Maximilian Johnston

Smartphone breast applications – What's the evidence?

INTRODUCTION There are around 40,000 healthcare applications (apps) available for smartphones. Apps have been reviewed in many specialties. Breast cancer is the most common malignancy in females with almost 1.38 million new cases a year worldwide. Despite the high prevalence of breast disease, apps in this field have not been reviewed to date. We have evaluated apps relevant to breast disease with an emphasis on their evidence base (EB) and medical professional involvement (MPI). METHODS Searching the major app stores (apple iTunes, Google Play, BlackBerry World, Windows Phone) using the most common breast symptoms and diseases identified relevant apps. Extracted data for each app included target consumer, disease focus, app function, documentation of any EB, documentation of MPI in development, and potential safety concerns. RESULTS One-hundred-and-eighty-five apps were reviewed. The majority focused on breast cancer (n = 139, 75.1%). Educational (n = 94) and self-assessment tools (n = 30) were the most common functions demonstrated. EB and MPI was identified in 14.2% and 12.8% of apps respectively. Potential safety concerns were identified in 29 (15.7%) apps. CONCLUSIONS There is a lack of EB and MPI in the development of current breast apps. Safety concerns highlight the need for regulation, full authorship disclosure and clinical trials. A robust framework for identifying high quality applications is necessary. This will address the current barrier pertaining to a lack of consumer confidence in their use and further aid to promote their widespread implementation within healthcare.

The ownership and clinical use of smartphones by doctors and nurses in the UK: a multicentre survey study

Background Much interest has arisen around the use of smartphones, tablet devices and related apps in the healthcare context. It has been suggested that increasing numbers of healthcare professionals are using these technologies in the workplace. We have performed an up-to-date UK-based, multicentre, cross-sectional survey study exploring the ownership rates and uses of these technologies among doctors and nurses, specifically focusing on the clinical environment. Methods After initial piloting, all doctors (n=2107) and nurses (n=4069) at 5 hospital sites were invited to complete a 36-item (nurses) or 38-item (doctors) survey. Exploratory descriptive statistics were calculated and the χ2 test was used to compare differences in categorical data between groups. Statistical significance was taken at a level of p<0.05. Results 98.9% of doctors and 95.1% of nurses owned a smartphone, while 73.5% and 64.7% owned a tablet device, respectively. Also, 92.6% of the doctors and 53.2% of nurses found their smartphone to be ‘very useful’ or ‘useful’ in helping them to perform their clinical duties, while 89.6% of doctors and 67.1% of nurses owning medical apps were using these as part of their clinical practice. Doctors and nurses were using short-message-script messaging (64.7% and 13.8%, respectively), app-based messaging (33.1% and 5.7%), and picture messaging (46.0% and 7.4%) (p=0.0001 for all modalities) to send patient-related clinical information to their colleagues. Therefore, 71.6% of doctors and 37.2% of nurses wanted a secure means of sending such information. Conclusions Compared to earlier studies, we have demonstrated much higher smartphone ownership among doctors and nurses, who perceive these devices to be useful when performing their clinical duties. Large numbers of staff are sending patient related clinical information using smartphone messaging modalities. Care must be taken by doctors and nurses to ensure that no identifiable patient data is transmitted in this way, and healthcare organisations must develop strategies and policies to support the safe and secure use of these technologies by front-line staff.

Escalation of care and failure to rescue: A multicenter, multiprofessional qualitative study

BACKGROUND The escalation of care process has not been explored in surgery, despite the role of communication failures in adverse events. This study aimed to develop a conceptual framework of the influences on escalation of care in surgery allowing solutions to facilitate management of sick patients to be developed. METHODS A multicenter qualitative study was conducted in three hospitals in London, UK. A total of 41 participants were recruited, including 16 surgeons, 11 surgical PGY1s, six surgical nurses, four intensivists, and four critical care outreach team members. Participants were submitted to semistructured interviews that were analyzed using grounded theory methodology. RESULTS A decision to escalate was based upon five key themes: patient, individual, team, environmental, and organizational factors. Most participants felt that supervision and escalation of care were problematic in their hospital, with unclear escalation protocols and poor availability of senior surgical staff the most common concerns. Mobile phones and direct conversation were identified to be more effective when escalating care than hospital pager systems. Transparent escalation protocols, increased senior clinician supervision, and communication skills training were highlighted as strategies to improve escalation of care. CONCLUSION This is the first study to describe escalation of care in surgery, a key process for protecting the safety of deteriorating surgical patients. Factors affecting the decision to escalate are complex, involving clinical and professional aspects of care. An understanding of this process could pave the way for interventions to facilitate escalation in order to improve patient outcome.

The uses of smartphones and tablet devices in surgery: A systematic review of the literature

BACKGROUND Smartphones and tablet devices have become ubiquitous, and their adoption in the health care arena is growing. Reviews have looked at their utilities within medical specialties. Despite the many surgical apps available currently, there has not been a comprehensive literature review evaluating uses of these platforms within surgical disciplines. We reviewed the literature systematically in this regard. METHODS Embase, MEDLINE, Health Management Informatics Consortium, and PsychINFO databases were searched for empiric quantitative studies evaluating interventions based in the use of smartphone or tablet device within surgical disciplines targeted at surgeons, patients, or the wider public. RESULTS Of the 39 studies included, 24 evaluated smartphone-based interventions and 15 looked at tablet devices, whereas 30 were app-based interventions and 9 were not. A wide range of effective and innovative utilities were identified and categorized into 8 domains; Diagnostics (n = 11), telemedicine (n = 9), operative navigation (n = 6), training (n = 5), data collection (n = 3), patient education (n = 2), behavior change (n = 2), and operative planning (n = 1). CONCLUSION This comprehensive systematic literature review of smartphone and tablet device use in surgery demonstrates a wide range of innovative utilities in the pre-, intra-, and postoperative contexts. Although results of individual studies generally were favorable, limitations in methodologies existed in many, and although studies clearly highlight the substantial potential of smartphone and tablet devices in the surgical setting, trials of greater quality will be necessary to pave the way for their widespread adoption.

An overview of research priorities in surgical simulation: what the literature shows has been achieved during the 21st century and what remains

BACKGROUND Key research priorities for surgical simulation have been identified in recent years. The aim of this study was to establish the progress that has been made within each research priority and what still remains to be achieved. METHODS Members of the Association for Surgical Education Simulation Committee conducted individualized literature reviews for each research priority that were brought together by an expert panel. RESULTS Excellent progress has been made in the assessment of individual and teamwork skills in simulation. The best methods of feedback and debriefing have not yet been established. Progress in answering more complex questions related to competence and transfer of training is slower than other questions. A link between simulation training and patient outcomes remains elusive. CONCLUSIONS Progress has been made in skills assessment, curricula development, debriefing and decision making in surgery. The impact of simulation training on patient outcomes represents the focus of simulation research in the years to come.

Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients.

OBJECTIVE To systematically risk assess and analyze the escalation of care process in surgery so as to identify problems and provide recommendations for intervention. BACKGROUND The ability to escalate care appropriately when managing deteriorating patients is a hallmark of surgical competence and safe postoperative care. Healthcare-Failure-Mode-Effects-Analysis (HFMEA) is a methodology adapted from safety-critical industries, which allows for hazardous process failures to be prospectively identified and solutions to be recommended. METHODS Forty-two hours of ethnographic observations on surgical wards in 3 London hospitals (phase 1) formed the basis of an escalation process diagram. A risk-assessment survey identified failures associated with process steps and attributed hazard scores (phase 2). Patient safety and clinical risk experts validated hazard scores through a group consensus meeting (phase 3). Hazardous failures were taken forward to multidisciplinary HFMEA where cause analysis was applied and interventions were recommended (phase 4). RESULTS Observations identified 33 steps in the escalation process. The risk-assessment survey (30 surgical staff members, 100% response) and expert consensus group identified 18 hazardous failures associated with these steps. The HFMEA team identified 3 adequately controlled failures; therefore, 15 were subjected to cause analysis. Outdated communication technology, understaffing, and hierarchical barriers were identified as root causes of failure. Participants recommended interventions based on these findings including defined escalation protocols, human factors education, enhanced communication technology, and improved clinical supervision. CONCLUSIONS Failures in the escalation process amenable to intervention were systematically identified. This mapping of the escalation process will allow tailored interventions to enhance surgical training and patient safety.

Effectiveness of interventions to improve patient handover in surgery: A systematic review.

BACKGROUND Handover of patient care is a critical process in the transfer of information between clinical teams and clinicians during transitions in patient care. The handover process may take many forms and is often unstructured and unstandardized, potentially resulting in error and the potential for patient harm. The Joint Commission has implicated such errors in up to 80% of sentinel events and has published guidelines (using an acronym termed SHARE) for the development of intervention tools for handover. This study aims to review interventions to improve handovers in surgery and to assess compliance of described methodologies with the guidelines of the Joint Commission for design and implementation of handover improvement tools. METHODS A systematic review was conducted in line with MOOSE guidelines. Electronic databases Medline, EMBASE, and PsyInfo were searched and interventions to improve surgical handover identified. Intervention types, development methods, and outcomes were compared between studies and assessed against SHARE criteria. RESULTS Nineteen studies were included. These studies included paper and computerized checklists, proformas, and/or standardized operating protocols for handover. All reported some degree of improvement in handover. Description of development methods, staff training, and follow-up outcome data was poor. Only a single study was able to demonstrate compliance with all 5 domains guidelines of the of Joint Commission. CONCLUSION Improvements in information transfer may be achieved through checklist- or proforma-based interventions in surgical handover. Although initial data appear promising, future research must be backed by robust study design, relevant outcomes, and clinical implementation strategies to identify the most effective means to improve information transfer and optimize patient outcomes.

Systematic review with meta-analysis of the impact of surgical fellowship training on patient outcomes

The number of surgeons entering fellowship training before independent practice is increasing. This may have a negative impact on surgeons in training. The impact of fellowship training on patient outcomes is not yet known. This review aimed to investigate the impact of fellowship training in surgery on patient outcomes.

Requirements of a new communication technology for handover and the escalation of patient care: a multi‐stakeholder analysis

RATIONALE, AIMS AND OBJECTIVES In order to enable safe and efficient information transfer between health care professionals during clinical handover and escalation of care, existing communication technologies must be updated. This study aimed to provide a user-informed guide for the development of an application-based communication system (ABCS), tailored for use in patient handover and escalation of care. METHODS Current methods of inter-professional communication in health care along with information system needs for communication technology were identified through literature review. A focus group study was then conducted according to a topic guide developed by health innovation and safety researchers. Fifteen doctors and 11 nurses from three London hospitals participated in a mixture of homogeneous and heterogeneous sessions. The sessions were recorded and transcribed verbatim before being subjected to thematic analysis. RESULTS Seventeen information system needs were identified from the literature review. Participants identified six themes detailing user perceptions of current communication technology, attitudes to smartphone technology and anticipated requirements of an application produced for handover and escalation of care. Participants were in favour of an ABCS over current methods and expressed enthusiasm for a system with integrated patient information and group-messaging functions. CONCLUSION Despite concerns regarding confidentiality and information governance a robust guide for development and implementation of an ABCS was produced, taking input from multiple stakeholders into account. Handover and escalation of care are vital processes for patient safety and communication within these must be optimized. An ABCS for health care professionals would be a welcome innovation and may lead to improvements in patient safety.

Improving Escalation of Care: Development and Validation of the Quality of Information Transfer Tool.

Objective:To develop and provide validity and feasibility evidence for the QUality of Information Transfer (QUIT) tool. Background:Prompt escalation of care in the setting of patient deterioration can prevent further harm. Escalation and information transfer skills are not currently measured in surgery. Methods:This study comprised 3 phases: the development (phase 1), validation (phase 2), and feasibility analysis (phase 3) of the QUIT tool. Phase 1 involved identification of core skills needed for successful escalation of care through literature review and 33 semistructured interviews with stakeholders. Phase 2 involved the generation of validity evidence for the tool using a simulated setting. Thirty surgeons assessed a deteriorating postoperative patient in a simulated ward and escalated their care to a senior colleague. The face and content validity were assessed using a survey. Construct and concurrent validity of the tool were determined by comparing performance scores using the QUIT tool with those measured using the Situation-Background-Assessment-Recommendation (SBAR) tool. Phase 3 was conducted using direct observation of escalation scenarios on surgical wards in 2 hospitals. Results:A 7-category assessment tool was developed from phase 1 consisting of 24 items. Twenty-one of 24 items had excellent content validity (content validity index >0.8). All 7 categories and 18 of 24 (P < 0.05) items demonstrated construct validity. The correlation between the QUIT and SBAR tools used was strong indicating concurrent validity (r = 0.694, P < 0.001). Real-time scoring of escalation referrals was feasible and indicated that doctors currently have better information transfer skills than nurses when faced with a deteriorating patient. Conclusions:A validated tool to assess information transfer for deteriorating surgical patients was developed and tested using simulation and real-time clinical scenarios. It may improve the quality and safety of patient care on the surgical ward.