Supporting clinical practice at the bedside using wireless technology

Implementation and use of computerised clinical decision support (CCDS) in emergency pre-hospital care: a qualitative study of paramedic views and experience using Strong Structuration Theory

BACKGROUND

Computerised clinical decision support (CCDS) has been shown to improve processes of care in some healthcare settings, but there is little evidence related to its use or effects in pre-hospital emergency care. CCDS in this setting aligns with policies to increase IT use in ambulance care, enhance paramedic decision-making skills, reduce avoidable emergency department attendances and improve quality of care and patient experience. This qualitative study was conducted alongside a cluster randomised trial in two ambulance services of the costs and effects of web-based CCDS system designed to support paramedic decision-making in the care of older people following a fall. Paramedics were trained to enter observations and history for relevant patients on a tablet, and the CCDS then generated a recommended course of action which could be logged. Our aim was to describe paramedics' experience of the CCDS intervention and to identify factors affecting its implementation and use.

METHODS

We invited all paramedics who had been randomly allocated to the intervention arm of the trial to participate in interviews or focus groups. The study was underpinned by Strong Structuration Theory, a theoretical model for studying innovation based on the relationship between what people do and their context. We used the Framework approach to data analysis.

RESULTS

Twenty out of 22 paramedics agreed to participate. We developed a model of paramedic experience of CCDS with three domains: context, adoption and use, and outcomes. Aspects of context which had an impact included organisational culture and perceived support for non-conveyance decisions. Experience of adoption and use of the CCDS varied between individual paramedics, with some using it with all eligible patients, some only with patients they thought were 'suitable' and some never using it. A range of outcomes were reported, some of which were different from the intended role of the technology in decision support.

CONCLUSION

Implementation of new technology such as CCDS is not a one-off event, but an ongoing process, which requires support at the organisational level to be effective.

TRIAL REGISTRATION

ISRCTN Registry 10538608 . Registered 1 May 2007. Retrospectively registered.

Review of implementation strategies to change healthcare provider behaviour in the emergency department

OBJECTIVES

Advances in emergency medicine research can be slow to make their way into clinical care, and implementing a new evidence-based intervention can be challenging in the emergency department. The Canadian Association of Emergency Physicians (CAEP) Knowledge Translation Symposium working group set out to produce recommendations for best practice in the implementation of a new science in Canadian emergency departments.

METHODS

A systematic review of implementation strategies to change health care provider behaviour in the emergency department was conducted simultaneously with a national survey of emergency physician experience. We summarized our findings into a list of draft recommendations that were presented at the national CAEP Conference 2017 and further refined based on feedback through social media strategies.

RESULTS

We produced 10 recommendations for implementing new evidence-based interventions in the emergency department, which cover identifying a practice gap, evaluating the evidence, planning the intervention strategy, monitoring, providing feedback during implementation, and desired qualities of future implementation research.

CONCLUSIONS

We present recommendations to guide future emergency department implementation initiatives. There is a need for robust and well-designed implementation research to guide future emergency department implementation initiatives.

A culturally tailored Internet cancer support group for Asian American breast cancer survivors: A randomized controlled pilot intervention study

Introduction The necessity of culturally competent Internet Cancer Support Groups (ICSGs) for ethnic minorities has recently been highlighted in order to increase its attractiveness and usage. The purpose of this study was to determine the preliminary efficacy of a culturally tailored registered-nurse-moderated ICSG for Asian American breast cancer survivors in enhancing the women's breast cancer survivorship experience. Methods The study included two phases: (a) a usability test and an expert review; and (b) a randomized controlled pilot intervention study. The usability test was conducted among five Asian American breast cancer survivors using a one-month online forum, and the expert review was conducted among five experts using the Cognitive Walkthrough method. The randomized controlled pilot intervention study (a pre-test and post-test design) was conducted among 65 Asian American breast cancer survivors. The data were analysed using content analysis and descriptive and inferential statistics including the repeated ANOVA. Results All users and experts positively evaluated the program and provided their suggestions for the display, educational contents, and user-friendly structure. There were significant positive changes in the support care needs and physical and psychological symptoms ( p < 0.05) of the control group. There were significant negative changes in the uncertainty level of the intervention group ( p < 0.10). Controlling for background and disease factors, the intervention group showed significantly greater improvements than the control group in physical and psychological symptoms and quality of life ( p < 0.10). Discussion The findings supported the positive effects of ICSGs on support care needs, psychological and physical symptoms, and quality of life.

Information and Communication Technologies for the Dissemination of Clinical Practice Guidelines to Health Professionals: A Systematic Review

BACKGROUND

The transfer of research knowledge into clinical practice can be a continuous challenge for researchers. Information and communication technologies, such as websites and email, have emerged as popular tools for the dissemination of evidence to health professionals.

OBJECTIVE

The objective of this systematic review was to identify research on health professionals' perceived usability and practice behavior change of information and communication technologies for the dissemination of clinical practice guidelines.

METHODS

We used a systematic approach to retrieve and extract data about relevant studies. We identified 2248 citations, of which 21 studies met criteria for inclusion; 20 studies were randomized controlled trials, and 1 was a controlled clinical trial. The following information and communication technologies were evaluated: websites (5 studies), computer software (3 studies), Web-based workshops (2 studies), computerized decision support systems (2 studies), electronic educational game (1 study), email (2 studies), and multifaceted interventions that consisted of at least one information and communication technology component (6 studies).

RESULTS

Website studies demonstrated significant improvements in perceived usefulness and perceived ease of use, but not for knowledge, reducing barriers, and intention to use clinical practice guidelines. Computer software studies demonstrated significant improvements in perceived usefulness, but not for knowledge and skills. Web-based workshop and email studies demonstrated significant improvements in knowledge, perceived usefulness, and skills. An electronic educational game intervention demonstrated a significant improvement from baseline in knowledge after 12 and 24 weeks. Computerized decision support system studies demonstrated variable findings for improvement in skills. Multifaceted interventions demonstrated significant improvements in beliefs about capabilities, perceived usefulness, and intention to use clinical practice guidelines, but variable findings for improvements in skills. Most multifaceted studies demonstrated significant improvements in knowledge.

CONCLUSIONS

The findings suggest that health professionals' perceived usability and practice behavior change vary by type of information and communication technology. Heterogeneity and the paucity of properly conducted studies did not allow for a clear comparison between studies and a conclusion on the effectiveness of information and communication technologies as a knowledge translation strategy for the dissemination of clinical practice guidelines.

Interventions to increase the use of electronic health information by healthcare practitioners to improve clinical practice and patient outcomes

BACKGROUND

There is a large volume of health information available, and, if applied in clinical practice, may contribute to effective patient care. Despite an abundance of information, sub-optimal care is common. Many factors influence practitioners' use of health information, and format (electronic or other) may be one such factor.

OBJECTIVES

To assess the effects of interventions aimed at improving or increasing healthcare practitioners' use of electronic health information (EHI) on professional practice and patient outcomes.

SEARCH METHODS

We searched The Cochrane Library (Wiley), MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO), and LISA (EBSCO) up to November 2013. We contacted researchers in the field and scanned reference lists of relevant articles.

SELECTION CRITERIA

We included studies that evaluated the effects of interventions to improve or increase the use of EHI by healthcare practitioners on professional practice and patient outcomes. We defined EHI as information accessed on a computer. We defined 'use' as logging into EHI. We considered any healthcare practitioner involved in patient care. We included randomized, non-randomized, and cluster randomized controlled trials (RCTs, NRCTs, CRCTs), controlled clinical trials (CCTs), interrupted time series (ITS), and controlled before-and-after studies (CBAs).The comparisons were: electronic versus printed health information; EHI on different electronic devices (e.g. desktop, laptop or tablet computers, etc.; cell / mobile phones); EHI via different user interfaces; EHI provided with or without an educational or training component; and EHI compared to no other type or source of information.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias for each study. We used GRADE to assess the quality of the included studies. We reassessed previously excluded studies following our decision to define logins to EHI as a measure of professional behavior. We reported results in natural units. When possible, we calculated and reported median effect size (odds ratio (OR), interquartile ranges (IQR)). Due to high heterogeneity across studies, meta-analysis was not feasible.

MAIN RESULTS

We included two RCTs and four CRCTs involving 352 physicians, 48 residents, and 135 allied health practitioners. Overall risk of bias was low as was quality of the evidence. One comparison was supported by three studies and three comparisons were supported by single studies, but outcomes across the three studies were highly heterogeneous. We found no studies to support EHI versus no alternative. Given these factors, it was not possible to determine the relative effectiveness of interventions. All studies reported practitioner use of EHI, two reported on compliance with electronic practice guidelines, and none reported on patient outcomes.One trial (139 participants) measured guideline adherence for an electronic versus printed guideline, but reported no difference between groups (median OR 0.85, IQR 0.74 to 1.08). One small cross-over trial (10 participants) reported increased use of clinical guidelines when provided with a mobile versus stationary, desktop computer (mean use per shift: intervention group (IG) 3.6, standard deviation (SD) 1.7 vs. control group (CG) 2.0 (SD 1.9), P value = 0.033). One cross-over trial (203 participants) reported that using a customized versus a generic interface had little impact on practitioners' use of EHI (mean difference in adjusted end-of-study rate: 0.77 logins/month/user, 95% confidence interval (CI) CI 0.43 to 1.11). Three trials included education or training and reported increased use of EHI by practitioners following training.

AUTHORS' CONCLUSIONS

This review provided no evidence that the use of EHI translates into improved clinical practice or patient outcomes, though it does suggest that when practitioners are provided with EHI and education or training, the use of EHI increases. We have defined use as the activity of logging into an EHI resource, but based on our findings use does not automatically translate to the application of EHI in practice. While using EHI may be an important component of evidence-based medicine, alone it is insufficient to improve patient care or clinical practices. For EHI to be applied in patient care, it will be necessary to understand why practitioners' are reluctant to apply EHI when treating people, and to determine the most effective way(s) to reduce this reluctance.

Toward improving the diagnosis and the treatment of adolescent pelvic inflammatory disease in emergency departments: results of a brief, educational intervention

OBJECTIVE

To assess the utility of an abbreviated teaching tool (ATT) in improving emergency medicine pediatricians' knowledge of the diagnosis and the treatment of pelvic inflammatory disease (PID).

METHODS

An 18-question internet-based survey, which included questions about the diagnosis and the treatment of PID, was administered to members of the American Academy of Pediatrics Section on Emergency Medicine. Participants were randomized to receive either a weblink to the Centers for Disease Control and Prevention (CDC) sexually transmitted disease treatment guidelines (weblink group) or a 1-page ATT that summarized the CDC guidelines (ATT group) to assist with completion of the survey. We compared the accuracy of responses between the 2 groups.

RESULTS

Two hundred thirty-seven subjects responded to the survey (109 from the weblink group and 128 from ATT group). There were no significant differences between the groups with respect to sex, geographic location, practice setting, years of experience, or reported frequency of recent PID diagnoses. Ninety-seven percent of the ATT group correctly identified the appropriate antibiotic regimen in compliance with the CDC guidelines compared with 61% of the weblink group (OR, 19.4; 95% confidence interval, 6.6-76.9); the ATT group was also more likely to correctly identify appropriate treatment options overall (OR, 9.6; 95% confidence interval, 4.9-19.3).

CONCLUSIONS

Although the overall PID knowledge in our sample was low, the physicians with access to a 1-page teaching tool summarizing the CDC treatment recommendations for PID performed significantly better when asked questions involving PID treatment as compared with providers with access to the CDC Web site. Further studies should investigate whether access to a similar tool can improve patient care.

The impact of electronic medical records on patient-doctor communication during consultation: a narrative literature review

RATIONALE, AIMS AND OBJECTIVE

The effect of Electronic Medical Record (EMR) use on Patient-Doctor Communication (PDC) has rarely been studied. As data accumulate, the purpose of this article is to review the literature on EMR effect on PDC, to identify recurring themes and to offer preliminary guidelines and future directions for medical education and research.

METHOD

A database search was conducted and 14 articles that met inclusion criteria (published in the past 10 years, empirical investigations, direct assessment of the EMR impact on patient-doctor communication) were selected for review. A qualitative, grounded theory-like approach was employed to analyse the data.

RESULTS

EMR use often has a positive impact on information exchange, but exerts a negative influence on patient centredness. Some physician characteristics such as their computer skills and behavioural style assist in overcoming this negative influence.

CONCLUSION

The use of EMR exerts both positive and negative impacts on physician-patient relationships. The negative impacts can be overcome by some simple means as well as better designs of EMR systems and medical education interventions. Physicians' everyday practices of integrating EMR use into the clinical encounter as well as better design of EMR systems and EMR and communication training may facilitate PDC in computerized settings.

Electronic retrieval of health information by healthcare providers to improve practice and patient care

BACKGROUND

The movement towards evidence-based practice makes explicit the need for access to current best evidence to improve health. Advances in electronic technologies have made health information more available, but does availability affect the rate of use of evidence in practice?

OBJECTIVES

To assess the effectiveness of interventions intended to provide electronic retrieval (access to information) to health information by healthcare providers to improve practice and patient care.

SEARCH STRATEGY

We obtained studies from computerized searches of multiple electronic bibliographic databases, supplemented by checking reference lists, and consultation with experts.

SELECTION CRITERIA

Randomized controlled trials (RCTs) including cluster randomized trials (CRCTs), controlled clinical trials (CCT), and interrupted time series analyses (ITS) of any language publication status examining interventions of effectiveness of electronic retrieval of health information by healthcare providers.

DATA COLLECTION AND ANALYSIS

Duplicate relevancy screening of searches, data abstraction and risk of bias assessment was undertaken.

MAIN RESULTS

We found two studies that examined this question. Neither study found any changes in professional behavior following an intervention that facilitated electronic retrieval of health information. There was some evidence of improvements in knowledge about the electronic sources of information reported in one study. Neither study assessed changes in patient outcomes or the costs of provision of the electronic resource and the implementation of the recommended evidence-based practices.

AUTHORS' CONCLUSIONS

Overall there was insufficient evidence to support or refute the use of electronic retrieval of healthcare information by healthcare providers to improve practice and patient care.

Knowledge Translation: Closing the Evidence-to-Practice Gap

Knowledge translation describes any activity or process that facilitates the transfer of high-quality evidence from research into effective changes in health policy, clinical practice, or products. This increasingly important discipline attempts to conceptually combine elements of research, education, quality improvement, and electronic systems development to create a seamless linkage between interventions that improve patient care and their routine implementation in daily clinical practice. We outline the gap between research and practice and present a case study of an emergency medicine example of validated evidence that has failed to achieve widespread implementation. The authors describe a model of organization of evidence and its relationship with the process that links research from the scientific endeavor to changes in practice that affect patient outcomes. Obstacles to evidence uptake are explored, as well as the limitations of current educational strategies. Innovative strategies in realms such as computerized decision support systems designed to enhance evidence uptake are also described. The potential interface between knowledge translation and continuous quality improvement, as well as the role for bedside tools, is also presented. Research in knowledge translation includes studies that attempt to quantify and understand the discrepancies between what is known and what is done, as well as those that examine the impact and acceptability of interventions designed to narrow or close these gaps. Sentinel examples in this line of research conducted in the emergency department setting are described.

Nurses' acceptance of the decision support computer program for cancer pain management

This article describes nurses' acceptance of a decision support computer program for cancer pain management and explores the relationships between the nurses' acceptance and their sociodemographic characteristics. A feminist perspective was used as a theoretical guide for the research process. This was an Internet intervention study among 122 nurses working with cancer patients. Nurses' acceptance of the decision support computer program was measured using the Questionnaire for User Interaction Satisfaction. The data were analyzed using descriptive and inferential statistics, including analysis of variance and correlation analyses. There were significant differences in the total scores of user satisfaction by sex, religion, ethnicity, job title, and specialty. The results suggest that nurses do welcome decision support systems and that nurses' sociodemographic and professional characteristics should be considered in the development of decision support systems.