Shilo Anders

A pilot test of a tailored mobile and web-based diabetes messaging system for adolescents

We conducted a pilot trial of a new mobile and web-based intervention to improve diabetes adherence. The text messaging system was designed to motivate and remind adolescents about diabetes self-care tasks. Text messages were tailored according to individually-reported barriers to diabetes self-care. A total of 23 adolescents with type 1 diabetes used the system for a period of three months. On average, they received 10 text messages per week (range 8–12). A matched historical control group from the same clinic was used for comparison. After three months, system users rated the content, usability and experiences with the system, which were very favourable. Comparison of the intervention and control groups indicated a significant interaction between group and time. Both groups had similar HbA1c levels at baseline. After three months, the mean HbA1c level in the intervention group was unchanged (8.8%), but the mean level in the control group was significantly higher (9.9%), P = 0.006. The results demonstrate the feasibility of the messaging system, user acceptance and a promising effect on glycaemic control. Integrating this type of messaging system with online educational programming could prove to be beneficial.

Mediating the intersections of organizational routines during the introduction of a health IT system.

Public interest in the quality and safety of health care has spurred examination of specific organizational routines believed to yield risk in health care work. Medication administration routines, in particular, have been the subject of numerous improvement projects involving information technology development, and other forms of research and regulation. This study draws from ethnographic observation to examine how the common routine of medication administration intersects with other organizational routines, and why understanding such intersections is important. We present three cases describing intersections between medication administration and other routines, including a pharmacy routine, medication administration on the next shift and management reporting. We found that each intersection had ostensive and performative dimensions; and furthermore, that IT-enabled changes to one routine led to unintended consequences in its intersection with others, resulting in misalignment of ostensive and performative aspects of the intersection. Our analysis focused on the activities of a group of nurses who provide technology use mediation (TUM) before and after the rollout of a new health IT system. This research offers new insights on the intersection of organizational routines, demonstrates the value of analyzing TUM activities to better understand the relationship between IT introduction and changes in routines, and has practical implications for the implementation of technology in complex practice settings.

MyHealthAtVanderbilt: policies and procedures governing patient portal functionality.

Explicit guidelines are needed to develop safe and effective patient portals. This paper proposes general principles, policies, and procedures for patient portal functionality based on MyHealthAtVanderbilt (MHAV), a robust portal for Vanderbilt University Medical Center. We describe policies and procedures designed to govern popular portal functions, address common user concerns, and support adoption. We present the results of our approach as overall and function-specific usage data. Five years after implementation, MHAV has over 129,800 users; 45% have used bi-directional messaging; 52% have viewed test results and 45% have viewed other medical record data; 30% have accessed health education materials; 39% have scheduled appointments; and 29% have managed a medical bill. Our policies and procedures have supported widespread adoption and use of MHAV. We believe other healthcare organizations could employ our general guidelines and lessons learned to facilitate portal implementation and usage.

Novel use of electronic whiteboard in the operating room increases surgical team compliance with pre-incision safety practices

BACKGROUND Despite evidence that use of a checklist during the pre-incision time out improves patient morbidity and mortality, compliance with performing the required elements of the checklist has been low. In an effort to improve compliance, a standardized time out interactive Electronic Checklist System [iECS] was implemented in all hospital operating room (OR) suites at 1 institution. The purpose of this 12-month prospective observational study was to assess whether an iECS in the OR improves and sustains improved surgical team compliance with the pre-incision time out. METHODS Direct observational analyses of preprocedural time outs were performed on 80 cases 1 month before, and 1 and 9 months after implementation of the iECS, for a total of 240 observed cases. Three observers, who achieved high interrater reliability (kappa = 0.83), recorded a compliance score (yes, 1; no, 0) on each element of the time out. An element was scored as compliant if it was clearly verbalized by the surgical team. RESULTS Pre-intervention observations indicated that surgical staff verbally communicated the core elements of the time out procedure 49.7 ± 12.9% of the time. After implementation of the iECS, direct observation of 80 surgical cases at 1 and 9 months indicated that surgical staff verbally communicated the core elements of the time out procedure 81.6 ± 11.4% and 85.8 ± 6.8% of the time, respectively, resulting in a statistically significant (P < .0001) increase in time out procedural compliance. CONCLUSION Implementation of a standardized, iECS can dramatically increase compliance with preprocedural time outs in the OR, an important and necessary step in improving patient outcomes and reducing preventable complications and deaths.

Surgical debriefing: a reliable roadmap to completing the patient safety cycle

Morbidity and mortality due to preventable medical errors are a disastrous reality in medicine. Debriefing, a process that allows individuals to discuss team performance in a constructive, supportive environment, has been linked to improved performance in various medical and surgical fields, including improvements in specific procedures, teamwork and communication, and error identification. However, the neurosurgical literature on this topic is limited. The authors review the debriefing literature in the field of medicine, with a specific emphasis on the operating room, and they report their own institutional experience with a debriefing module, from invention to pilot implementation, at Vanderbilt University Medical Center. The authors share the challenges and lessons learned from their quality improvement project. The field of neurosurgery would undoubtedly benefit from embracing debriefing, as its potential has been established in other medical specialties and can serve as a valuable role in immediately learning from mistakes. The authors hope that their colleagues can learn from this experience and improve their own.

Methodology and Bias in Assessing Compliance with a Surgical Safety Checklist

BACKGROUND Surgical safety checklists, such as the perioperative time-out, have been shown to improve performance on a variety of patient safety measures. A variety of methods have been used to assess compliance with the perioperative time-out, but no standardized methodology with a reliable observer group currently exists. An observation-based methodology was used to assess time-out compliance at an academic medical center. METHODS A single observer group made up of medical students and nurses recorded compliance with each of the 11 standardized items of the time-out. A total of 193 time-out procedures were observed, 48 by medical students and 145 by nurses. RESULTS One item (procedure to be performed) achieved > 95% compliance. Three items (surgical site; availability of necessary blood products, implants, devices; and start of antibiotics) achieved 80%-95% compliance. Seven items achieved < 80% compliance (presence of required members of procedure team, presence of person who marked patient, patient identity, side marking, relevant images, allergies, and discussion of relevant special considerations). Compliance with the four core time-out items was 78.2%. Of the 11 items on the time-out being evaluated, there was a statistically significant difference between medical student and nursing observations for 10 items (p < .05). CONCLUSIONS In our cohort of observed time-outs, the compliance rate was low, calling into question time-out quality, and, more importantly, patient safety. Measures must be taken by large hospitals to regularly audit time-out compliance and create effective programming to improve performance. Although observational assessment is an effective method to assess compliance with surgical safety checklists, observer group bias has the potential to skew results.

Blood product positive patient identification: comparative simulation-based usability test of two commercial products.

BACKGROUND: The blood product administration process has been subject to various quality improvement initiatives aimed at reducing errors, including blood product labels that are missing, inaccessible, unreadable, or mismatched to orders and/or patients. This article reports the results of a formal simulation‐based usability test of two comparable technologies designed to reduce blood product administration errors.

The Effects of Health Information Technology Change Over Time: A Study of Tele-ICU Functions

OBJECTIVES Longitudinal studies exploring the evolution of health information technology functions provide valuable information about how technology systems are integrated and exploited in situ. This study reports changes in the distribution of functions for a specific health information technology, the tele-ICU, over time. The studied tele-ICU provided care to six remote ICUs within a local geographic region in the same state and had nursing staff around the clock. METHODS The intervention logs of tele-ICU nurses were collected during two discrete times and coded into nine emergent functional categories, who initiated the intervention and, if required, subsequent escalation. All coded functional categories were investigated for significant changes over time in the nursing logged interventions. RESULTS A total of 1927 interventions were coded into the nine emergent functional categories. Seven of the nine categories (78%) were significantly different between 2005 and 2007. The functions of the tele-ICU system continue to change and develop over time. CONCLUSION These findings suggest that the tele-ICU increased support when ICU nurses were off the unit, inter-hospital coordinating and adherence to best practices, while simultaneously decreasing real-time support for ICU nurses. This research suggests that sustaining safety features in a new technology over time have post-conditions after implementation.

Usability evaluation of the SMART application for youth with mTBI

OBJECTIVE There is a dearth of evidence-based treatments available to address the significant morbidity associated with mild traumatic brain injury (mTBI). To address this gap, we designed a novel user-friendly, web-based application. We describe the preliminary evaluation of feasibility and usability of the application to promote recovery following mTBI in youth, the Self-Monitoring Activity-Restriction and Relaxation Treatment (SMART). SMART incorporates real-time recommendations for individualized symptom management and activity restriction along with training in cognitive-behavioral coping strategies. METHODS We conducted a usability evaluation to assess and modify the SMART system prior to further study and deployment. Children ages 11-18 years presenting to the emergency department were recruited after symptoms resolved. Usability was assessed using a 60-min think-aloud protocol of teens and parents describing their interaction with the application. Upon completion of the tasks, each participant also completed the system usability scale (SUS). RESULTS We performed tests with 4 parent/child dyads. The average age of the children was 13 years (standard deviation=1.8). The parents were an average of 41.5 years old (standard deviation=6.2). Research revealed that the participants were enthusiastic about the interactive portions of the tool particularly the video based sessions. Parents were concerned about the speed at which their child might move through the program and the children thought that the system required large amounts of reading. Based on user feedback, researchers modified SMART to include an audio file in every module and improved the systems aesthetic properties. The mean SUS score was 85, with high SUS scores (>68) indicating satisfactory usability. CONCLUSION High initial usability and favorable user feedback provide a foundation for further iterative development and testing of the SMART application as a tool for managing recovery from concussion.

Significant Physiological Disturbances Associated With Non-Routine Event Containing and Routine Anesthesia Cases.

Objectives A nonroutine event (NRE) is defined as any event that deviates from ideal clinical care for a given patient in a specific clinical situation. We sought to compare anesthesia providers’ reporting of NREs with the incidence of significant physiological disturbances (SPDs) detected via retrospective videotape review. SPD criteria were defined prestudy to be deviations of physiological parameters (heart rate, systolic blood pressure, and oxygen saturation) requiring clinical intervention. We hypothesized that SPDs would occur more frequently in NRE cases than in routine (no reported NRE) cases. Methods A trained observer reviewed videotapes of anesthesia care from 16 randomly selected NRE-containing and 16 matched routine cases for SPD occurrence using custom software. Data were analyzed using nonparametric tests. Results Although a preponderance of the anesthetic in both types of cases were uneventful (i.e., free of SPD in 97 ± 1.6% of routine case time versus 89 ± 3.9% of NRE case time), there was at least one SPD episode in 69% of routine and 88% of NRE cases. NRE-containing cases had significantly more SPDs than routine cases (1.4 ± 0.9 SPDs/case hour for NRE versus 0.8 ± 0.3 for routine cases). Twice as many SPDs during NRE-containing cases were clinically related to a reported NRE as opposed to unrelated. Conclusions SPDs occur more often in NRE-containing cases. The incidence of approximately one NRE-independent SPD per case was similar in NRE-containing and routine case. Further research is needed to ascertain the relationship of both NREs and SPDs to patient outcomes.