Jason Slagle

Impact of electronic health record technology on the work and workflow of physicians in the intensive care unit

OBJECTIVEnTo assess the impact of EHR technology on the work and workflow of ICU physicians and compare time spent by ICU resident and attending physicians on various tasks before and after EHR implementation.nnnDESIGNnEHR technology with electronic order management (CPOE, medication administration and pharmacy system) and physician documentation was implemented in October 2007.nnnMEASUREMENTnWe collected a total of 289 h of observation pre- and post-EHR implementation. We directly observed the work of residents in three ICUs (adult medical/surgical ICU, pediatric ICU and neonatal ICU) and attending physicians in one ICU (adult medical/surgical ICU).nnnRESULTSnEHR implementation had an impact on the time distribution of tasks as well as the temporal patterns of tasks. After EHR implementation, both residents and attending physicians spent more of their time on clinical review and documentation (40% and 55% increases, respectively). EHR implementation also affected the frequency of switching between tasks, which increased for residents (from 117 to 154 tasks per hour) but decreased for attendings (from 138 to 106 tasks per hour), and the temporal flow of tasks, in particular around what tasks occurred before and after clinical review and documentation. No changes in the time spent in conversational tasks or the physical care of the patient were observed.nnnCONCLUSIONSnThe use of EHR technology has a major impact on ICU physician work (e.g., increased time spent on clinical review and documentation) and workflow (e.g., clinical review and documentation becoming the focal point of many other tasks). Further studies should evaluate the impact of changes in physician work on the quality of care provided.

The Composition of Intern Work While on Call

ABSTRACTBACKGROUNDThe work of house staff is being increasingly scrutinized as duty hours continue to be restricted.OBJECTIVETo describe the distribution of work performed by internal medicine interns while on call.DESIGNProspective time motion study on general internal medicine wards at a VA hospital affiliated with a tertiary care medical center and internal medicine residency program.PARTICIPANTSInternal medicine interns.MAIN MEASURESTrained observers followed interns during a “call” day. The observers continuously recorded the tasks performed by interns, using customized task analysis software. We measured the amount of time spent on each task. We calculated means and standard deviations for the amount of time spent on six categories of tasks: clinical computer work (e.g., writing orders and notes), non-patient communication, direct patient care (work done at the bedside), downtime, transit and teaching/learning. We also calculated means and standard deviations for time spent on specific tasks within each category. We compared the amount of time spent on the top three categories using analysis of variance.KEY RESULTSThe largest proportion of intern time was spent in clinical computer work (40xa0%). Thirty percent of time was spent on non-patient communication. Only 12xa0% of intern time was spent at the bedside. Downtime activities, transit and teaching/learning accounted for 11xa0%, 5xa0% and 2xa0% of intern time, respectively.CONCLUSIONOur results suggest that during on call periods, relatively small amounts of time are spent on direct patient care and teaching/learning activities. As intern duty hours continue to decrease, attention should be directed towards preserving time with patients and increasing time in education.

The feasibility of text reminders to improve medication adherence in adolescents with asthma

OBJECTIVEnPersonal health applications have the potential to help patients with chronic disease by improving medication adherence, self-efficacy, and quality of life. The goal of this study was to assess the impact of MyMediHealth (MMH) - a website and a short messaging service (SMS)-based reminder system - on medication adherence and perceived self-efficacy in adolescents with asthma.nnnMETHODSnWe conducted a block-randomized controlled study in academic pediatric outpatient settings. There were 98 adolescents enrolled. Subjects who were randomized to use MMH were asked to create a medication schedule and receive SMS reminders at designated medication administration times for 3 weeks. Control subjects received action lists as a part of their usual care. Primary outcome measures included MMH usage patterns and self-reports of system usability, medication adherence, asthma control, self-efficacy, and quality of life.nnnRESULTSnEighty-nine subjects completed the study, of whom 46 were randomized to the intervention arm. Compared to controls, we found improvements in self-reported medication adherence (Pu2009=u2009.011), quality of life (Pu2009=u2009.037), and self-efficacy (Pu2009=u2009.016). Subjects reported high satisfaction with MMH; however, the level of system usage varied widely, with lower use among African American patients.nnnCONCLUSIONSnMMH was associated with improved medication adherence, perceived quality of life, and self-efficacy.Trial Registration This project was registered under http://clinicaltrials.gov/ identifier NCT01730235.

MyMediHealth - Designing a next generation system for child-centered medication management

BACKGROUNDnThe last mile of the medication use system requires tools to help patients comply with medication administration rules and monitor for side effects. Personal health records (PHR) and emerging user-adopted communication tools promise to change the landscape of medication management; however, no research has been done to demonstrate how these tools might be constructed to support children with special healthcare needs. The overarching goal of the MyMediHealth project was to investigate ways in which PHRs and supported applications can improve the safety and quality of medication delivery in this population.nnnDESIGN APPROACHnThis project employed user-centered design to identify requirements for a child-centered medication management system. We collected information through site visits, facilitated group discussions, and iterative design sessions with adult caregivers. Once design requirements were articulated and validated, we constructed an initial prototype medication scheduler, which was evaluated by 202 parents using scripted activities completed using an online interactive prototype. The results of this analysis informed the development of a working prototype.nnnSTATUSnWe have completed a working prototype of a scheduling system, a text-message-based alert and reminder system, and a medication administration record based on web-entered patient data.nnnIMPLICATIONSnPilot testing of the working prototype by stakeholders yielded strong endorsement and helpful feedback for future modifications, which are now underway as a part of an expanded project to test this system in a real-world environment.

Improving actual handover behavior with a simulation-based training intervention

A simulation-based training intervention to improve patient handovers between anesthesia providers (APs) and Post-Anesthesia Care Unit (PACU) nurses (RNs) in adult (VUH) and pediatric (VCH) PACUs, was developed, implemented, and evaluated. The intervention included didactic webinars, an electronic handover report tool, a 2-hour simulation-based training session and a 1-hr “refresher” course several months later. Training focused on interpersonal skills and overcoming obstacles to effective handovers. Trained nurses observed and evaluated 981 actual PACU handovers over 12 months using a standardized rating tool. A different blinded observer scored pre- and post-training simulated handovers. A culture survey was administered before and after the intervention. After training, handover quality improved significantly with more than 70% of handovers rated as “effective” in both PACUs (P<0.001). The training status of the handover giver (AP) was the critical determinant of handover effectiveness. Following full implementation, new (untrained) clinicians performed effective handovers suggesting culture change and/or implicit training.

Assessing Medication Safety Technology in the Intensive Care Unit

Understanding the strengths and weaknesses of a technology in the context of the distributed system in which it is working is critical to assessing and improving the performance of that system. Taking a systems approach requires knowledge about how all agents in a system work together to achieve the goals of that system. With these aims, the alerting mechanism of infusion pumps containing Dose-Error Reduction Software (DERS) was studied to determine its effectiveness in the Intensive Care Units (ICUs) of three hospitals. In 1,146 of the 9,557 pump alerts (12.0%), the alert caused the clinician to change the input. Of these, 1,030 were changed to within the hospitals recommended dosing limits. The alert was overridden for 8,400 (88.0%) of the alerts. The data show that this technology successfully informed clinicians over 1000 times that unintended doses had been inputted and stopped those doses from reaching the patient, thereby averting potential Medication Events. The data also suggest that, because nearly 90% of the alerts were overridden, a well-intended and valuable alert may be perceived by the clinicians as a false alarm and may be overlooked. Another key finding from this analysis was that clinicians may have used potentially unsafe workarounds to administer intravenous drug boluses (i.e., more rapid infusion of a defined dose or volume) and to keep the patients line active between infusions. In a separate parallel study, clinician self-report of potentially harmful medication events was studied. During 559 hours of direct observation, clinicians detected 27 (IV and non-IV) medication events. All of the reported events were outside of the scope of what DERS technology was designed to detect. In addition, during the same time period the technology detected five potentially harmful IV medication events that the clinicians did not report. The results of these two studies indicate two possible classes of solutions that could reduce the impact and likelihood of medication administration errors. One class of solutions involves the procedures and policies of the hospital, ensuring that process and technology implementations are optimally tuned, taking human performance and the current practice of the clinicians into account. The other class of solutions involves using new strategies and technologies to ensure that each system agent has access to other agents perspectives, and the broader systems perspective. Studies such as these can provide insight into the use of safety technology during critical care processes and provide direction for future research, including more effective design of alerting mechanisms of ICU devices.

Simulation Training for Rapid Assessment and Improved Teamwork-Lessons Learned from a Project Evaluating Clinical Handoffs

Effective communication between clinicians is a crucial component of safe care. High-quality communication may be especially critical during care transitions between clinicians (handoffs). In a two-year quasi-experimental Quality Improvement project, we are using simulation learning to evaluate and improve communication between anesthesia providers and nurses as care is transitioned from the operating room to the post-anesthesia care unit (PACU). Using a multiple baseline, staggered entry, prospective cohort design with repeated measures, we are introducing a training intervention and evaluating its effects on dyadic communication. The primary hypothesis is that simulation-based communication skills training of PACU personnel will significantly improve the quality of handoffs. Clinicians performance is being compared before and after their training on four dimensions of handoff effectiveness: information transfer; use of best evidence handoff strategies; interpersonal skills; and team behaviors. Clinicians also rate their own handoffs. Lessons learned and results to date will be presented.

Development of a Job Task Analysis Tool for Assessing the Work of Physicians in the Intensive Care Unit

This paper describes the development of a job task analysis tool for observing and recording physician tasks in the ICU. Real-time direct observations were conducted by outside observers using a computerized data collection tool developed to document the tasks performed by ICU physicians. The aim of the analysis was to quantify the tasks of the physicians, including measures of frequency, duration, and sequence for tasks. In this paper, we report on the development process, as well as the validity and reliability of the job task analysis tool. Initial results from our analyses provide support for the validity and reliability of the taxonomy developed for assessing work of ICU physicians.

A Task Analysis of the First Weeks of Training of Novice Anesthesiologists

The training of novice anesthesiologists by more experienced clinicians occurs via an apprenticeship model taking place during actual patient care in a hands-on, one-on-one method that has not been well studied. Two skilled observers recorded the activities of the trainee and the instructor independently during thirty-one surgical cases conducted during the first three weeks of anesthesia training. The results indicate that the training of novice anesthesiologists initially emphasizes manual task performance during which time the more experienced clinicians perform many critical cognitive tasks (i.e., partial task training). Trainees workload was high, particularly in the initial portion of the case (“putting the patient to sleep”). Teaching consumed most of the middle of the case when the clinical workload was lower. Behavioral and cognitive task analysis may be used to evaluate the efficiency and safety of current or proposed training strategies.

How Do Residents Spend Their Time in the Intensive Care Unit

Purpose:To describe the work of residents and the distribution of their time in 6 intensive care units (ICUs) of 2 medical centers (MCs). Methods:A total of 242 hours of observation to capture data on tasks performed by residents in 6 ICUs, including adult, pediatric, medical and surgical units, were conducted. For each observation period, the percentages of total time spent on each task and on the aggregated task categories were calculated. Results:Overall, while in the ICUs, residents spent almost half of their time in clinical review and documentation (19%), conversation with team physicians (16%), conversation attendance (6%) and order management (6%). The 2 MCs differed in the time that residents spent on administrative review and documentation (4% in one MC and 15% in the other). The pediatric ICUs were similar in the 2 MCs, whereas the adult ICUs exhibited differences in the time spent on order management and administrative review and documentation. Conclusions:While in the ICUs, residents spent most time performing direct patient care and care coordination activities. The distribution of activities varied across 2 MCs and across ICUs, which highlights the need to consider the local context on residents work in ICUs.