Phillip V. Asaro

Effects of Computerized Provider Order Entry and Nursing Documentation on Workflow

OBJECTIVES The objective was to measure the effects of the implementation of computerized provider order entry (CPOE) and electronic nursing documentation on provider workflow in the emergency department (ED). METHODS The authors performed a before-and-after time-motion study of the activities of physicians and nurses. The percentages of time spent in task categories were calculated by provider session and averaged across provider sessions. RESULTS There was a shift in physician time from working with paper alone, 13.1% to 9.6% (p = 0.05), to working with paper while using a computer, 1.6% to 4.3% (p = 0.02), and an increase in time spent working on computer and/or paper from 30.0% to 38.9% (p = 0.02). For nurses, the increase in time spent on computer from 9.5% to 25.7% (p < 0.01) was offset by a decrease in time spent working with paper from 16.5% to 1.8% (p < 0.01). Direct care decreased minimally for nurses from 56.9% to 55.3% (p = 0.69), but from 36.8% to 29.1% (p = 0.07) for physicians, approaching statistical significance. Care planning decreased for nurses from 9.4% to 6.4% (p = 0.04) and from 21.7% to 19.5% (p = 0.60) for physicians. CONCLUSIONS The net effects of an implementation on provider workflow depend not only on changes in tasks directly related to the provider-computer interface, but also on changes in underlying patient care processes and information flows. The authors observed an unanticipated shift in physician time from interacting with nurses and patients toward retrieving information from the electronic patient record. Implementers should carefully consider how implementations will affect information flow and then expect the unexpected.

Effects of a triage process conversion on the triage of high-risk presentations.

OBJECTIVES The objective was to determine effects of a modification in triage process on triage acuity distribution in general and among patients with conditions requiring time-sensitive therapy. METHODS The authors retrospectively reviewed triage acuity distributions before and after modification of their triage process that entailed conversion from the Canadian Triage and Acuity Scale (CTAS) to the Emergency Severity Index (ESI). The authors calculated the ratio of the odds of being triaged to a nonemergent level (3, 4, or 5) under ESI to the odds of being triaged as nonemergent under CTAS. The authors calculated sensitivity and specificity of triage to an emergent acuity level (1 or 2) for identifying patients with common presentations who required time-sensitive care. RESULTS There were shifts from higher to lower acuity levels for all subsets, with odds ratios ranging from 2.80 (95% confidence interval [CI] = 2.75 to 2.86) for all patients to 21.39 (95% CI = 14.66 to 31.21) for patients over 55 years of age with a chief complaint of chest pain. The sensitivity of triage for identifying abdominal pain patients requiring admission to an intensive care unit (ICU) or operating room (OR) or emergency department (ED) death was 80.7% (95% CI = 73.2 to 86.5) before versus 50.8% (95% CI = 43.5 to 58.1) following the transition to ESI. Specificity under CTAS, 55.2% (95% CI = 54.0 to 56.4), was significantly lower than under ESI, 83.6% (95% CI = 82.7 to 84.4). The authors found similar effects for patients presenting with chest pain. CONCLUSIONS Monitoring for changes in the sensitivity of the triage process for detecting patients with potentially time-sensitive conditions should be considered when modifying triage processes. Further work should be done to determine if the decreased sensitivity seen in this study occurs in other institutions converting to ESI, and potential causative factors should be explored.

Making public health data available to community-level decision makers--goals, issues, and a case report.

Effective community health assessment and planning depends on the availability of appropriate public health data. Web-based technologies have created an unprecedented opportunity for making data available to community-level public health decision makers. An interactive data retrieval system targeted to the community-level user must provide an intuitive and easy-to-learn user interface with functionality and statistical complexity appropriate to the expected users while maintaining confidentiality of personal health information. The authors use the Missouri Information for Community Assessment Web site as an example to discuss goals and issues involved in the development of such systems.

Emergency Department Central Line-associated Bloodstream Infections (CLABSI) Incidence in the Era of Prevention Practices.

OBJECTIVES The incidence of central line-associated bloodstream infections (CLABSI) attributed to central venous catheters (CVCs) inserted in the emergency department (ED) is not widely reported. The goal was to report the incidence of ED CLABSI. Secondary goals included determining the effect of a CVC bundle introduced by the hospital infection prevention department to decrease CLABSI during the surveillance period. METHODS This was a prospective observational study over a 28-month period at an academic tertiary care center. A standardized electronic CVC procedure note identified CVC insertions in the ED. Abstractors reviewed inpatient records to determine ED CVC catheter-days. An infection prevention specialist identified CLABSIs originating in the ED using National Hospital Safety Network definitions from blood culture results collected up to 2 days after ED CVC removal. During the period of surveillance, a hospital-wide CVC insertion bundle was introduced to standardize insertion practices and prevent CLABSIs. Institutional CLABSI rates were determined by infection prevention from routine surveillance data. RESULTS Over the 28-month study period, 98 emergency physicians inserted 994 CVCs in 940 patients. The ED CVCs remained in place for more than 2 days in 679 patients, and the median number of days an ED CVC remained in use during the hospital stay was 3 (interquartile range = 2 to 7 days). There were 4,504 ED catheter-days and nine CLABSIs attributed to ED CVCs. The ED CLABSI rate was 2.0/1,000 catheter-days (95% confidence interval [CI] = 1.0 to 3.8). The concurrent institutional intensive care unit (ICU) CLABSI rate was 2.3/1,000 catheter-days (95% CI = 1.9 to 2.7). The ED CLABSI rate prebundle was 3.0/1,000 catheter-days and postbundle was 0.5/1,000 catheter-days (p = 0.038). CONCLUSIONS The CLABSI rates in this academic medical center ED were in the range of those reported by the ICU. The effect of ED CLABSI prevention practices requires further research dedicated to surveying ED CLABSI rates.