexed in SID, Magiran, Iran medex, PubMed and Embase databases until June 2013. A data collection form was designed to extract required data such as types of systems evaluated, evaluation methods and tools.

RESULTS

In this study, 53 out of 1103 retrieved articles were selected as relevant and reviewed by the authors. This study indicated that 28 studies used questionnaires to evaluate the system and in 27 studies the study instruments were distributed within a research population. In 26 papers the researchers collected the information by means of interviews, observations, heuristic evaluation and the review of documents and records. The main effects of the evaluated systems in health care settings were improving quality of services, reducing time, increasing accessibility to information, reducing costs and decreasing medical errors.

CONCLUSION

Evaluation of health information systems is central to their development and enhancement, and to understanding their effect on health and health services. Despite numerous evaluation methods available, the reviewed studies used a limited number of methods to evaluate HIS. Additionally, the studies mainly discussed the positive effects of HIS on health care services.

The organizational and clinical impact of integrating bedside equipment to an information system: a systematic literature review of patient data management systems (PDMS)

OBJECTIVE

The introduction of an information system integrated to bedside equipment requires significant financial and resource investment; therefore understanding the potential impact is beneficial for decision-makers. However, no systematic literature reviews (SLRs) focus on this topic. This SLR aims to gather evidence on the impact of the aforementioned system, also known as a patient data management system (PDMS) on both organizational and clinical outcomes.

MATERIALS AND METHODS

A literature search was performed using the databases Medline/PubMed and CINHAL for English articles published between January 2000 and December 2012. A quality assessment was performed on articles deemed relevant for the SLR.

RESULTS

Eighteen articles were included in the SLR. Sixteen articles investigated the impact of a PDMS on the organizational outcomes, comprising descriptive, quantitative and qualitative studies. A PDMS was found to reduce the charting time, increase the time spent on direct patient care and reduce the occurrence of errors. Only two articles investigated the clinical impact of a PDMS. Both reported an improvement in clinical outcomes when a PDMS was integrated with a clinical decision support system (CDSS).

CONCLUSIONS

A PDMS has shown to offer many advantages in both the efficiency and the quality of care delivered to the patient. In addition, a PDMS integrated to a CDSS may improve clinical outcomes, although further studies are required for validation.

Clinical and financial considerations for implementing an ICU telemedicine program

As the population in the United States increases and ages, the need to provide high-quality, safe, and cost-effective care to the most critically ill patients will be of great importance. With the projected shortage of intensivists, innovative changes to improve efficiency and increase productivity will be necessary. Telemedicine programs in the ICUs (tele-ICUs) are a successful strategy to improve intensivist access to critically ill patients. Although significant capital and maintenance costs are associated with tele-ICUs, these costs can be offset by indirect financial benefits, such as decreased length of stay. To achieve the positive clinical outcomes desired, tele-ICUs must be carefully designed and implemented. In this article, we discuss the clinical benefits of tele-ICUs. We review the financial considerations, including direct and indirect reimbursement and development and maintenance costs. Finally, we review design and implementation considerations for tele-ICUs.

The effect of an electronic health record system on nursing staff time in a nursing home: a longitudinal cohort study

BACKGROUND

Nursing homes are increasingly introducing electronic health record (EHR) systems into nursing practice; however, there is limited evidence about the effect of these systems on nursing staff time.

AIMS

To investigate the effect of introducing an EHR system on time spent on activities by nursing staff in a nursing home.

METHOD

An observational work sampling study was undertaken with nursing staff between 2009 and 2011 at two months before, and at 3, 6, 12, and 23 months after implementation of an EHR system at an Australian nursing home. An observer used pre-determined tasks to record activities of the nursing staff at nine-minute intervals.

RESULTS

There was no significant change in registered nurses and endorsed enrolled nurses' time on most activities after implementation. Personal carers' time on oral-communication reduced, and time on documentation increased at most measurement periods in the first 12 months after implementation. At 23 months, time on these activities had returned to pre-implementation levels. Nursing staff time on direct care remained stable after implementation. No considerable change was observed in time spent on other activities after implementation.

CONCLUSION

Findings suggest that successful introduction of an EHR system in a nursing home may not interfere with nursing staff time on direct care duties. However, there is scope for improving the support provided by EHR systems through incorporation of functions to support collaborative nursing care.

The implementation of an Intensive Care Information System allows shortening the ICU length of stay

Intensive care information systems (ICIS) implemented in intensive care unit (ICU) were shown to improve patient safety, reduce medical errors and increase the time devolved by medical/nursing staff to patients care. Data on the real impact of ICIS on patient outcome are scarce. This study aimed to evaluate the effects of ICIS on the outcome of critically-ill patients. From January 2004 to August 2006, 1,397 patients admitted to our ICU were enrolled in this observational study. This period was divided in two phases: before the implementation of ICIS (BEFORE) and after implementation of ICIS (AFTER). We compared standard ICU patient's outcomes: mortality, length of stay in ICU, hospital stay, and the re-admission rate depending upon BEFORE and AFTER. Although patients admitted AFTER were more severely ill than those of BEFORE (SAPS II: 32.1±17.5 vs. 30.5±18.5, p=0.014, respectively), their ICU length of stay was significantly shorter (8.4±15.2 vs. 6.8±12.9 days; p=0.048) while the re-admission rate and mortality rate were similar (4.4 vs. 4.2%; p=0.86, and 9.6 vs 11.2% p=0.35, respectively) in patients admitted AFTER. We observed that the implementation of ICIS allowed shortening of ICU length of stay without altering other patient outcomes.

The impact of health information technology on staffing

Hospitals nationwide must demonstrate meaningful use by 2015 or face fines. For over 20 years, researchers have attempted to assess the impact of electronic record keeping technologies on the quality, safety, and efficiency of care, but results are inconclusive and hospital managers have little evidence on which to base staffing decisions as we hurtle toward the era of the paperless hospital.

Human Factors in Critical Care Medical Environments

The purpose of this chapter on human factors in critical care medical environments is to provide a systematic review of the human factors and ergonomics contributions that led to significant improvements in patient safety over the last five decades. The review will focus on issues that contributed to patient injury and fatalities and how human factors and ergonomics can improve performance of providers in critical care. Given the complexity of critical care delivery, a review needs to cover a wide range of subjects. In this review, I take a sociotechnical systems perspective on critical care and discuss the people, their technical and nontechnical skills, the importance of teamwork, technology, and ergonomics in this complex environment. After a description of the importance of a safety climate, the chapter will conclude with a summary on how human factors and ergonomics can improve quality in critical care delivery.

The work of adult and pediatric intensive care unit nurses

BACKGROUND

Researchers have used various methods to describe and quantify the work of nurses. Many of these studies were focused on nursing in general care settings; therefore, less is known about the unique work nurses perform in intensive care units (ICUs).

OBJECTIVES

The aim of this study was to observe adult and pediatric ICU nurses in order to quantify and compare the duration and frequency of nursing tasks across four ICUs as well as within two discrete workflows: nurse handoffs at shift change and patient interdisciplinary rounds.

METHODS

A behavioral task analysis of adult and pediatric nurses was used to allow unobtrusive, real-time observation. A total of 147 hours of observation were conducted in an adult medical-surgical, a cardiac, a pediatric, and a neonatal ICU at one rural, tertiary care community teaching hospital.

RESULTS

Over 75% of ICU nurses' time was spent on patient care activities. Approximately 50% of this time was spent on direct patient care, over 20% on care coordination, 28% on nonpatient care, and approximately 2% on indirect patient care activities. Variations were observed between units; for example, nurses in the two adult units spent more time using monitors and devices. A high rate and variety of tasks were also observed: Nurses performed about 125 activities per hour, averaging a switch between tasks every 29 seconds.

DISCUSSION

This study provides useful information about how nurses spend their time in various ICUs. The methodology can be used in future research to examine changes in work related to, for example, implementation of health information technology.

Clinical documentation: composition or synthesis?

OBJECTIVE

To understand the nature of emerging electronic documentation practices, disconnects between documentation workflows and computing systems designed to support them, and ways to improve the design of electronic documentation systems.

MATERIALS AND METHODS

Time-and-motion study of resident physicians' note-writing practices using a commercial electronic health record system that includes an electronic documentation module. The study was conducted in the general medicine unit of a large academic hospital.

RESULTS

During the study, 96 note-writing sessions by 11 resident physicians, resulting in close to 100 h of observations were seen. Seven of the 10 most common transitions between activities during note composition were between documenting, and gathering and reviewing patient data, and updating the plan of care.

DISCUSSION

The high frequency of transitions seen in the study suggested that clinical documentation is fundamentally a synthesis activity, in which clinicians review available patient data and summarize their impressions and judgments. At the same time, most electronic health record systems are optimized to support documentation as uninterrupted composition. This mismatch leads to fragmentation in clinical work, and results in inefficiencies and workarounds. In contrast, we propose that documentation can be best supported with tools that facilitate data exploration and search for relevant information, selective reading and annotation, and composition of a note as a temporal structure.

CONCLUSIONS

Time-and-motion study of clinicians' electronic documentation practices revealed a high level of fragmentation of documentation activities and frequent task transitions. Treating documentation as synthesis rather than composition suggests new possibilities for supporting it more effectively with electronic systems.

Lessons learned from implementation of a perinatal documentation system

Implementation of an electronic medical record (EMR) system is a complex process with broad implications. In a Midwestern hospital perinatal setting, EMR implementation involved several critical steps: strategic planning and project goal setting; project structure and governance; system requirements analysis; vendor selection and contract negotiation; and EMR training. No difference in patient care activities and communications among clinicians was found between pre- and post-EMR implementation; however, nurses' perceptions of EMR were more negative afterward. Lessons learned and implications are provided.