Rebecca Kowalski

Use and Acceptance of Mobile Technologies in Health Care

Mobile technology use in healthcare is increasing for both patients and providers. Despite the increasing popularity of mobile devices such as smartphones and tablets, little is known about their perceived value by users in the healthcare context. Additionally, available studies are often restricted to evaluating the success of specific interventions and do not adequately capture the users’ basic attitudes. Our objective was to describe this use, perceptions of use, and barriers to optimal use in a tertiary care, academic health system in Delaware. An anonymous web-based survey was distributed via email to care providers including doctors, nurse practitioners, and nurses who work in direct patient care roles at Christiana Care Health System in Newark, DE. A separate survey was administered by trained research associates to a convenience sample of patients at Christiana Care in the Emergency Department over a four-month period.

Lost in Translation: Factors Influencing Successful Implementation of Evidence-Based Guidelines into Clinical Decision Support

Evidence-based guidelines are being produced at a very rapid rate but implementation into effective clinical decision support (CDS) is rare. Currently, there exists a gap between guideline development and successful implementation. Guidance for the development of trustworthy guidelines is lacking (Schünemann et al., 2014), and poor uptake of guidelines continues to be a major problem across healthcare systems (Gupta et al., 2016). Integration of guidelines through CDS can facilitate evidence-based medicine, which promises to standardize care and improve compliance with evidence-based protocols, thus improving patient outcomes (Chaudhry et al., 2006). The unsuccessful implementation of evidence-based guidelines is in part due to over-complexity (Francke, Smit, Veer, & Mistiaen, 2008), poor usability (Kastner et al., 2014), and poor applicability (Lugtenberg, Zegers-van Schaick, Westert, & Burgers, 2009). There are many external and internal factors that impact how new guidelines are received by the medical field. These factors refer to implementability, which is a set of characteristics that predict ease of, and obstacles to, guideline implementation (Kastner et al., 2014). The most frequently described facilitators of guideline uptake were format, content, language, and usability (Kastner et al., 2014). The aims of the current project were to: 1) Identify characteristics that support or impede evidence-based guideline implementation as CDS in critical care settings. 2) Create taxonomy to evaluate these characteristics. 3) Use that taxonomy to extract, summarize, and review relevant evidence-based guidelines. From a search of the current literature on implementability of evidence-based guidelines, we searched for articles published in PubMed between 2007 and 2017. Combinations of the following Medical Subject Headings (MeSH) terms were used: “guideline” AND “implementability”. Criteria for inclusion were: i) discussion of characteristics of features in guidelines; ii) English language; iii) recommendations for guideline development were summarized and used in the spectrum of healthcare; and iv) discussion of CDS. Generated from these recommendations, our novel taxonomy included the following five elements: development, format, content, language, and usability. We used this taxonomy to assess the CDS-implementability of 15 different guidelines across varying clinical domains, representing a cross-section of medicine with regards to clinical condition, target population, and guideline developer. Using the taxonomy as an abstraction tool, we identified characteristics of each of the 15 guidelines that would support and hinder their successful implementation into CDS. Our results showed that the different characteristics of implementability can be quantitatively measured, which would prove useful during the guidelines development. The implementability of a guideline, if considered throughout the development cycle, could lead to successful uptake into CDS in critical care settings.

A Framework to Tackle Risk Identification and Presentation Challenges in Sepsis

Introduction Sepsis trajectories, including onset and recovery, can be difficult to assess, but electronic health records (EHRs) can accurately capture sepsis as a dynamic episode. Methods Retrospective dataset of 276,722 clinical observations (4,726 unique patients) during a two-month period in 2015 were extracted from the EHRs. A Cox proportional hazard model was built to test hazard ratios of risk factors to the first sepsis episode onset within 72 hours for patients with presumed infection. Predisposition, infection, response, and organ failure (PIRO) score-based framework was used in a logistic regression to identify factors associated with in-hospital mortality within the sepsis population. Results 47.54% of patients with an infection episode experienced at least one sepsis episode (N=1,044 out of 2,196) within 72 hours of admission. The mortality rate was higher for patients with sepsis episodes (7.24%) compared to patient with only organ dysfunction episodes (4.84%) or only with infection episodes (3.96%). Analysis identified factors associated with the first sepsis episode onset and those associated with in-hospital mortality. Discussion Our study addresses identification of infection, organ dysfunction, and sepsis as dynamic episodes utilizing EHR data and provides a systematic approach to detect risk factors related to sepsis onset and in-hospital mortality.

Applying User-Interface Design Heuristics on Computerized Clinical Decision Support Systems

Studies evaluating Computerized Clinical Decision Support Systems (CCDSS) assess success and impact by studying patient/clinician outcomes in clinician workflow. However, the literature lacks studies that evaluate CCDSSs as interactive computer systems. Evaluating the design of these systems from a human factors engineering perspective can optimize interactions between clinicians and the system, and eventually improve both patient and clinician outcomes.

Expert surgical consensus for prenatal counseling using the Delphi method

BACKGROUND Pediatric surgeons frequently offer prenatal consultation for congenital pulmonary airway malformation (CPAM) and congenital diaphragmatic hernia (CDH); however, there is no evidence-based consensus to guide prenatal decision making and counseling for these conditions. Eliciting feedback from experts is integral to defining best practice regarding prenatal counseling and intervention. METHODS A Delphi consensus process was undertaken using a panel of pediatric surgeons identified as experts in fetal therapy to address current limitations. Areas of discrepancy in the literature on CPAM and CDH were identified and used to generate a list of content and intervention questions. Experts were invited to participate in an online Delphi survey. Items that did not reach first-round consensus were broken down into additional questions, and consensus was achieved in the second round. RESULTS Fifty-four surgeons (69%) responded to at least one of the two survey rounds. During round one, consensus was reached on 54 of 89 survey questions (61%), and 45 new questions were developed. During round two, consensus was reached on 53 of 60 survey questions (88%). CONCLUSIONS We determined expert consensus to establish guidelines regarding perinatal management of CPAM and CDH. Our results can help educate pediatric surgeons participating in perinatal care of these patients. LEVEL OF EVIDENCE V.

Optimizing usability and signal capture: a proactive risk assessment for the implementation of a wireless vital sign monitoring system

Abstract Wearable vital sign monitors are a promising step towards optimal patient surveillance, providing continuous data to allow for early detection and treatment of patient deterioration. However, as wearable monitors become more widely adopted in healthcare, there is a corresponding need to carefully design the implementation of these tools to promote their integration into clinical workflows and defend against potential misuse and patient harm. Prior to the roll-out of these monitors, our multidisciplinary team of clinicians, clinical engineers, information technologists and research investigators conducted a modified Healthcare Failure Mode and Effect Analysis (HFMEA), a proactive evaluation of potential problems which could be encountered in the use of a wireless vital signs monitoring system. This evaluation was accomplished by focussing on the identification of procedures and actions that would be required during the devices’ regular usage, as well as the implementation of the system as a comprehensive process. Using this method, the team identified challenges that would arise throughout the lifecycle of the device and developed recommendations to address them. This proactive risk assessment can guide the implementation of wearable patient monitors, optimising the use of innovative health information technology.

Assessment of nursing response to a real-time alerting tool for sepsis : A provider survey

Background An information technology solution to provide a real-time alert to the nursing staff is necessary to assist in identifying patients who may have sepsis and avoid the devastating effects of its late recognition. The objective of this study is to evaluate the perception and adoption of sepsis clinical decision support. Methods A cross-sectional survey over a three-week period in 2015 was conducted in a major tertiary care facility. A sepsis alert was launched into five pilot units (including: surgery, medical-ICU, step-down, general medicine, and oncology). The pilot unit providers consisted of nurses from five inpatient units. Frequency, summary statistics, Chi-square, and nonparametric Kendall tests were used to determine the significance of the association and correlation between six evaluation domains. Results A total of 151 nurses responded (53% response rate). Questions included in the survey addressed the following domains: usability, accuracy, impact on workload, improved performance, provider preference, and physician response. The level of agreeability regarding physician response was significantly different between units (p=0.0136). There were significant differences for improved performance (p=0.0068) and physician response (p=0.0503) across levels of exposure to the alert. The strongest correlations were between questions related to usability and the domains of: accuracy (τ=0.64), performance (τ=0.66), and provider preference (τ=0.62), as well as, between the domains of: provider performance and provider preference (τ=0.67). Discussion Performance and preference of providers were evaluated to identify strengths and weaknesses of the sepsis alert. Effective presentation of the alert, including how and what is displayed, may offer better cognitive support in identifying and treating septic patients.

Advancing Patient Safety through the Creation of a Mobile Usability Lab

The demand for usability testing is becoming increasingly important as healthcare moves toward a commitment to zero patient harm and higher value of care provided. Usability testing and simulation, techniques used in user-centered interaction design to evaluate healthcare systems, promote safe, high-quality care for patients. We propose the concept of a “Mobile Usability Lab”, a novel way to conduct usability testing system-wide. The Mobile Usability Lab describes a unique opportunity to step away from the standard state-of-the-art usability lab and take a creative approach to usability testing. To demonstrate the utility of this concept, we present a case study detailing a hospital-wide comparative device evaluation of new defibrillators. We recommend that research and clinical teams explore the concept of a mobile usability lab to evaluate products in the clinical environment. This work can reduce preventable harm through the optimization of health care delivery.

Designing Health Care Facilities to Maximize Productivity and Patient Outcomes

The built environment of health care systems plays a crucial role in factors such as patient safety, staff satisfaction, patient experience, and optimal health. As hospital centers are being renovated or expanded over the past decade or so, the clinical built environment of many of them have not been redesigned to align with today’s evolving clinical roles. Just as medicine has increasingly moved toward “evidence-based medicine,” where clinical choices are informed by research, healthcare design is increasingly guided by rigorous research linking the physical environment of hospitals to patients and staff outcomes and is moving toward “evidence-based design”. The goal of human simulations in the context of architectural builds is to present the workflow (both normal and emergent) in the design of the complex cooperative work environment. The results obtained can be used to change the design process by improving the built environment to support end users to provide optimal health, exceptional experience, and organizational vitality. These proceedings describe the process and provide an example of the evaluation of a future single patient neonatal intensive care unit room.