Information Overload in Emergency Medicine Physicians: A Multisite Case Study Exploring the Causes, Impact, and Solutions in Four North England National Health Service Trusts

The role of information systems in emergency department decision-making-a literature review

OBJECTIVES

Healthcare providers employ heuristic and analytical decision-making to navigate the high-stakes environment of the emergency department (ED). Despite the increasing integration of information systems (ISs), research on their efficacy is conflicting. Drawing on related fields, we investigate how timing and mode of delivery influence IS effectiveness. Our objective is to reconcile previous contradictory findings, shedding light on optimal IS design in the ED.

MATERIALS AND METHODS

We conducted a systematic review following PRISMA across PubMed, Scopus, and Web of Science. We coded the ISs' timing as heuristic or analytical, their mode of delivery as active for automatic alerts and passive when requiring user-initiated information retrieval, and their effect on process, economic, and clinical outcomes.

RESULTS

Our analysis included 83 studies. During early heuristic decision-making, most active interventions were ineffective, while passive interventions generally improved outcomes. In the analytical phase, the effects were reversed. Passive interventions that facilitate information extraction consistently improved outcomes.

DISCUSSION

Our findings suggest that the effectiveness of active interventions negatively correlates with the amount of information received during delivery. During early heuristic decision-making, when information overload is high, physicians are unresponsive to alerts and proactively consult passive resources. In the later analytical phases, physicians show increased receptivity to alerts due to decreased diagnostic uncertainty and information quantity. Interventions that limit information lead to positive outcomes, supporting our interpretation.

CONCLUSION

We synthesize our findings into an integrated model that reveals the underlying reasons for conflicting findings from previous reviews and can guide practitioners in designing ISs in the ED.

Supporting nurses in acute and emergency care settings to speak up

Nurses' competence and confidence in raising concerns with senior clinicians is integral to patient safety and the quality of patient care. If nurses do not speak up when needed it can contribute to incidences of failure to rescue. There are many barriers to nurses speaking up in busy emergency departments and complex major trauma patient cases. Assessment and communication tools such as the SBAR (situation, background, assessment, recommendation) approach and communication techniques such as graded assertiveness can help to overcome some of these barriers. This article uses a case study to discuss how nurses can respectfully but efficiently escalate their concerns to the trauma team leader. It describes barriers to nurses speaking up and tools that can support nurses to speak up, with a focus on graded assertiveness.

Digital stressors and resources perceived by emergency physicians and associations to their digital stress perception, mental health, job satisfaction and work engagement

BACKGROUND

Digital technologies are increasingly being integrated into healthcare settings, including emergency departments, with the potential to improve efficiency and patient care. Although digitalisation promises many benefits, the use of digital technologies can also introduce new stressors and challenges among medical staff, which may result in the development of various negative work and health outcomes. Therefore, this study aims to identify existing digital stressors and resources among emergency physicians, examine associations with various work- and health-related parameters, and finally identify the potential need for preventive measures.

METHODS

In this quantitative cross-sectional study, an online questionnaire was used to examine the relationship between digital stressors (technostress creators), digital resources (technostress inhibitors), technostress perception as well as mental health, job satisfaction and work engagement among 204 physicians working in German emergency medicine departments. Data collection lasted from December 2022 to April 2023. Validated scales were used for the questionnaire (e.g. "Technostress"-scale and the Copenhagen Psychosocial Questionnaire (COPSOQ). Descriptive and multiple regression analyses were run to test explorative assumptions.

RESULTS

The study found medium levels of technostress perception among the participating emergency physicians as well as low levels of persisting technostress inhibitors. The queried physicians on average reported medium levels of exhaustion symptoms, high levels of work engagement and job satisfaction. Significant associations between digital stressors and work- as well as health-related outcomes were analyzed.

CONCLUSION

This study provides a preliminary assessment of the persistence of digital stressors, digital resources and technostress levels, and their potential impact on relevant health and work-related outcomes, among physicians working in German emergency departments. Understanding and mitigating these stressors is essential to promote the well-being of physicians and ensure optimal patient care. As digitisation processes will continue to increase, the need for preventive support measures in dealing with technology stressors is obvious and should be expanded accordingly in the clinics. By integrating such support into everyday hospital life, medical staff in emergency departments can better focus on patient care and mitigate potential stress factors associated with digital technologies.

Machine learning in clinical practice: Evaluation of an artificial intelligence tool after implementation

OBJECTIVE

Artificial intelligence (AI) has gradually found its way into healthcare, and its future integration into clinical practice is inevitable. In the present study, we evaluate the accuracy of a novel AI algorithm designed to predict admission based on a triage note after clinical implementation. This is the first of such studies to investigate real-time AI performance in the emergency setting.

METHODS

The novel AI algorithm that predicts admission using a triage note was translated into clinical practice and integrated within St Vincent's Hospital Melbourne's electronic emergency patient management system. The data were collected from 1 January 2021 to 17 August 2022 to evaluate the diagnostic accuracy of the AI system after implementation.

RESULTS

A total of 77 125 ED presentations were included. The live AI algorithm has a sensitivity of 73.1% (95% confidence interval 72.5-73.8), specificity of 74.3% (73.9-74.7), positive predictive value of 50% (49.6-50.4) and negative predictive value of 88.7% (88.5-89) with a total accuracy of 74% (73.7-74.3). The accuracy of the system was at the lowest for admission to psychiatric units (34%) and at the highest for gastroenterology and medical admission (84% and 80%, respectively).

CONCLUSION

Our study showed the diagnostic evaluation of a real-time AI clinical decision-support tool became less accurate than the original. Although real-time sensitivity and specificity of the AI tool was still acceptable as a decision-support tool in the ED, we propose that continuous training and evaluation of AI-enabled clinical support tools in healthcare are conducted to ensure consistent accuracy and performance to prevent inadvertent consequences.

[Should we take into account the informational stress of the medical oncologist?]

Information overload, informational stress and its deleterious consequences constitute a subject of growing interest in the way of work. This is quite well documented among anesthesiologists. Studies have also been carried out on cancer patients or on the general public in terms of cancer prevention. After having defined the concepts and the consequences, we hypothesize the presence of informational stress among medical oncologists. We illustrate this hypothesis regarding adjuvant treatment of breast cancer. Specific studies (qualitative and quantitative ones) would be particularly interesting in oncology.

Experience of Health Care Professionals Using Digital Tools in the Hospital: Qualitative Systematic Review

BACKGROUND

The digitalization of health care has many potential benefits, but it may also negatively impact health care professionals' well-being. Burnout can, in part, result from inefficient work processes related to the suboptimal implementation and use of health information technologies. Although strategies to reduce stress and mitigate clinician burnout typically involve individual-based interventions, emerging evidence suggests that improving the experience of using health information technologies can have a notable impact.

OBJECTIVE

The aim of this systematic review was to collect evidence of the benefits and challenges associated with the use of digital tools in hospital settings with a particular focus on the experiences of health care professionals using these tools.

METHODS

We conducted a systematic literature review following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to explore the experience of health care professionals with digital tools in hospital settings. Using a rigorous selection process to ensure the methodological quality and validity of the study results, we included qualitative studies with distinct data that described the experiences of physicians and nurses. A panel of 3 independent researchers performed iterative data analysis and identified thematic constructs.

RESULTS

Of the 1175 unique primary studies, we identified 17 (1.45%) publications that focused on health care professionals' experiences with various digital tools in their day-to-day practice. Of the 17 studies, 10 (59%) focused on clinical decision support tools, followed by 6 (35%) studies focusing on electronic health records and 1 (6%) on a remote patient-monitoring tool. We propose a theoretical framework for understanding the complex interplay between the use of digital tools, experience, and outcomes. We identified 6 constructs that encompass the positive and negative experiences of health care professionals when using digital tools, along with moderators and outcomes. Positive experiences included feeling confident, responsible, and satisfied, whereas negative experiences included frustration, feeling overwhelmed, and feeling frightened. Positive moderators that may reinforce the use of digital tools included sufficient training and adequate workflow integration, whereas negative moderators comprised unfavorable social structures and the lack of training. Positive outcomes included improved patient care and increased workflow efficiency, whereas negative outcomes included increased workload, increased safety risks, and issues with information quality.

CONCLUSIONS

Although positive and negative outcomes and moderators that may affect the use of digital tools were commonly reported, the experiences of health care professionals, such as their thoughts and emotions, were less frequently discussed. On the basis of this finding, this study highlights the need for further research specifically targeting experiences as an important mediator of clinician well-being. It also emphasizes the importance of considering differences in the nature of specific tools as well as the profession and role of individual users.

TRIAL REGISTRATION

PROSPERO CRD42023393883; https://tinyurl.com/2htpzzxj.

A narrative review of the physiology and health effects of burnout associated with veterinarian-pertinent occupational stressors

Chronic workplace stress and burnout are serious problems in veterinary medicine. Although not classified as a medical condition, burnout can affect sleep patterns and contributes to chronic low grade systemic inflammation, autonomic imbalance, hormonal imbalances and immunodeficiencies, thereby increasing the risks of physical and psychological ill health in affected individuals. Cultural misconceptions in the profession often lead to perceptions of burnout as a personal failure, ideas that healthcare professionals are somehow at lower risk for suffering, and beliefs that affected individuals can or should somehow heal themselves. However, these concepts are antiquated, harmful and incorrect, preventing the design of appropriate solutions for this serious and growing challenge to the veterinary profession. Veterinarians must first correctly identify the nature of the problem and understand its causes and impacts before rational solutions can be implemented. In this first part of two companion reviews, burnout will be defined, pathophysiology discussed, and healthcare and veterinary-relevant occupational stressors that lead to burnout identified.

Routine Versus On-Demand Blood Sampling in Critically Ill Patients: A Systematic Review

OBJECTIVES

We aimed to provide an overview of the current evidence on routine versus on-demand blood sampling in critical care. We assessed the reported proportion of patients exposed to daily routine blood sampling, the tests performed, characteristics associated with more frequent blood sampling, and the reported benefits and harms of routine blood sampling compared with on-demand sampling.

DATA SOURCES

We systematically searched the Cochrane Library, the Excerpta Medica Database, and the Medical Literature Analysis and Retrieval System Online for studies assessing routine versus on-demand blood testing in critically ill patients from inception to September 2022.

STUDY SELECTION

Abstracts and full texts were assessed independently and in duplicate by two reviewers.

STUDY EXTRACTION

Data were extracted independently and in duplicate by two reviewers using predefined extraction forms.

DATA SYNTHESIS

Of 12,212 records screened, 298 full-text articles were assessed for eligibility. We included 70 studies; 50 nonrandomized interventional studies and 20 observational studies. Exposure to routine blood testing was 52-100% (very low certainty of evidence). Blood testing seemed to occur more frequently in medical intensive care settings with a median of 18 blood tests per patient day (interquartile range, 10-33) (very low certainty of evidence). Mixed biochemistry seemed to be the most frequently performed blood tests across all settings (five tests per patient day; interquartile range, 2-10) (very low certainty of evidence). Reductions in routine blood testing seemed to be associated with reduced transfusion rates and costs without apparent adverse patient outcomes (low certainty of evidence).

CONCLUSIONS

In this systematic review, routine blood testing in critically ill patients was common and varied considerably. A reduction in routine blood testing appeared to be associated with reduced transfusion rates and costs without adverse effects, but the evidence was very uncertain.

The safety risk of information overload and bureaucracy in oncology clinical trial conduct

Performance of clinical trials has led to major therapeutic developments and substantial improvements in the field of medical oncology. To ensure patient's safety, regulatory aspects for proper clinical trial conduct have been increased over the past two decades but seem to cause information overload and ineffective bureaucracy, possibly even impacting patient safety. To put this in perspective, after the implementation of Directive 2001/20/EC in the European Union, a 90 per cent increase in trial launching time, a 25 per cent decrease in patient participation and a 98 per cent rise in administrative trial costs were reported. The time to initiate a clinical trial has increased from a few months to several years in the past three decades. Moreover, there is a serious risk that information overload with relatively unimportant data endangers the decision-making processes and distracts from essential patient safety information. It is now a critical moment in time to improve efficient clinical trial conduct for our future patients diagnosed with cancer. We are convinced that a reduction of the administrative regulations, information overload, and simplification of the procedures for trial conductance may improve patient safety. In this Current Perspective, we give insight in the current regulatory aspects of clinical research, evaluate the practical consequences of these regulations, and propose specific improvements for optimal clinical trial conduct.

Neurocardiovascular coupling in congenital diaphragmatic hernia patients undergoing different types of surgical treatment

BACKGROUND

The effect of peri-operative management on the neonatal brain is largely unknown. Triggers for perioperative brain injury might be revealed by studying changes in neonatal physiology peri-operatively.

OBJECTIVE

To study neonatal pathophysiology and cerebral blood flow regulation peri-operatively using the neuro-cardiovascular graph.

DESIGN

Observational, prospective cohort study on perioperative neuromonitoring. Neonates were included between July 2018 and April 2020.

SETTING

Multicentre study in two high-volume tertiary university hospitals.

PATIENTS

Neonates with congenital diaphragmatic hernia were eligible if they received surgical treatment within the first 28 days of life. Exclusion criteria were major cardiac or chromosomal anomalies, or syndromes associated with altered cerebral perfusion or major neurodevelopmental impairment. The neonates were stratified into different groups by type of peri-operative management.

INTERVENTION

Each patient was monitored using near-infrared spectroscopy and EEG in addition to the routine peri-operative monitoring. Neurocardiovascular graphs were computed off-line.

MAIN OUTCOME MEASURES

The primary endpoint was the difference in neurocardiovascular graph connectivity in the groups over time.

RESULTS

Thirty-six patients were included. The intraoperative graph connectivity decreased in all patients operated upon in the operation room (OR) with sevoflurane-based anaesthesia ( P  < 0.001) but remained stable in all patients operated upon in the neonatal intensive care unit (NICU) with midazolam-based anaesthesia. Thoracoscopic surgery in the OR was associated with the largest median connectivity reduction (0.33 to 0.12, P  < 0.001) and a loss of baroreflex and neurovascular coupling. During open surgery in the OR, all regulation mechanisms remained intact. Open surgery in the NICU was associated with the highest neurovascular coupling values.

CONCLUSION

Neurocardiovascular graphs provided more insight into the effect of the peri-operative management on the pathophysiology of neonates undergoing surgery. The neonate's clinical condition as well as the surgical and the anaesthesiological approach affected the neonatal physiology and CBF regulation mechanisms at different levels.

TRIAL REGISTRATION

NL6972, URL: https://www.trialre-gister.nl/trial/6972 .

The Mediating Role of Patients' Trust Between Web-Based Health Information Seeking and Patients' Uncertainty in China: Cross-sectional Web-Based Survey

BACKGROUND

In the physician-patient relationship, patients' uncertainty about diseases and the lack of trust in physicians not only hinder patients' rehabilitation but also disrupt the harmony in this relationship. With the development of the web-based health industry, patients can easily access web-based information about health care and physicians, thus reducing patients' uncertainty to some extent. However, it is not clear how patients' web-based health information-seeking behaviors reduce their uncertainty.

OBJECTIVE

On the basis of the principal-agent theory and the perspective of uncertainty reduction, this study aims to investigate the mechanism of how web-based disease-related information and web-based physician-related information reduce patients' uncertainty.

METHODS

A web-based survey involving 337 participants was conducted. In this study, we constructed a structural equation model and used SmartPLS (version 3.3.3; SmartPLS GmbH) software to test the reliability and validity of the measurement model. The path coefficients of the structural model were also calculated to test our hypotheses.

RESULTS

By classifying patients' uncertainties into those concerning diseases and those concerning physicians, this study identified the different roles of the two types of patients' uncertainty and revealed that web-based disease-related information quality and web-based physician-related information can act as uncertainty mitigators. The quality of disease-related information reduces patients' perceived information scarcity about the disease (β=-.588; P<.001), and the higher the information scarcity perceived by patients, the higher their uncertainty toward the disease (β=.111; P=.02). As for physician-related information, web-based word-of-mouth information about physicians reduces patients' perceived information scarcity about the physician (β=-.511; P<.001), mitigates patients' fears about physician opportunism (β=-.268; P<.001), and facilitates patients' trust (β=.318; P<.001). These factors further influence patients' uncertainty about the physician. In addition, from the test of mediating effect, patients' trust in the physician fully mediates the relationship between their perceived information scarcity about the physician's medical service and their uncertainty about the physician. Patients' trust also partially mediates the relationship between their fear of the physician's opportunism and their uncertainty about the physician. As for the two different types of uncertainty, patients' uncertainty about the physician also increases their uncertainty about the diseases (β=.587; P<.001).

CONCLUSIONS

This study affirms the role of disease-related web-based information quality and physician-related web-based word-of-mouth information in reducing patients' uncertainties. With regard to the traits of principal-agent relationships, this study describes the influence mechanism based on patients' perceived information scarcity, fears of physicians' opportunism, and patients' trust. Moreover, information about physicians is effective in reducing patients' uncertainties, but only if the information enhances patients' trust in their physicians. This research generates new insights into understanding the impact of web-based health information on patients' uncertainties.

Requirements for bespoke ICU Dashboard in response to the COVID-19 Pandemic

Background

Intensive care units (ICUs) around the world are in high demand due to patients with COVID-19 requiring hospitalization. As researchers at the University of Bristol, we were approached to develop a bespoke data visualization dashboard to assist two local ICUs during the pandemic that will centralize disparate data sources in the ICU to help reduce the cognitive load on busy ICU staff in the ever-evolving pandemic.

Objective

The aim of this study was to conduct interviews with ICU staff in University Hospitals Bristol and Weston National Health Service Foundation Trust to elicit requirements for a bespoke dashboard to monitor the high volume of patients, particularly during the COVID-19 pandemic.

Methods

We conducted six semistructured interviews with clinical staff to obtain an overview of their requirements for the dashboard and to ensure its ultimate suitability for end users. Interview questions aimed to understand the job roles undertaken in the ICU, potential uses of the dashboard, specific issues associated with managing COVID-19 patients, key data of interest, and any concerns about the introduction of a dashboard into the ICU.

Results

From our interviews, we found the following design requirements: (1) a flexible dashboard, where the functionality can be updated quickly and effectively to respond to emerging information about the management of this new disease; (2) a mobile dashboard, which allows staff to move around on wards with a dashboard, thus potentially replacing paper forms to enable detailed and consistent data entry; (3) a customizable and intuitive dashboard, where individual users would be able to customize the appearance of the dashboard to suit their role; (4) real-time data and trend analysis via informative data visualizations that help busy ICU staff to understand a patient’s clinical trajectory; and (5) the ability to manage tasks and staff, tracking both staff and patient movements, handovers, and task monitoring to ensure the highest quality of care.

Conclusions

The findings of this study confirm that digital solutions for ICU use would potentially reduce the cognitive load of ICU staff and reduce clinical errors at a time of notably high demand of intensive health care.

A randomized controlled trial for evaluating the impact of integrating a computerized clinical decision support system and a socially assistive humanoid robot into grand rounds during pre/post-operative care

Although clinical decision support systems (CDSSs) are increasingly emphasized as one of the possible levers for improving care, they are still not widely used due to different barriers, such as doubts about systems’ performance, their complexity and poor design, practitioners’ lack of time to use them, poor computer skills, reluctance to use them in front of patients, and deficient integration into existing workflows. While several studies on CDSS exist, there is a need for additional high-quality studies using large samples and examining the differences between outcomes following a decision based on CDSS support and those following decisions without this kind of information. Even less is known about the effectiveness of a CDSS that is delivered during a grand round routine and with the help of socially assistive humanoid robots (SAHRs). In this study, 200 patients will be randomized into a Control Group (i.e. standard care) and an Intervention Group (i.e. standard care and novel CDSS delivered via a SAHR). Health care quality and Quality of Life measures will be compared between the two groups. Additionally, approximately 22 clinicians, who are also active researchers at the University Clinical Center Maribor, will evaluate the acceptability and clinical usability of the system. The results of the proposed study will provide high-quality evidence on the effectiveness of CDSS systems and SAHR in the grand round routine.

Rate of change in investigational treatment options: An analysis of reports from a large precision oncology decision support effort

PURPOSE

Genomic analysis of individual patients is now affordable, and therapies targeting specific molecular aberrations are being tested in clinical trials. Genomically-informed therapy is relevant to many clinical domains, but is particularly applicable to cancer treatment. However, even specialized clinicians need help to interpret genomic data, to navigate the complicated space of clinical trials, and to keep up with the rapidly expanding biomedical literature. To quantitate the cognitive load on treating clinicians, we attempt to quantitate the rate of change in potential treatment options for patients considering genomically-relevant and genomically-selected therapy for cancer.

MATERIALS AND METHODS

To this end, we analyzed patient-specific reports generated by a precision oncology decision support team (PODS) at a large academic cancer center. Two types of potential treatment options were analyzed: FDA-approved genomically-relevant and genomically-selected therapies and therapies available via clinical trials. We focused on two clinically-actionable alterations: ERBB2 (Her2/neu; amplified vs. non-amplified) and BRAF mutation (V600 vs. non-V600). To determine changes in available treatment options, we grouped patients into similar groups by disease site (ERBB2: breast, gastric and "other"; BRAF: melanoma, non-melanoma).

RESULTS

A total of 2927 reports for 2366 unique patients were generated 8/2016-12/2018. Reports included 9902 gene variants and 150 disease classifications. BRAF mutation and ERBB2 amplification were annotated with therapeutic options in 270 reports (225 unique patients). The median survival time of a therapeutic option was nine months.

CONCLUSION

When compared to "traditional" clinical practice guideline recommendations, treatment options for personalized cancer therapy change seven times more rapidly; partly due to change in knowledge and partly due to logistics such as clinical trial availability.