Supporting patient care in the emergency department with a computerized whiteboard system

Modern Paediatric Emergency Department: Potential Improvements in Light of New Evidence

The increasing attendance of paediatric emergency departments has become a serious health issue. To reduce an elevated burden of medical errors, inevitably caused by a high level of stress exerted on emergency physicians, we propose potential areas for improvement in regular paediatric emergency departments. In an effort to guarantee the demanded quality of care to all incoming patients, the workflow in paediatric emergency departments should be sufficiently optimised. The key component remains to implement one of the validated paediatric triage systems upon the patient's arrival at the emergency department and fast-tracking patients with a low level of risk according to the triage system. To ensure the patient's safety, emergency physicians should follow issued guidelines. Cognitive aids, such as well-designed checklists, posters or flow charts, generally improve physicians' adherence to guidelines and should be available in every paediatric emergency department. To sharpen diagnostic accuracy, the use of ultrasound in a paediatric emergency department, according to ultrasound protocols, should be targeted to answer specific clinical questions. Combining all mentioned improvements might reduce the number of errors linked to overcrowding. The review serves not only as a blueprint for modernising paediatric emergency departments but also as a bin of useful literature which can be suitable in the paediatric emergency field.

A Pilot of Digital Whiteboards for Improving Patient Satisfaction in the Emergency Department: Nonrandomized Controlled Trial

BACKGROUND

Electronic paper (E-paper) screens use electrophoretic ink to provide paper-like low-power displays with advanced networking capabilities that may potentially serve as an alternative to traditional whiteboards and television display screens in hospital settings. E-paper may be leveraged in the emergency department (ED) to facilitate communication. Providing ED patient status updates on E-paper screens could improve patient satisfaction and overall experience and provide more equitable access to their health information.

OBJECTIVE

We aimed to pilot a patient-facing digital whiteboard using E-paper to display relevant orienting and clinical information in real time to ED patients. We also sought to assess patients' satisfaction after our intervention and understand our patients' overall perception of the impact of the digital whiteboards on their stay.

METHODS

We deployed a 41-inch E-paper digital whiteboard in 4 rooms in an urban, tertiary care, and academic ED and enrolled 110 patients to understand and evaluate their experience. Participants completed a modified Hospital Consumer Assessment of Health Care Provider and Systems satisfaction questionnaire about their ED stay. We compared responses to a matched control group of patients triaged to ED rooms without digital whiteboards. We designed the digital whiteboard based on iterative feedback from various departmental stakeholders. After establishing IT infrastructure to support the project, we enrolled patients on a convenience basis into a control and an intervention (digital whiteboard) group. Enrollees were given a baseline survey to evaluate their comfort with technology and an exit survey to evaluate their opinions of the digital whiteboard and overall ED satisfaction. Statistical analysis was performed to compare baseline characteristics as well as satisfaction.

RESULTS

After the successful prototyping and implementation of 4 digital whiteboards, we screened 471 patients for inclusion. We enrolled 110 patients, and 50 patients in each group (control and intervention) completed the study protocol. Age, gender, and racial and ethnic composition were similar between groups. We saw significant increases in satisfaction on postvisit surveys when patients were asked about communication regarding delays (P=.03) and what to do after discharge (P=.02). We found that patients in the intervention group were more likely to recommend the facility to family and friends (P=.04). Additionally, 96% (48/50) stated that they preferred a room with a digital whiteboard, and 70% (35/50) found the intervention "quite a bit" or "extremely" helpful in understanding their ED stay.

CONCLUSIONS

Digital whiteboards are a feasible and acceptable method of displaying patient-facing data in the ED. Our pilot suggested that E-paper screens coupled with relevant, real-time clinical data and packaged together as a digital whiteboard may positively impact patient satisfaction and the perception of the facility during ED visits. Further study is needed to fully understand the impact on patient satisfaction and experience.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04497922; https://clinicaltrials.gov/ct2/show/NCT04497922.

Requirements and challenges of hospital dashboards: a systematic literature review

Background

Today, the use of data in administrative and clinical processes is quite challenging due to the large volume of data, data collection from various sources, and lack of data structure. As a data management tool, dashboards play an important role in timely visual display of critical information on key performances.

Objectives

This systematic review aimed to identify functional and non-functional requirements, as well as challenges of using dashboards in hospitals.

Methods

In this systematic review, four databases, including the Web of Science, PubMed, EMBASE, and Scopus, were searched to find relevant articles from 2000 until May 30, 2020. The final search was conducted on May 30, 2020. Data collection was performed using a data extraction form and reviewing the content of relevant studies on the potentials and challenges of dashboard implementation.

Results

Fifty-four out of 1254 retrieved articles were selected for this study based on the inclusion and exclusion criteria. The functional requirements for dashboards included reporting, reminders, customization, tracking, alert creation, and assessment of performance indicators. On the other hand, the non-functional requirements included the dashboard speed, security, ease of use, installation on different devices (e.g., PCs and laptops), integration with other systems, web-based design, inclusion of a data warehouse, being up-to-data, and use of data visualization elements based on the user’s needs. Moreover, the identified challenges were categorized into four groups: data sources, dashboard content, dashboard design, implementation, and integration in other systems at the hospital level.

Conclusion

Dashboards, by providing information in an appropriate manner, can lead to the proper use of information by users. In order for a dashboard to be effective in clinical and managerial processes, particular attention must be paid to its capabilities, and the challenges of its implementation need to be addressed.

Impact of an integrated whiteboard system on physics QA turnaround time

Purpose

To evaluate the impact of a digital whiteboard system integrated with data from the oncology information system (OIS) on the urgency of physics quality assurance (QA) tasks in the radiation oncology department.

Methods

Quality check list (QCL) items in the Mosaiq OIS corresponding to eight discrete, sequential steps in the treatment planning process were created. A whiteboard to graphically display active QCLs automatically and in real time was implemented in March 2020 using R shiny. QCL data with completion status were collected in two 12‐month time periods before and after whiteboard implementation: January 2019–December 2019 and July 2020–June 2021. For all plans requiring patient‐specific QA, we recorded when each plan was available for physics QA and which treatments started the following day. We further classified those plans into four categories (urgency levels 1–4 with 4 being the most urgent) depending on how much time was available to perform QA. We compared the proportion of these next‐day QAs in each category between time periods accounting for plan type, day of the week, and time of year.

Results

Overall QA numbers were similar between time periods with 797 and 765 QAs total. The total proportion of next‐day QA decreased by 27% and the proportions of urgency levels 1 and 4 both showed significant decreases after whiteboard implementation of 29.2% and 54.9%, respectively (p<0.05). All plan types had reduced proportions of next‐day QAs, especially nonstereotactic body radiation therapy (non‐SBRT) (30.3% decrease, p<0.05). Fridays and the months of October–December had the highest proportion of next‐day QAs but showed significant reductions of 19.1% and 40.6% in the proportion of next‐day QAs, respectively (p<0.05).

Conclusions

The integrated whiteboard system significantly reduced the proportion of last‐minute physics work, increasing patient safety. Advantages of the integrated whiteboard were low cost, low overhead with automatic interface to the OIS, and concurrent user support.

Emergency Department Quality Dashboard; a Systematic Review of Performance Indicators, Functionalities, and Challenges

Introduction:

Effective information management in the emergency department (ED) can improve the control and management of ED processes. Dashboards, known as data management tools, efficiently provide information and contribute greatly to control and management of ED. This study aimed to identify performance indicators quality dashboard functionalities, and analyze the challenges associated with dashboard implementation in the ED.

Methods:

This systematic review began with a search in four databases (Web of Science, PubMed, Embase, and Scopus) from 2000 to May 30, 2020, when the final search for papers was conducted. The data were collected using a data extraction form and the contents of the extracted papers were analyzed through ED performance indicators, dashboard functionalities, and implementation challenges.

Results:

Performance indicators reported in the reviewed papers were classified as the quality of care, patient flow, timeliness, costs, and resources. The main dashboard functionalities noted in the papers included reporting, customization, alert creation, resource management, and real-time information display. The dashboard implementation challenges included data sources, data quality, integration with other systems, adaptability of dashboard functionalities to user needs, and selection of appropriate performance indicators.

Conclusions:

Quality dashboards facilitate processes, communication, and situation awareness in the ED; hence, they can improve care provision in this department. To enhance the effectiveness and efficiency of ED dashboards, officials should set performance indicators and consider the conformity of dashboard functionalities with user needs. They should also integrate dashboards with other relevant systems at the departmental and hospital levels.

Reliability of skeletal muscle ultrasound in critically ill trauma patients

Objective

To evaluate the safety and feasibility of the ultrasound assessment of quadriceps in the emergency setting. To assess the intra- and interrater reliability for the acquisition and analysis of ultrasound images of muscle thickness and echogenicity in critically ill trauma patients between health professionals with different levels of expertise.

Methods

Diagnostic accuracy study. Two examiners (expert and novice) acquired ultrasound images from ten patients; an experienced, blinded analyst quantified the images. In a separate group of ten patients, two analysts (expert and novice) quantified quadriceps muscle thickness and echogenicity (square or trace method) from images acquired by one examiner.

Results

Excellent reliability was found for image acquisition and analysis (intraclass correlation coefficients > 0.987; p < 0.001). The standard error of the measurement values ranged from 0.01 - 0.06cm for muscle thickness and from 0.75 - 2.04 arbitrary units for muscle echogenicity. The coefficients of variation were < 6% for thickness and echogenicity. The echogenicity values were higher when using the square technique than when using the tracing technique (p = 0.003).

Conclusion

Ultrasound is safe, feasible, and reliable for muscle assessment in critically ill trauma patients, regardless of the assessor's level of expertise.

"Me First, Others Later" A focused ethnography of ongoing cultural features of waiting in an Iranian emergency department

BACKGROUND

Waiting is an inevitable experience in all emergency departments (EDs). This waiting time may negatively influence the patients and their relatives' satisfaction, healthcare professionals' (HCPs) performance, and the quality of care provided. This study aims to explore, gain understanding of and describe what it is like to wait in an Iranian emergency department (ED) with particular focus on cultural features.

METHOD

A focused ethnographic approach based on Spradley's (1980) developmental research sequence was conducted in the ED of a tertiary academic medical center in northwest Iran over a 9-month study period from July 2017 to March 2018. Participant observation, ethnographic interviews and examination of related documents and artefacts were used to collect data. All the data were recorded in either field notes or verbatim transcripts and were analysed using Spradley's ethnographic data analysis method concurrently.

RESULTS

The overarching theme of "Me first, others later" emerged. Within this overarching theme there were seven sub-themes as follows: human-related factors, system-related factors, patients and their relatives' beliefs and behaviors, HCPs' beliefs and behaviors, consequences for patients and their relatives, consequences for HCPs, and consequences for ED environment and care process.

CONCLUSION

The mentality 'me first, others later' as the main cultural barrier to emergency care, strenuously undermined our positive practice environment. An accountable patient/relative support liaison, a clearly-delineated process of ED care delivery, guidelines for providing culturally competent ED care, and public awareness programs are needed to address the concerns and conflicts which establish a mutual trust and rapport.

The way from pen and paper to electronic documentation in a German emergency department

Background

Some of the advantages of implementing electronic emergency department information systems (EDIS) are improvements in data availability and simplification of statistical evaluations of emergency department (ED) treatments. However, for multi-center evaluations, standardized documentation is necessary. The AKTIN project (“National Emergency Department Register: Improvement of Health Services Research in Acute Medicine in Germany”) has used the “German Emergency Department Medical Record” (GEDMR) published by the German Interdisciplinary Association of Intensive and Emergency Care as the documentation standard for its national data registry.

Methods

Until March 2016 the documentation standard in ED was the pen-and-paper version of the GEDMR. In April 2016 we implemented the GEDMR in a timeline-based EDIS. Related to this, we compared the availability of structured treatment information of traumatological patients between pen-and-paper-based and electronic documentation, with special focus on the treatment time.

Results

All 796 data fields of the 6 modules (basic data, severe trauma, patient surveillance, anesthesia, council, neurology) were adapted for use with the existing EDIS configuration by a physician working regularly in the ED. Electronic implementation increased availability of structured anamnesis and treatment information. However, treatment time was increased in electronic documentation both immediately (2:12 ± 0:04 h; n = 2907) and 6 months after implementation (2:18 ± 0:03 h; n = 4778) compared to the pen-and-paper group (1:43 ± 0:02 h; n = 2523; p < 0.001).

Conclusions

We successfully implemented standardized documentation in an EDIS. The availability of structured treatment information was improved, but treatment time was also increased. Thus, further work is necessary to improve input time.

Design and Evaluation of an Integrated, Patient-Focused Electronic Health Record Display for Emergency Medicine

BACKGROUND

Hospital emergency departments (EDs) are dynamic environments, involving coordination and shared decision making by staff who care for multiple patients simultaneously. While computerized information systems have been widely adopted in such clinical environments, serious issues have been raised related to their usability and effectiveness. In particular, there is a need to support clinicians to communicate and maintain awareness of a patient's health status, and progress through the ED plan of care.

OBJECTIVE

This study used work-centered usability methods to evaluate an integrated patient-focused status display designed to support ED clinicians' communication and situation awareness regarding a patient's health status and progress through their ED plan of care. The display design was informed by previous studies we conducted examining the information and cognitive support requirements of ED providers and nurses.

METHODS

ED nurse and provider participants were presented various scenarios requiring patient-prioritization and care-planning tasks to be performed using the prototype display. Participants rated the display in terms of its cognitive support, usability, and usefulness. Participants' performance on the various tasks, and their feedback on the display design and utility, was analyzed.

RESULTS

Participants provided ratings for usability and usefulness for the display sections using a work-centered usability questionnaire-mean scores for nurses and providers were 7.56 and 6.6 (1 being lowest and 9 being highest), respectively. General usability scores, based on the System Usability Scale tool, were rated as acceptable or marginally acceptable. Similarly, participants also rated the display highly in terms of support for specific cognitive objectives.

CONCLUSION

A novel patient-focused status display for emergency medicine was evaluated via a simulation-based study in terms of work-centered usability and usefulness. Participants' subjective ratings of usability, usefulness, and support for cognitive objectives were encouraging. These findings, including participants' qualitative feedback, provided insights for improving the design of the display.

Examining barriers to healthcare providers' adoption of a hospital-wide electronic patient journey board

BACKGROUND

The dynamic environment that characterizes patient care in hospitals requires extensive communication between staff. Electronic status board applications are used to improve the flow of communication in hospitals. To date there has been limited work exploring the adoption of these applications in general acute ward settings.

AIM

This study aimed to identify barriers to the adoption of an electronic patient journey board (EPJB)¹ application in acute wards of a hospital.

METHOD

Data were collected at a large public teaching hospital in Sydney, Australia. The EPJB was implemented across all hospital wards with the aim of improving multidisciplinary communication in wards. Observations (29.5 h) and contextual interviews (n = 33) with hospital staff were conducted in two acute wards of the hospital.

RESULTS

Two manual whiteboards were used on wards, in addition to the EPJB, to compensate for information not being available or accessible on the EPJB. Despite the stated purpose of the EPJB, the tool did not appear to support team communication on wards. Barriers to adoption and optimal use of the EPJB included inappropriate location and configuration of the system, limitations in information timeliness, quality and lack of customisation (for different user groups), inconsistent information updates and the absence of a shared understanding of the purpose of the EPJB among the various user groups.

CONCLUSION

Multiple socio-technical barriers influenced uptake and optimal use of the EPJB by healthcare providers. Engaging users early in the design and implementation of electronic status board applications is required to ensure effective use of these complex interventions on general wards.

Learning Analytics in Medical Education Assessment: The Past, the Present, and the Future

With the implementation of competency-based medical education (CBME) in emergency medicine, residency programs will amass substantial amounts of qualitative and quantitative data about trainees' performances. This increased volume of data will challenge traditional processes for assessing trainees and remediating training deficiencies. At the intersection of trainee performance data and statistical modeling lies the field of medical learning analytics. At a local training program level, learning analytics has the potential to assist program directors and competency committees with interpreting assessment data to inform decision making. On a broader level, learning analytics can be used to explore system questions and identify problems that may impact our educational programs. Scholars outside of health professions education have been exploring the use of learning analytics for years and their theories and applications have the potential to inform our implementation of CBME. The purpose of this review is to characterize the methodologies of learning analytics and explore their potential to guide new forms of assessment within medical education.

Can teamwork and situational awareness (SA) in ED resuscitations be improved with a technological cognitive aid? Design and a pilot study of a team situation display

Effective teamwork in ED resuscitations, including information sharing and situational awareness, could be degraded. Technological cognitive aids can facilitate effective teamwork.

OBJECTIVE

This study focused on the design of an ED situation display and pilot test its influence on teamwork and situational awareness during simulated resuscitation scenarios.

MATERIAL AND METHODS

The display design consisted of a central area showing the critical dynamic parameters of the interventions with an events time-line below it. Static information was placed at the sides of the display. We pilot tested whether the situation display could lead to higher scores on the Clinical Teamwork Scale (CTS), improved scores on a context-specific Situational Awareness Global Assessment Technique (SAGAT) tool, and team communication patterns that reflect teamwork and situational awareness.

RESULTS

Resuscitation teamwork, as measured by the CTS, was overall better with the presence of the situation display as compared with no situation display. Team members discussed interventions more with the situation display compared with not having the situation display. Situational awareness was better with the situation display only in the trauma scenario.

DISCUSSION

The situation display could be more effective for certain ED team members and in certain cases.

CONCLUSIONS

Overall, this pilot study implies that a situation display could facilitate better teamwork and team communication in the resuscitation event.

Dashboard visualizations: Supporting real-time throughput decision-making

Providing timely and effective care in the emergency department (ED) requires the management of individual patients as well as the flow and demands of the entire department. Strategic changes to work processes, such as adding a flow coordination nurse or a physician in triage, have demonstrated improvements in throughput times. However, such global strategic changes do not address the real-time, often opportunistic workflow decisions of individual clinicians in the ED. We believe that real-time representation of the status of the entire emergency department and each patient within it through information visualizations will better support clinical decision-making in-the-moment and provide for rapid intervention to improve ED flow. This notion is based on previous work where we found that clinicians' workflow decisions were often based on an in-the-moment local perspective, rather than a global perspective. Here, we discuss the challenges of designing and implementing visualizations for ED through a discussion of the development of our prototype Throughput Dashboard and the potential it holds for supporting real-time decision-making.

Mental Status Documentation: Information Quality and Data Processes

Delirium is a fluctuating disturbance of cognition and/or consciousness associated with poor outcomes. Caring for patients with delirium requires integration of disparate information across clinicians, settings and time. The goal of this project was to characterize the information processes involved in nurses' assessment, documentation, decisionmaking and communication regarding patients' mental status in the inpatient setting. VA nurse managers of medical wards (n=18) were systematically selected across the US. A semi-structured telephone interview focused on current assessment, documentation, and communication processes, as well as clinical and administrative decision-making was conducted, audio-recorded and transcribed. A thematic analytic approach was used. Five themes emerged: 1) Fuzzy Concepts, 2) Grey Data, 3) Process Variability 4) Context is Critical and 5) Goal Conflict. This project describes the vague and variable information processes related to delirium and mental status that undermine effective risk, prevention, identification, communication and mitigation of harm.

Factors Affecting Quality of Emergency Service in Iran's Military Hospitals: A Qualitative Study

INTRODUCTION

Quality is a key factor for the success of any organization. Moreover, accessing quality in the emergency department is highly significant due to the sensitive and complex role of this department in hospitals as well as the healthcare and medical treatment system. This study aimed to identify, from the perspective of medical experts and nurses serving in the military health and medical treatment system, the factors that affect the quality of emergency service provided in selected military hospitals in Iran.

METHODS

This qualitative research was performed in Valiaser Hospital of Tehran (Iran) in 2015, using the framework analysis method. The purposive sampling technique was used for data collection. A total of 14 participants included two emergency medicine specialists, four general physicians, two senior nurses (holding M.Sc. degrees), and six nurses (holding B.Sc. degree). Data were collected through semistructured interviews. Sampling continued until data saturation occurred. The Atlas/Ti software was employed for data analysis.

RESULTS

Four basic themes emerged as the effective factors on the quality of emergency services, namely, structural themes, process/performance themes, outcome themes, and environmental/contextual themes. Moreover, through a framework analysis, 47 subthemes were specified and summarized as indicators of the different aspects of the main themes.

CONCLUSION

The factors affecting the quality of emergency services in Iran's selected military hospitals are especially complicated due to the diversity of the missions involved; thus, different factors can influence this quality. Therefore, an effort should be made to tackle the existing obstacles, facilitate the identification of these effective factors, and promotion of the quality of healthcare services.

Managing and Communicating Operational Workflow: Designing and Implementing an Electronic Outpatient Whiteboard

BACKGROUND

Healthcare team members in emergency department contexts have used electronic whiteboard solutions to help manage operational workflow for many years. Ambulatory clinic settings have highly complex operational workflow, but are still limited in electronic assistance to communicate and coordinate work activities.

OBJECTIVE

To describe and discuss the design, implementation, use, and ongoing evolution of a coordination and collaboration tool supporting ambulatory clinic operational workflow at Vanderbilt University Medical Center (VUMC).

METHODS

The outpatient whiteboard tool was initially designed to support healthcare work related to an electronic chemotherapy order-entry application. After a highly successful initial implementation in an oncology context, a high demand emerged across the organization for the outpatient whiteboard implementation. Over the past 10 years, developers have followed an iterative user-centered design process to evolve the tool.

RESULTS

The electronic outpatient whiteboard system supports 194 separate whiteboards and is accessed by over 2800 distinct users on a typical day. Clinics can configure their whiteboards to support unique workflow elements. Since initial release, features such as immunization clinical decision support have been integrated into the system, based on requests from end users.

CONCLUSIONS

The success of the electronic outpatient whiteboard demonstrates the usefulness of an operational workflow tool within the ambulatory clinic setting. Operational workflow tools can play a significant role in supporting coordination, collaboration, and teamwork in ambulatory healthcare settings.

Designing for privacy management in hospitals: Understanding the gap between user activities and IT staff's understandings

PURPOSE

We examined the role of privacy in collaborative clinical work and how it is understood by hospital IT staff. The purpose of our study was to identify the gaps between hospital IT staff members' perceptions of how electronic health record (EHR) users' protect the privacy of patient information and how users actually protect patients' private information in their daily collaborative activities. Since the IT staff play an important role in implementing and maintaining the EHR, any gaps that exist between the IT staff's perceptions of user work practices and the users' actual work practices can result in a number of problems in the configuration, implementation, or customization of the EHR, which can lead to collaboration challenges, interrupted workflow, and privacy breaches.

METHODS

We used qualitative data collection methods for this study. We conducted semi-structured interviews with 20 hospital IT staff members. We also conducted observations of EHR users in the in-patient units of the same hospital.

RESULTS

We identified gaps in IT staff's understandings of users' work activities, especially in regards to privacy-compromising workarounds that are used by users and why they are used.

DISCUSSION

We discuss the reasons why this gap may exist between IT staff and users and ways to improve IT staff's understanding of why users perform certain privacy-compromising workarounds.

CONCLUSION

A hospital's IT staff face a daunting task in ensuring users' collaborative work practices are supported by the system while providing effective privacy mechanisms. In order to achieve both goals, the IT staff must have a clear understanding of their users' practices. However, as this study highlights, there may be a mismatch between the IT staff's understandings of how users protect patient privacy and how users actually protect privacy.

Mapping patient path in the Pediatric Emergency Department: A workflow model driven approach

The workflow models of the patient journey in a Pediatric Emergency Department (PED) seems to be an effective approach to develop an accurate and complete representation of the PED processes. This model can drive the collection of comprehensive quantitative and qualitative service delivery and patient treatment data as an evidence base for the PED service planning. Our objective in this study is to identify crowded situation indicators and bottlenecks that contribute to over-crowding. The greatest source of delay in patient flow is the waiting time from the health care request, and especially the bed request to exit from the PED for hospital admission. It represented 70% of the time that these patients occupied in the PED waiting rooms. The use of real data to construct the workflow model of the patient path is effective in identifying sources of delay in patient flow, and aspects of the PED activity that could be improved. The development of this model was based on accurate visits made in the PED of the Regional University Hospital Center (CHRU) of Lille (France). This modeling, which has to represent most faithfully possible the reality of the PED of CHRU of Lille, is necessary. It must be detailed enough to produce an analysis allowing to identify the dysfunctions of the PED and also to propose and to estimate prevention indicators of crowded situations. Our survey is integrated into the French National Research Agency (ANR) project, titled: "Hospital: Optimization, Simulation and avoidance of strain" (HOST).

Implementation and evaluation of an integrated computerized asthma management system in a pediatric emergency department: a randomized clinical trial

OBJECTIVE

The use of evidence-based guidelines can improve the care for asthma patients. We implemented a computerized asthma management system in a pediatric emergency department (ED) to integrate national guidelines. Our objective was to determine whether patient eligibility identification by a probabilistic disease detection system (Bayesian network) combined with an asthma management system embedded in the workflow decreases time to disposition decision.

METHODS

We performed a prospective, randomized controlled trial in an urban, tertiary care pediatric ED. All patients 2-18 years of age presenting to the ED between October 2010 and February 2011 were screened for inclusion by the disease detection system. Patients identified to have an asthma exacerbation were randomized to intervention or control. For intervention patients, asthma management was computer-driven and workflow-integrated including computer-based asthma scoring in triage, and time-driven display of asthma-related reminders for re-scoring on the electronic patient status board combined with guideline-compliant order sets. Control patients received standard asthma management. The primary outcome measure was the time from triage to disposition decision.

RESULTS

The Bayesian network identified 1339 patients with asthma exacerbations, of which 788 had an asthma diagnosis determined by an ED physician-established reference standard (positive predictive value 69.9%). The median time to disposition decision did not differ among the intervention (228 min; IQR=(141, 326)) and control group (223 min; IQR=(129, 316)); (p=0.362). The hospital admission rate was unchanged between intervention (25%) and control groups (26%); (p=0.867). ED length of stay did not differ among intervention (262 min; IQR=(165, 410)) and control group (247 min; IQR=(163, 379)); (p=0.818).

CONCLUSIONS

The control and intervention groups were similar in regards to time to disposition; the computerized management system did not add additional wait time. The time to disposition decision did not change; however the management system integrated several different information systems to support clinicians' communication.

Effects of electronic emergency-department whiteboards on clinicians' time distribution and mental workload

Whiteboards are a central tool at emergency departments. We investigate how the substitution of electronic for dry-erase whiteboards affects emergency department clinicians' mental workload and distribution of their time. With the electronic whiteboard, physicians and nurses spend more of their time in the work areas where other clinicians are present and whiteboard information is permanently displayed, and less in the patient rooms. Main reasons for these changes appear to be that the electronic whiteboard facilitates better timeouts and handovers. Physicians and nurses are, however, in the patient rooms for longer periods at a time, suggesting a more focused patient contact. The physicians' mental workload has increased during timeouts, whereas the nurses' mental workload has decreased at the start of shifts when they form an overview of the emergency department. Finally, the secretaries, but neither physicians nor nurses, access whiteboard information on computers other than the permanent displays.

Designing privacy-friendly digital whiteboards for mediation of clinical progress

BACKGROUND

In hospitals, digital versions of dry-erase whiteboards are increasingly becoming more common. One of the purposes with such whiteboards is to support coordination of care by augmenting visibility and availability of clinical information. However, clinical information usually concerns patients and is regarded as sensitive personal health information, meaning that it should be access controlled. The purpose of this study is to explore how digital whiteboards can be designed for supporting coordination of care, by providing clinicians with useful information in a usable way, and at the same time protect patient privacy.

METHODS

A demo application was designed, demonstrated and evaluated iteratively. In total, 15 professional ward nurses role-played a scenario in which the application played a central part. Afterwards, the participants were interviewed. All interviews were recorded, transcribed verbatim, and analysed qualitatively.

RESULTS

The participants valued having updated clinical information presented on a digital whiteboard, even if the information was de-identified and abstracted. According to the participants, such information could possibly improve inter-departmental communication, reduce the number of electronic health record-logins, and make nurses more rapidly aware of new information. The participants expected that they would be able to re-identify much of the de-identified information in real situations based on their insight into their patients' recent and expected care activities. Moreover, they also valued being able to easily access more detailed information and verify patient identities. While abstraction and de-identification was regarded to sufficiently protect the patients' privacy, the nurses also pointed out the importance of having control over what can be seen by other patients and passers-by if detailed medical information was accessed on a digital whiteboard.

CONCLUSIONS

Presenting updated information from patient care activities on a digital whiteboard in a de-identified and abstracted format may support coordination of care at a hospital ward without compromising patient privacy.

Validation of the Confusion Assessment Method for the Intensive Care Unit in older emergency department patients

OBJECTIVES

In the emergency department (ED), health care providers miss delirium approximately 75% of the time, because they do not routinely screen for this syndrome. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is a brief (<1 minute) delirium assessment that may be feasible for use in the ED. The study objective was to determine its validity and reliability in older ED patients.

METHODS

In this prospective observational cohort study, patients aged 65 years or older were enrolled at an academic, tertiary care ED from July 2009 to February 2012. An emergency physician (EP) and research assistants (RAs) performed the CAM-ICU. The reference standard for delirium was a comprehensive (~30 minutes) psychiatrist assessment using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria. All assessments were blinded to each other and were conducted within 3 hours. Sensitivities, specificities, and likelihood ratios were calculated for both the EP and the RAs using the psychiatrist's assessment as the reference standard. Kappa values between the EP and RAs were also calculated to measure reliability.

RESULTS

Of 406 patients enrolled, 50 (12.3%) had delirium. The median age was 73.5 years old (interquartile range [IQR] = 69 to 80 years), 202 (49.8%) were female, and 57 (14.0%) were nonwhite. The CAM-ICU's sensitivities were 72.0% (95% confidence interval [CI] = 58.3% to 82.5%) and 68.0% (95% CI = 54.2% to 79.2%) in the EP and RAs, respectively. The CAM-ICU's specificity was 98.6% (95% CI = 96.8% to 99.4%) for both raters. The negative likelihood ratios (LR-) were 0.28 (95% CI = 0.18 to 0.44) and 0.32 (95% CI = 0.22 to 0.49) in the EP and RAs, respectively. The positive likelihood ratios (LR+) were 51.3 (95% CI = 21.1 to 124.5) and 48.4 (95% CI = 19.9 to 118.0), respectively. The kappa between the EP and RAs was 0.92 (95% CI = 0.85 to 0.98), indicating excellent interobserver reliability.

CONCLUSIONS

In older ED patients, the CAM-ICU is highly specific, and a positive test is nearly diagnostic for delirium when used by both the EP and RAs. However, the CAM-ICU's sensitivity was modest, and a negative test decreased the likelihood of delirium by a small amount. The consequences of a false-negative CAM-ICU are unknown and deserve further study.

Digital video analysis of health professionals' interactions with an electronic whiteboard: a longitudinal, naturalistic study of changes to user interactions

As hospital departments continue to introduce electronic whiteboards in real clinical settings a range of human factor issues have emerged and it has become clear that there is a need for improved methods for designing and testing these systems. In this study, we employed a longitudinal and naturalistic method in the usability evaluation of an electronic whiteboard system. The goal of the evaluation was to explore the extent to which usability issues experienced by users change as they gain more experience with the system. In addition, the paper explores the use of a new approach to collection and analysis of continuous digital video recordings of naturalistic "live" user interactions. The method developed and employed in the study included recording the users' interactions with system during actual use using screen-capturing software and analyzing these recordings for usability issues. In this paper we describe and discuss both the method and the results of the evaluation. We found that the electronic whiteboard system contains system-related usability issues that did not change over time as the clinicians collectively gained more experience with the system. Furthermore, we also found user-related issues that seemed to change as the users gained more experience and we discuss the underlying reasons for these changes. We also found that the method used in the study has certain advantages over traditional usability evaluation methods, including the ability to collect analyze live user data over time. However, challenges and drawbacks to using the method (including the time taken for analysis and logistical issues in doing live recordings) should be considered before utilizing a similar approach. In conclusion we summarize our findings and call for an increased focus on longitudinal and naturalistic evaluations of health information systems and encourage others to apply and refine the method utilized in this study.

Diagnosing delirium in older emergency department patients: validity and reliability of the delirium triage screen and the brief confusion assessment method

STUDY OBJECTIVE

Delirium is a common form of acute brain dysfunction with prognostic significance. Health care professionals caring for older emergency department (ED) patients miss delirium in approximately 75% of cases. This error results from a lack of available measures that can be performed rapidly enough to be incorporated into clinical practice. Therefore, we developed and evaluated a novel 2-step approach to delirium surveillance for the ED.

METHODS

This prospective observational study was conducted at an academic ED in patients aged 65 years or older. A research assistant and physician performed the Delirium Triage Screen (DTS), designed to be a highly sensitive rule-out test, and the Brief Confusion Assessment Method (bCAM), designed to be a highly specific rule-in test for delirium. The reference standard for delirium was a comprehensive psychiatrist assessment using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria. All assessments were independently conducted within 3 hours of one another. Sensitivities, specificities, and likelihood ratios with their 95% confidence intervals (95% CIs) were calculated.

RESULTS

Of 406 enrolled patients, 50 (12.3%) had delirium diagnosed by the psychiatrist reference standard. The DTS was 98.0% sensitive (95% CI 89.5% to 99.5%), with an expected specificity of approximately 55% for both raters. The DTS's negative likelihood ratio was 0.04 (95% CI 0.01 to 0.25) for both raters. As the complement, the bCAM had a specificity of 95.8% (95% CI 93.2% to 97.4%) and 96.9% (95% CI 94.6% to 98.3%) and a sensitivity of 84.0% (95% CI 71.5% to 91.7%) and 78.0% (95% CI 64.8% to 87.2%) when performed by the physician and research assistant, respectively. The positive likelihood ratios for the bCAM were 19.9 (95% CI 12.0 to 33.2) and 25.2 (95% CI 13.9 to 46.0), respectively. If the research assistant DTS was followed by the physician bCAM, the sensitivity of this combination was 84.0% (95% CI 71.5% to 91.7%) and specificity was 95.8% (95% CI 93.2% to 97.4%). If the research assistant performed both the DTS and bCAM, this combination was 78.0% sensitive (95% CI 64.8% to 87.2%) and 97.2% specific (95% CI 94.9% to 98.5%). If the physician performed both the DTS and bCAM, this combination was 82.0% sensitive (95% CI 69.2% to 90.2%) and 95.8% specific (95% CI 93.2% to 97.4%).

CONCLUSION

In older ED patients, this 2-step approach (highly sensitive DTS followed by highly specific bCAM) may enable health care professionals, regardless of clinical background, to efficiently screen for delirium. Larger, multicenter trials are needed to confirm these findings and to determine the effect of these assessments on delirium recognition in the ED.

Work-practice changes associated with an electronic emergency department whiteboard

Electronic whiteboards are introduced at emergency departments (EDs) to improve work practices. This study investigates whether the time physicians and nurses at an ED spend in patient rooms versus at the control desk increases after the introduction of an electronic whiteboard. After using this whiteboard for four months nurses, but not physicians, spend more of their time with the patients. With the electronic whiteboard, nurses spend 28% of their time in patient rooms and physicians 20%. Importantly, the changes facilitated by the electronic whiteboard are also dependent on implementation issues, existing work practices and the clinicians' experience. Another change in the work practices is distributed access to whiteboard information from the computers in patient rooms. A decrease in the mental workload of the coordinating nurse was envisaged but has not emerged. Achieving more changes appears to require an increase in whiteboard functionality and a firmer grip on the implementation process.

Modifications and integration of the electronic tracking board in a pediatric emergency department

Electronic health records (EHRs) are used for data storage; provider, laboratory, and patient communication; clinical decision support; procedure and medication orders; and decision support alerts. Clinical decision support is part of any EHR and is designed to help providers make better decisions. The emergency department (ED) poses a unique environment to the use of EHRs and clinical decision support. Used effectively, computerized tracking boards can help improve flow, communication, and the dissemination of pertinent visit information between providers and other departments in a busy ED. We discuss the unique modifications and decisions made in the implementation of an EHR and computerized tracking board in a pediatric ED. We discuss the changing views based on provider roles, customization to the user interface including the layout and colors, decision support, tracking board best practices collected from other institutions and colleagues, and a case study of using reminders on the electronic tracking board to drive pain reassessments.

The hazard of software updates to clinical workstations: a natural experiment

Emergency department (ED) electronic tracking boards provide a snapshot view of patient status and a quick link to other clinical applications, such as a web-based image viewer client to view current and previous radiology images from the picture archiving and communication systems (PACS). We describe a case where an update to Microsoft Internet Explorer severed the link between the ED tracking board and web-based image viewer. The loss of this link resulted in decreased web-based image viewer access rates for ED patients during the 10 days of the incident (2.8 views/study) compared with image review rates for a similar 10-day period preceding this event (3.8 views/study, p<0.001). Single-click user interfaces that transfer user and patient contexts are efficient mechanisms to link disparate clinical systems. Maintaining hazard analyses and rigorously testing all software updates to clinical workstations, including seemingly minor web-browser updates, are important to minimize the risk of unintended consequences.

The pursuit of better diagnostic performance: a human factors perspective

Despite the relatively slow start in treating diagnostic error as an amenable research topic at the beginning of the patient safety movement, interest has steadily increased over the past few years in the form of solicitations for research, regularly scheduled conferences, an expanding literature and even a new professional society. Yet improving diagnostic performance increasingly is recognised as a multifaceted challenge. With the aid of a human factors perspective, this paper addresses a few of these challenges, including questions that focus on who owns the problem, treating cognitive and system shortcomings as separate issues, why knowledge in the head is not enough, and what we are learning from health information technology (IT) and the use of checklists. To encourage empirical testing of interventions that aim to improve diagnostic performance, a systems engineering approach making use of rapid-cycle prototyping and simulation is proposed. To gain a fuller understanding of the complexity of the sociotechnical space where diagnostic work is performed, a final note calls for the formation of substantive partnerships with those in disciplines beyond the clinical domain.

An asthma management system in a pediatric emergency department

INTRODUCTION

Pediatric asthma exacerbations account for >1.8 million emergency department (ED) visits annually. Asthma guidelines are intended to guide time-dependent treatment decisions that improve clinical outcomes; however, guideline adherence is inadequate. We examined whether an automatic disease detection system increases clinicians' use of paper-based guidelines and decreases time to a disposition decision.

METHODS

We evaluated a computerized asthma detection system that triggered NHLBI-adopted, evidence-based practice to improve care in an urban, tertiary care pediatric ED in a 3-month (7/09-9/09) prospective, randomized controlled trial. A probabilistic system screened all ED patients for acute asthma. For intervention patients, the system generated the asthma protocol at triage for intervention patients to guide early treatment initiation, while clinicians followed standard processes for control patients. The primary outcome measures included time to patient disposition.

RESULTS

The system identified 1100 patients with asthma exacerbations, of which 704 had a final asthma diagnosis determined by a physician-established reference standard. The positive predictive value for the probabilistic system was 65%. The median time to disposition decision did not differ among the intervention (289 min; IQR = (184, 375)) and control group (288 min; IQR = (185, 375)) (p=0.21). The hospital admission rate was unchanged between intervention (37%) and control groups (35%) (p = 0.545). ED length of stay did not differ among the intervention (331 min; IQR = (226, 581)) and control group (331 min; IQR = (222, 516)) (p = 0.568).

CONCLUSION

Despite a high level of support from the ED leadership and staff, a focused education effort, and implementation of an automated disease detection, the use of the paper-based asthma protocol remained low and time to patient disposition did not change.

ED crowding and the use of nontraditional beds

BACKGROUND AND OBJECTIVES

In an effort to compensate for crowding, many emergency departments (EDs) evaluate and treat patients in nontraditional settings such as gurneys in hallways and conference rooms. The impact of this practice on ED evaluation time is unknown.

RESEARCH DESIGN AND SUBJECTS

A historical cohort of adult ED visits to an academic hospital between August 1, 2009 and August 1, 2010, was used to evaluate the relationship between ED bed assignment (traditional, hallway, or conference room bed) and mean ED evaluation time, defined as the time spent in an ED bed before admission or discharge. Chief complaints were categorized into the 5 most frequent categories: abdominal/genitourinary, joint/muscle, general (fever, malaise), head/neck, and other. Multiple linear regression and marginal prediction were used to calculate the mean ED evaluation times for each bed type, overall, and by chief complaint category.

RESULTS

During the study period, 15 073 patient visits met the inclusion criteria. After adjustment for patient and ED factors, assignments to hallway and conference room beds were associated with increases in a mean ED evaluation time of 13.3 minutes (95% confidence interval, 13.2-13.3) and 10.9 minutes (95% confidence interval, 10.8-10.9), respectively, compared with the traditional bed ED evaluation time. This varied by chief complaint category.

CONCLUSIONS

Use of nontraditional beds is associated with increases in mean ED evaluation time; however, these increases are small and may be further minimized by restricting the use of nontraditional beds to patients with specific chief complaints. Nontraditional beds may have a role in improving ED throughput during times of crowding.

The effect of computerized provider order entry (CPOE) on ordering patterns for chest pain patients in the emergency department

This study addressed the effect of CPOE implementation on chest pain ordering patterns for patients in the emergency department. Retrospective order data was collected to assess the implementation. 300 randomly selected, time matched patients with a chief complaint of chest pain were selected in a before/after study. Patient demographics, treatment and disposition data were collected on clinical orders. Order volume, completeness and completion times were assessed before and after implementation. Overall order volume increased significantly from 11.6 pre-CPOE to 19.9 post-implementation (p<.01). Order documentation deficiencies were noted pre-implementation with 35.6% containing all order elements. Order completion times were unchanged; however, laboratory completion times increased for admitted patients post-implementation. Order volume increased after CPOE implementation, likely due to improved ED-based admission order capture for admitted patients. Order completeness improved significantly including standing order documentation. Overall, CPOE implementation is associated with improved clinical documentation with limited effect on clinical testing turn-around times.

A computerized pneumococcal vaccination reminder system in the adult emergency department

BACKGROUND

Pneumococcal vaccination is an effective strategy to prevent invasive pneumococcal disease in the elderly. Emergency department (ED) visits present an underutilized opportunity to increase vaccination rates; however, designing a sustainable vaccination program in an ED is challenging. We examined whether an information technology supported approach would provide a feasible and sustainable method to increase vaccination rates in an adult ED.

METHODS

During a 1-year period we prospectively evaluated a team-oriented, workflow-embedded reminder system that integrated four different information systems. The computerized triage application screened all patients 65 years and older for pneumococcal vaccine eligibility with information from the electronic patient record. For eligible patients the computerized provider order entry system reminded clinicians to place a vaccination order, which was passed to the order tracking application. Documentation of vaccine administration was then added to the longitudinal electronic patient record. The primary outcome was the vaccine administration rate in the ED. Multivariate logistic regression analysis was used to estimate the odds ratios and their 95% confidence intervals, representing the overall relative risks of ED workload related variables associated with vaccination rate.

RESULTS

Among 3371 patients 65 years old and older screened at triage 1309 (38.8%) were up-to-date with pneumococcal vaccination and 2062 (61.2%) were eligible for vaccination. Of the eligible patients, 621 (30.1%) consented to receive the vaccination during their ED visit. Physicians received prompts for 428 (68.9%) patients. When prompted, physicians declined to order the vaccine in 192 (30.9%) patients, while 222 (10.8%) of eligible patients actually received the vaccine. The computerized reminder system increased vaccination rate from a baseline of 38.8% to 45.4%. Vaccination during the ED visit was associated younger age (OR: 0.972, CI: 0.953-0.991), Caucasian race (OR: 0.329, CI: 0.241-0.448), and longer ED boarding times (OR: 1.039, CI: 1.013-1.065).

CONCLUSION

The integrated informatics solution seems to be a feasible and sustainable model to increase vaccination rates in a challenging ED environment.

Exploring strategies to improve emergency department intake

BACKGROUND

The emergency department (ED) is the point of entry for nearly two-thirds of patients admitted to the average United States (US) hospital. Due to unacceptable waits, 3% of patients will leave the ED without being seen by a physician.

OBJECTIVES

To study intake processes and identify new strategies for improving patient intake.

METHODS

A year-long learning collaborative was created to study innovations involving the intake of ED patients. The collaborative focused on the collection of successful innovations for ED intake for an "improvement competition." Using a qualitative scoring system, finalists were selected and their innovations were presented to the members of the collaborative at an Association for Health Research Quality-funded conference.

RESULTS

Thirty-five departments/organizations submitted abstracts for consideration involving intake innovations, and 15 were selected for presentation at the conference. The innovations were presented to ED leaders, researchers, and policymakers. Innovations were organized into three groups: physical plant changes, technological innovations, and process/flow changes.

CONCLUSION

The results of the work of a learning collaborative focused on ED intake are summarized here as a qualitative review of new intake strategies. Early iterations of these new and unpublished innovations, occurring mostly in non-academic settings, are presented.

Disrupted rhythms and mobile ICT in a surgical department

PURPOSE

This study presents a study of mobile information and communication technology (ICT) for healthcare professionals in a surgical ward. The purpose of the study was to create a participatory design process to investigate factors that affect the acceptance of mobile ICT in a surgical ward.

METHODS

Observations, interviews, a participatory design process, and pilot testing of a prototype of a co-constructed application were used.

RESULTS

Informal rhythms existed at the department that facilitated that people met and interacted several times throughout the day. These gatherings allowed for opportunistic encounters that were extensively used for dialogue, problem solving, coordination, message and logistics handling. A prototype based on handheld mobile computers was introduced. The tool supported information seeking functionality that previously required local mobility. By making the nurses more freely mobile, the tool disrupted these informal rhythms. This created dissatisfaction with the system, and lead to discussion and introduction of other arenas to solve coordination and other problems.

CONCLUSIONS

Mobile ICT tools may break down informal communication and coordination structures. This may reduce the efficiency of the new tools, or contribute to resistance towards such systems. In some situations however such "disrupted rhythms" may be overcome by including additional sociotechnical mechanisms in the overall design to counteract this negative side-effect.

Comparison of extent of use, information accuracy, and functions for manual and electronic patient status boards

PURPOSE

Electronic software packages to support patient tracking and disposition decision making in emergency departments (EDs) are being considered for implementation in many hospitals. We compared extent of use, information accuracy, and functions of manual and electronic patient status boards at 2 EDs where both were continuously in use.

METHODS

Ethnographic observations were conducted at 2 Veterans Affairs Medical Center Emergency Departments using both manual and electronic patient status boards (100 h, 9 physicians at Site 1; 64 h, 14 physicians at Site 2). Data included board information collected at 20-min intervals, observable behavior while using boards, and interviews.

RESULTS

Few physicians (3/9 [33%] Site 1; 0/14 [0%] Site 2) used the e-board, whereas all physicians used the whiteboards. Whiteboards had fewer inaccuracies (6/462 [1%] Site 1; 21/864 [3%] Site 2) than e-boards (62/462 [13%] Site 1; 107/864 [12%] Site 2). The primary functions of the whiteboard were to track real-time changes to patient identifiers, locations, nursing assignments, and pending activities; facilitate patient handoffs; inform physicians and nurses about newly arrived patients assigned to them; inform nurses of physicians' orders; and inform physicians of the status of ordered items. The primary functions of the e-board were to support electronic data entry (by clerks) of patient admitting and departure times; and highlight patients who had been in the ED for longer than 6 h.

CONCLUSIONS

Whiteboards were more extensively used and had greater information accuracy than e-boards. Nevertheless, e-boards provided functionality not easily achievable with whiteboards.

Electronic Medical Records and the Efficiency of Hospital Emergency Departments

This study examined the relationship between electronic medical records (EMR) sophistication and the efficiency of U.S. hospital emergency departments (EDs). Using data from the 2006 National Hospital Ambulatory Medical Care Survey, survey-weighted ordinary least squares regressions were used to estimate the association of EMR sophistication with ED throughput and probability a patient left without treatment. Instrumental variables were used to test for the presence of endogeneity and reverse causality. Greater EMR sophistication had a mixed association with ED efficiency. Relative to EDs with minimal or no EMR, fully functional EMR was associated with 22.4% lower ED length of stay and 13.1% lower diagnosis/treatment time. However, the relationships varied by patient acuity level and diagnostic services provided. Surprisingly, EDs with basic EMR were not more efficient on average, and basic EMR had a nonlinear relationship with efficiency that varied with the number of EMR functions used.

Communication and team situation awareness in the OR: Implications for augmentative information display

Team Situation Awareness (TSA) is one of the critical factors in effective Operating Room (OR) teamwork and can impact patient safety and quality of care. While previous research showed a relationship between situation awareness, as measured by communication events, and team performance, the implications for developing technology to augment and facilitate TSA were not examined. This research aims to further study situation-related communications in the cardiac OR in order to uncover potential degradation in TSA which may lead to adverse events. The communication loop construct-the full cycle of information flow between the participants in the sequence-was used to assess susceptibility to breakdown. Previous research and the findings here suggest that communication loops that are open, non-directed, or with delayed closure, can be susceptible to information loss. These were quantitatively related to communication indicators of TSA such as questions, replies, and announcements. Taken together, both qualitative and quantitative analyses suggest that a high proportion of TSA-related communication (63%) can be characterized as susceptible to information loss. The findings were then used to derive requirements and design a TSA augmentative display. The design principles and potential benefits of such a display are outlined and discussed.

Care coordination in intensive care units: communicating across information spaces

OBJECTIVE

This study explores the interactions among phases of team coordination, patient-related information, decision-making levels, and role holders in intensive care units (ICUs).

BACKGROUND

The effects of communication improvement initiatives on adverse patient events or improved outcomes have been difficult to establish. Conceptual inconsistencies and methodological shortcomings suggest insufficient understanding about clinical communication and care coordination.

METHOD

Data were collected by shadowing a charge nurse, fellow, resident, and nurse in each of eight ICUs and recording each of their conversations during 12 hrs (32 role holders during 350 hrs).

RESULTS

Hierarchical log linear analyses show statistically significant three-way interactions between the patient information, phases of team coordination, and decision levels, chi2(df = 75) = 212, p < .0001; between roles, phases of team coordination, and decision levels, chi2(df = 60) = 109, p < .0001; and between roles, patient information, and decision levels, chi2(df = 60) = 155, p < .0001. Differences among levels of the variables were evaluated with the use of standardized parameter estimates and 95% confidence intervals.

CONCLUSION

ICU communication and care coordination involve complex decision structures and role interactions across two information spaces. Different role holders mediate vertical and lateral process flows with goals and directions representing an important conceptual transition. However, lateral isolation within decision levels (charge nurses) and information overload (residents) are potential communication and care coordination vulnerabilities. Results are consistent with and extend the findings of previous studies.

APPLICATION

The profile of ICU communication and care coordination provides a systemic framework that may inform future interventions and research.