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Warstadt NM, Caldwell JR, Tang N, Mandola S, Jamin C, Dahn C. Quality initiative to improve emergency department sepsis bundle compliance through utilisation of an electronic health record tool. BMJ Open Qual 2022; 11:bmjoq-2021-001624. [PMID: 34992053 PMCID: PMC8739442 DOI: 10.1136/bmjoq-2021-001624] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 12/10/2021] [Indexed: 12/23/2022] Open
Abstract
Introduction Sepsis is a common cause of emergency department (ED) presentation and hospital admission, accounting for a disproportionate number of deaths each year relative to its incidence. Sepsis outcomes have improved with increased recognition and treatment standards promoted by the Surviving Sepsis Campaign. Due to delay in recognition and other barriers, sepsis bundle compliance remains low nationally. We hypothesised that a targeted education intervention regarding use of an electronic health record (EHR) tool for identification and management of sepsis would lead to increased EHR tool utilisation and increased sepsis bundle compliance. Methods We created a multidisciplinary quality improvement team to provide training and feedback on EHR tool utilisation within our ED. A prospective evaluation of the rate of EHR tool utilisation was monitored from June through December 2020. Simultaneously, we conducted two retrospective cohort studies comparing overall sepsis bundle compliance for patients when EHR tool was used versus not used. The first cohort was all patients with intention-to-treat for any sepsis severity. The second cohort of patients included adult patients with time of recognition of sepsis in the ED admitted with a diagnosis of severe sepsis or septic shock. Results EHR tool utilisation increased from 23.3% baseline prior to intervention to 87.2% during the study. In the intention-to-treat cohort, there was a statistically significant difference in compliance between EHR tool utilisation versus no utilisation in overall bundle compliance (p<0.001) and for several individual components: initial lactate (p=0.009), repeat lactate (p=0.001), timely antibiotics (p=0.031), blood cultures before antibiotics (p=0.001), initial fluid bolus (p<0.001) and fluid reassessment (p<0.001). In the severe sepsis and septic shock cohort, EHR tool use increased from 71.2% pre-intervention to 85.0% post-intervention (p=0.008). Conclusion With training, feedback and EHR optimisation, an EHR tool can be successfully integrated into current workflows and appears to increase sepsis bundle compliance.
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Affiliation(s)
- Nicholus Michael Warstadt
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - J Reed Caldwell
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Nicole Tang
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Staci Mandola
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Catherine Jamin
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York, USA.,Divison of Critical Care Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Cassidy Dahn
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York, USA .,Divison of Critical Care Medicine, New York University Grossman School of Medicine, New York, New York, USA
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Sibbald M, Monteiro S, Sherbino J, LoGiudice A, Friedman C, Norman G. Should electronic differential diagnosis support be used early or late in the diagnostic process? A multicentre experimental study of Isabel. BMJ Qual Saf 2021; 31:426-433. [PMID: 34611040 PMCID: PMC9132870 DOI: 10.1136/bmjqs-2021-013493] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 09/09/2021] [Indexed: 12/17/2022]
Abstract
Background Diagnostic errors unfortunately remain common. Electronic differential diagnostic support (EDS) systems may help, but it is unclear when and how they ought to be integrated into the diagnostic process. Objective To explore how much EDS improves diagnostic accuracy, and whether EDS should be used early or late in the diagnostic process. Setting 6 Canadian medical schools. A volunteer sample of 67 medical students, 62 residents in internal medicine or emergency medicine, and 61 practising internists or emergency medicine physicians were recruited in May through June 2020. Intervention Participants were randomised to make use of EDS either early (after the chief complaint) or late (after the complete history and physical is available) in the diagnostic process while solving each of 16 written cases. For each case, we measured the number of diagnoses proposed in the differential diagnosis and how often the correct diagnosis was present within the differential. Results EDS increased the number of diagnostic hypotheses by 2.32 (95% CI 2.10 to 2.49) when used early in the process and 0.89 (95% CI 0.69 to 1.10) when used late in the process (both p<0.001). Both early and late use of EDS increased the likelihood of the correct diagnosis being present in the differential (7% and 8%, respectively, both p<0.001). Whereas early use increased the number of diagnostic hypotheses (most notably for students and residents), late use increased the likelihood of the correct diagnosis being present in the differential regardless of one’s experience level. Conclusions and relevance EDS increased the number of diagnostic hypotheses and the likelihood of the correct diagnosis appearing in the differential, and these effects persisted irrespective of whether EDS was used early or late in the diagnostic process.
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Affiliation(s)
- Matt Sibbald
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sandra Monteiro
- Department of Health Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Jonathan Sherbino
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Geoffrey Norman
- Department of Health Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Bange EM, Courtright KR, Parikh RB. Implementing automated prognostic models to inform palliative care: more than just the algorithm. BMJ Qual Saf 2021; 30:775-778. [PMID: 34001650 DOI: 10.1136/bmjqs-2021-013510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2021] [Indexed: 12/14/2022]
Affiliation(s)
- Erin M Bange
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Penn Center for Cancer Care Innovation, Abramson Cancer Center, Philadelphia, Pennsylvania, USA
| | - Katherine R Courtright
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ravi B Parikh
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA .,Penn Center for Cancer Care Innovation, Abramson Cancer Center, Philadelphia, Pennsylvania, USA.,Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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Baker M, Jaeger C, Hafley C, Waymack J. Appropriate CT cervical spine utilisation in the emergency department. BMJ Open Qual 2020; 9:bmjoq-2019-000844. [PMID: 33028655 PMCID: PMC7542617 DOI: 10.1136/bmjoq-2019-000844] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 07/30/2020] [Accepted: 09/18/2020] [Indexed: 12/03/2022] Open
Abstract
Introduction Over 40 000 CT scans are performed in our emergency department (ED) annually and utilisation is over 80% capacity. Improving medical appropriateness of CT scans may reduce total number of scans, time, cost and radiation exposure. Methods Lean Six Sigma methodology was used to improve the process. A National Emergency X-Radiography Utilisation Study (NEXUS)-based PowerForm was implemented in the electronic health record and providers were educated on the criteria. Results The rate of potentially medically inappropriate CT C-spine scans decreased from 45% (19/42) to 22% (90/403) (two-proportion test, p=0.002). After the intervention, there was no longer a difference between midlevel providers and physicians in the rate of medically inappropriate orders (19% vs 22%) (two-proportion test, p=0.850) compared with that before the intervention (56% vs 31%) (two-proportion test, p<0.01). Overall rates of CT C-spine scans ordered decreased from 69.3 to 62.6/week (t-test, p=0.019). Conclusion A validated clinical decision-making tool implemented into the medical record can improve quality of care. This study lays a foundation for other imaging studies with validated support tools with similar potential improvements.
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Affiliation(s)
- Mark Baker
- Department of Emergency Medicine, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Cassie Jaeger
- Department of Operations Improvement, Memorial Health System, Springfield, Illinois, USA
| | - Carol Hafley
- Midwest Healthcare Quality Alliance, Memorial Health System, Springfield, Illinois, USA
| | - James Waymack
- Department of Emergency Medicine, Southern Illinois University School of Medicine, Springfield, Illinois, USA
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Chahal JK, Antoniou S, Earley M, Ali S, Saja K, Singh H, MacCallum PK, Robson J. Preventing strokes in people with atrial fibrillation by improving ABC. BMJ Open Qual 2019; 8:e000783. [PMID: 31803855 PMCID: PMC6887489 DOI: 10.1136/bmjoq-2019-000783] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/04/2019] [Accepted: 10/15/2019] [Indexed: 11/09/2022] Open
Abstract
Nationally, anticoagulation for atrial fibrillation (AF) is improving but remains characterised by marked provider variation. Uncontrolled blood pressure and coronary artery disease further increase cardiovascular risk. Redbridge Clinical Commissioning Group (CCG) and local National Health Service (NHS) hospital trusts supported a programme to improve anticoagulation, blood pressure and cholesterol management; the ABC of AF improvement. The programme was delivered by a clinical pharmacist in 43 general practices, who used Active Patient Link (APL-AF) software to identify and electronically review the records of AF patients potentially suitable for anticoagulation. These patients were invited for a general practitioner (GP)-pharmacist consultation with initiation of anticoagulation where appropriate. Blood pressure and lipid treatment were also optimised. The university-based Clinical Effectiveness Group (CEG) provided software support using standard data entry templates from which the APL-AF software was enabled. This identified suitable patients (eg, on aspirin monotherapy, no treatment or inappropriate dual treatments) for clinical and treatment review. It also reported real-time overall practice performance. Additionally, GP education on direct oral anticoagulant initiation in general practices, use of software and performance reviews, took place for all practices in Redbridge. A weekly multidisciplinary team (MDT) video conference discussed complex patients with a cardiologist, haematologist, GP with specialist interest in cardiology, GP coordinator and clinical pharmacist. This enabled sharing of patient records between GPs and hospital specialists with improved communication and learning. Over 1 year 2016–2017, anticoagulation in eligible AF patients (CHA2DS2-VASc≥2) increased significantly by 6.3% from 77.0% to 83.3% (p<0.0001), in comparison to 2.8% average improvement in England. Exception reporting was also significantly reduced from 10.0% to 5.8%; a reduction of 4.2% in comparison to a reduction in England of 1.5%. Use of antiplatelet monotherapy was approximately halved, from 12.3% to 6.4%. These methods are being scaled locally in other London CCGs and are potentially scalable nationally, specifically targeting the poorer performing CCGs.
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Affiliation(s)
| | - Sotiris Antoniou
- Department of Pharmacy, Barts Health NHS Trust, London, UK.,Academic Health Science Network, UCL Partners, London, UK
| | - Mark Earley
- Department of Cardiology, Barts Health NHS Trust, London, UK
| | - Shabana Ali
- Primary Care & Planned Care, NHS Redbridge Clinical Commissioning Group, London, UK
| | - Khalid Saja
- Department of Haematology, Barking Havering and Redbridge University Hospitals NHS Trust, London, UK
| | - Harjit Singh
- Primary Care & Planned Care, NHS Redbridge Clinical Commissioning Group, London, UK
| | - Peter K MacCallum
- Department of Haematology, Barts Health NHS Trust, London, UK.,Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - John Robson
- Clinical Effectiveness Group, Queen Mary University of London, London, UK
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Zhang H, Huntley J, Bhome R, Holmes B, Cahill J, Gould RL, Wang H, Yu X, Howard R. Effect of computerised cognitive training on cognitive outcomes in mild cognitive impairment: a systematic review and meta-analysis. BMJ Open 2019; 9:e027062. [PMID: 31427316 PMCID: PMC6701629 DOI: 10.1136/bmjopen-2018-027062] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES To determine the effect of computerised cognitive training (CCT) on improving cognitive function for older adults with mild cognitive impairment (MCI). DESIGN Systematic review and meta-analysis. DATA SOURCES PubMed, Embase, Web of Science and the Cochrane Library were searched through January 2018. ELIGIBILITY CRITERIA Randomised controlled trials comparing CCT with control conditions in those with MCI aged 55+ were included. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted data and assessed the risk of bias. Effect sizes (Hedges' g and 95% CIs) were calculated and random-effects meta-analyses were performed where three or more studies investigated a comparable intervention and outcome. Heterogeneity was quantified using the I2 statistic. RESULTS 18 studies met the inclusion criteria and were included in the analyses, involving 690 participants. Meta-analysis revealed small to moderate positive treatment effects compared with control interventions in four domains as follows: global cognitive function (g=0.23, 95% CI 0.03 to 0.44), memory (g=0.30, 95% CI 0.11 to 0.50), working memory (g=0.39, 95% CI 0.12 to 0.66) and executive function (g=0.20, 95% CI -0.03 to 0.43). Statistical significance was reached in all domains apart from executive function. CONCLUSIONS This meta-analysis provides evidence that CCT improves cognitive function in older people with MCI. However, the long-term transfer of these improvements and the potential to reduce dementia prevalence remains unknown. Various methodological issues such as heterogeneity in outcome measures, interventions and MCI symptoms and lack of intention-to-treat analyses limit the quality of the literature and represent areas for future research.
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Affiliation(s)
- Haifeng Zhang
- Division of Psychiatry, University College London, London, UK
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing Dementia Key Lab, Beijing, China
| | | | - Rohan Bhome
- Division of Psychiatry, University College London, London, UK
| | - Benjamin Holmes
- Division of Psychiatry, University College London, London, UK
| | - Jack Cahill
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Rebecca L Gould
- Division of Psychiatry, University College London, London, UK
| | - Huali Wang
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing Dementia Key Lab, Beijing, China
| | - Xin Yu
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing Dementia Key Lab, Beijing, China
| | - Robert Howard
- Division of Psychiatry, University College London, London, UK
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Haque M, Das A, Scott TE, Bates D, Hardman JG. Primary blast lung injury simulator: a new computerised model. J ROY ARMY MED CORPS 2018; 165:45-50. [PMID: 30077974 DOI: 10.1136/jramc-2018-000989] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 05/30/2018] [Accepted: 05/31/2018] [Indexed: 11/03/2022]
Abstract
Mathematical modelling and computational simulation are becoming increasingly important tools in many fields of medicine where in vivo studies are expensive, difficult or impractical. This is particularly the case with primary blast lung injury, and in this paper, we give a brief overview of mathematical models before describing how we generated our blast lung injury simulator and describe some early results of its use.
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Affiliation(s)
- Mainul Haque
- Anaesthesia and Critical Care, School of Medicine, University of Nottingham, Nottingham
| | - A Das
- School of Engineering, University of Warwick, Warwick, UK
| | - T E Scott
- Academic Department of Military Anaesthesia and Critical Care, Ministry of Defence, Birmingham, UK
| | - D Bates
- School of Engineering, University of Warwick, Warwick, UK
| | - J G Hardman
- Anaesthesia and Critical Care, School of Medicine, University of Nottingham, Nottingham
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Snowden A, Kolb H. Two years of unintended consequences: introducing an electronic health record system in a hospice in Scotland. J Clin Nurs 2017; 26:1414-1427. [PMID: 27602553 DOI: 10.1111/jocn.13576] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2016] [Indexed: 12/01/2022]
Abstract
AIMS AND OBJECTIVES To explore the impact of implementing an electronic health record system on staff at a Scottish hospice. BACKGROUND Electronic health records are broadly considered preferable to paper-based systems. However, changing from one system to the other is difficult. This study analysed the impact of this change in a Scottish hospice. DESIGN Naturalistic prospective repeated-measures mixed-methods approach. METHODS Data on the usability of the system, staff engagement and staff experience were obtained at four time points spanning 30 months from inception. Quantitative data were obtained from surveys, and qualitative from concurrent analysis of free-text comments and focus group. Participants were all 150 employees of a single hospice in Scotland. RESULTS Both system usability and staff engagement scores decreased for the first two years before recovering at 30 months. Staff experience data pointed to two main challenges: (1) Technical issues, with subthemes of accessibility and usability. (2) Cultural issues, with subthemes of time, teamwork, care provision and perception of change. CONCLUSIONS It took 30 months for system usability and staff engagement scores to rise, after falling significantly for the first two years. The unintended outcomes of implementation included challenges to the way the patient story was both recorded and communicated. Nevertheless, this process of change was found to be consistent with the 'J-curve' theory of organisational change, and as such, it is both predictable and manageable for other organisations. RELEVANCE TO CLINICAL PRACTICE It is known that implementing an electronic health record system is complex. This paper puts parameters on this complexity by defining both the nature of the complexity ('J' curve) and the time taken for the organisation to begin recovery from the challenges (two years). Understanding these parameters will help health organisations across the world plan more strategically.
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Affiliation(s)
- Austyn Snowden
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
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Abstract
BACKGROUND Asthma quality of life questionnaires are not readily incorporated into clinical care. We therefore computerised the Paediatric Asthma Quality of Life Questionnaire (standardised) (PAQLQ(S)) and the Paediatric Asthma Caregivers Quality of Life Questionnaire (PACQLQ), with a colour-coded printed graphical report. OBJECTIVES To (a) assess the feasibility of the electronic questionnaires in clinical care and (b) compare the child's PAQLQ scores with the parent's score, physician's clinical score and spirometry. METHODS Children with asthma were given a clinical severity score of 1-4 (increasing severity) and then completed the PAQLQ(S) electronically (scores 1-7 for increasing quality of life in emotional, symptoms and activity limitation domains) followed by spirometry and physician review. Parents completed the PACQLQ. Inclusion criteria required fluent Hebrew and reliable performance of spirometry. Children with additional chronic diseases were excluded. RESULTS 147 children with asthma aged 7-17 years completed PAQLQs and 115 accompanying parents completed PACQLQs, taking 8.3 (4.3-15) and 4.4 (1.5-12.7) min, respectively (mean (range)). Graphical reports enabled physicians to address quality of life during even brief visits. Children's (PAQLQ) and parents' (PACQLQ) total scores correlated (r = 0.61, p<0.001), although the children's median emotional score of 6.3 was higher than their parents' 5.7 (p<0.001), whereas median activity limitation score was lower than their parents': 5.0 and 6.8, respectively (p<0.001). No correlation was found with physician's clinical score or spirometry. CONCLUSIONS Electronic PAQLQs are easy to use, providing additional insight to spirometry and physician's assessment, in routine asthma care. Future studies must assess impact on asthma management.
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Affiliation(s)
- H Mussaffi
- Kathy and Lee Graub Cystic Fibrosis Center and Pulmonary Unit, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
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