Hemoglobin on Admission for Childbirth and Postpartum Acute Care Use in a Southeastern Health Care System.

OBJECTIVE: Our objective was to evaluate whether hemoglobin on admission for childbirth is associated with postpartum acute care use (ACU). STUDY DESIGN: We conducted a retrospective cohort study of patients giving birth at a southeastern quaternary care hospital from January 2018 through June 2021 using electronic health records. Predelivery hemoglobin was categorized as <9, 9- < 10, 10- < 11, 11- < 12, and ≥12 g/dL. Acute care was defined as a visit to obstetric triage, the emergency department, or inpatient admission within 90 days postpartum. Generalized estimating equations quantified the crude and multivariable-adjusted association between predelivery hemoglobin and ACU. RESULTS: Among 8,677 pregnancies, 1,467 (17%) used acute care in the system within 90 days postpartum. In unadjusted models, those with predelivery hemoglobin <9 had twice the risk of postpartum ACU compared to those with hemoglobin ≥12 (95% confidence interval [CI]: 1.59-2.69), with a decrease in risk for each increase in hemoglobin category (9- < 10 g/dL: risk ratio [RR]: 1.47, CI: 1.21-1.79; 10- < 11 g/dL: RR: 1.44, CI: 1.26-1.64; 11- < 12 g/dL: RR: 1.20, CI: 1.07-1.34). The adjusted model showed a similar trend with smaller effect estimates (<9 g/dL: RR: 1.50, CI: 1.14-1.98; 9- < 10 g/dL: RR: 1.22, CI: 1.00-1.48; 10- < 11 g/dL: RR: 1.22, CI: 1.07-1.40; 11- < 12 g/dL: RR: 1.09, CI: 0.98-1.22). CONCLUSION: Low hemoglobin at childbirth admission was associated with increased postpartum ACU. Low hemoglobin on admission could signal to providers that additional follow-up, resources, and ongoing support are warranted to identify and address underlying health needs. Because hemoglobin is routinely assessed during the childbirth hospitalization, this indicator may be especially valuable for risk assessment among patients with limited prior engagement in health care. KEY POINTS: · Low hemoglobin on admission for birth is associated with postpartum acute care use.. · Hemoglobin on admission may aid in risk-stratification during childbirth hospitalization.. · Point-of-care metrics may help identify high-risk patients with limited preventive health care..

Perceptually Discriminating the Highest Priority Alarms Reduces Response Time: A Retrospective Pre-Post Study at Four Hospitals.

OBJECTIVE: Reduce nurse response time for emergency and high-priority alarms by increasing discriminability between emergency and all other alarms and suppressing redundant and likely false high-priority alarms in a secondary alarm notification system (SANS). BACKGROUND: Emergency alarms are the most urgent, requiring immediate action to address a dangerous situation. They are clinician-triggered and have higher positive predictive value (PPV). High-priority alarms are automatically triggered and have lower PPV. METHOD: We performed a retrospective pre-post study, analyzing data 15 months before and 25 months after a SANS redesign was implemented in four hospitals. For emergency alarms, we incorporated digitized human speech to distinguish them from automatically triggered alarms, leaving their onset and escalation pathways unchanged. For automatically triggered alarms, we suppressed some by delaying initial onset and escalation by 20 s. We used linear mixed models to assess the change in response time, Fisher's exact test for the proportion of response times longer than 120 s, and control charts for process stability. RESULTS: Response time for emergency alarms decreased at all hospitals (main, from 26.91 s to 22.32 s, p < .001; cardiac, from 127.10 s to 52.43 s, p < .001; cancer, from 18.03 s to 15.39 s, p < .001). Improvements were sustained. Automatically triggered alarms decreased 25.0%. Response time for the three automatically triggered cardiac alarms increased at the four hospitals. CONCLUSION: Auditory sound disambiguation was associated with a sustained reduced nurse response time for emergency alarms, but suppressing some high-priority automatically triggered alarms was not. APPLICATION: Distinguishing and escalating urgent, actionable alarms with higher PPV improves response time.

Applying Human Factors Engineering to Address the Telemetry Alarm Problem in a Large Medical Center.

OBJECTIVE: Address the alarm problem by redesigning, reorganizing, and reprioritizing to better discriminate alarm sounds and displays in a hospital. BACKGROUND: Alarms in hospitals are frequently misunderstood, disregarded, and overridden. METHOD: Discovery-oriented, intervention, and translational studies were conducted. Study objectives and measures varied, but had the shared goals of increasing positive predictive value (PPV) of critical alarms by reducing low-PPV alarms in the background, prioritizing alarms, redesigning alarm sounds to increase information content, and transparently conveying who initiated alarms. An alarm ontology was iteratively generated and refined until consensus was achieved. RESULTS: The ontology distinguishes five levels of urgency that incorporate likely PPV, three categories for who initiates the alarm (hospital staff, patient, or machine), whether it is clinical or technical, and clinical functions. CONCLUSION: This unique collaboration allowed us to make progress on the alarm problem by making unintuitive leaps, avoiding common missteps, and refuting conventional healthcare approaches. APPLICATION: Hospitals can consistently redesign, reorganize, reprioritize, and better discriminate alarms by priority, PPV, and content to reduce nurse response times.

Lessons from the Glass Cockpit: Innovation in Alarm Systems to Support Cognitive Work.

Nurses working in the hospital setting increasingly have become overburdened by managing alarms that, in many cases, provide low information value regarding patient health. The current trend, aided by disposable, wearable technologies, is to promote patient monitoring that does not require entering a patient's room. The development of telemetry alarms and middleware escalation devices adds to the continued growth of auditory, visual, and haptic alarms to the hospital environment but can fail to provide a more complete understanding of patient health. As we begin to innovate to both address alarm overload and improve patient management, perhaps using fundamentally different integration architectures, lessons from the aviation flight deck are worth considering. Commercial jet transport systems and their alarms have evolved slowly over many decades and have developed integration methods that account for operational context, provide multiple response protocol levels, and present a more integrated view of the airplane system state. We articulate three alarm system objectives: (1) supporting hazard management, (2) establishing context, and (3) supporting alarm prioritization. More generally, we present the case that alarm design in aviation can spur directions for innovation for telemetry monitoring systems in hospitals.

Using timbre to improve performance of larger auditory alarm sets.

Identifiability and perceived urgency were compared for two sets of alarms in a healthcare inpatient setting. One contained currently used alarms where possible, with new sounds added as needed. The other was designed together, was more heterogenous, used timbre to encode intended similarities and explicitly encoded intended urgency across the set. Twenty nurses reported the identity and perceived urgency of the sounds in each set. Participants correctly identified the sound (0.89 vs. 0.77) and alarm category (0.93 vs. 0.82) more often in the new set than in the baseline set. In addition, multiple sounds in the new set were more identifiable. The new sounds also had a larger range of perceived urgency and better urgency match. The results indicate that timbre is well-suited to encode alarm groupings in larger alarm sets and that this, along with increased heterogeneity and explicit urgency mapping, improves alarm set performance. Practitioner summary: Clinical alarms are frequently misidentified. We found that making alarms more acoustically rich, using timbre to convey alarm groups, and explicitly encoding intended urgency improved identifiability and urgency match. These findings can be used to improve alarm performance across all safety-critical industries.

Associations Among Nurse Fatigue, Individual Nurse Factors, and Aspects of the Nursing Practice Environment.

OBJECTIVE: This study examined the relationships among nurse fatigue, individual nurse factors, and the practice environment in the inpatient setting. BACKGROUND: Nurse fatigue affects the quality of care provision on inpatient units. Scant literature exists regarding how aspects of the practice environment relate to nurse fatigue. METHODS: A cross-sectional, correlational design was used in this survey study of 175 neonatal intensive care unit nurses from multiple hospitals. Data were collected using the Checklist Individual Strength questionnaire and the Practice Environment Scale of the Nursing Work Index. Hierarchical regression analysis was performed to examine the relationships. RESULTS: Higher fatigue was significantly associated with more hours worked, fewer hours of sleep, a physical or mental contributor to fatigue, and a recent distressing patient event. Lower fatigue was significantly associated with better nurse manager ability, leadership, and support. CONCLUSIONS: Nurse fatigue may be diminished with organizational and individual strategies. Developing tactics for nurse managers to better support staff members after a recent distressing patient event is indicated.

Workarounds to Intended Use of Health Information Technology: A Narrative Review of the Human Factors Engineering Literature.

Objective To integrate and synthesize insights from recent studies of workarounds to the intended use of health information technology (HIT) by health care professionals. Background Systems are safest when the documentation of how work is done in policies and procedures closely matches what people actually do when they are working. Proactively identifying and managing workarounds to the intended use of technology, including deviations from expected workflows, can improve system safety. Method A narrative review of studies of workarounds with HIT was conducted to identify themes in the literature. Results Three themes were identified: (1) Users circumvented new additional steps in the workflow when using HIT, (2) interdisciplinary team members communicated via HIT in text fields that were intended for other purposes, and (3) locally developed paper-based and manual whiteboard systems were used instead of HIT to support situation awareness of individuals and groups; an example of a locally developed system was handwritten notes about a patient on a piece of paper folded up and carried in a nurse's pocket. Conclusion Workarounds were employed to avoid changes to workflow, enable interdisciplinary communication, coordinate activities, and have real-time portable access to summarized and synthesized information. Application Implications for practice include providing summary overview displays, explicitly supporting role-based communication and coordination through HIT, and reducing the risk to reputation due to electronic monitoring of individual performance.

An Exploration of Contributing Factors to Patient Safety.

One in 3 patients is estimated to experience health care-related harm during hospitalization. This descriptive, cross-sectional study used the Safety Attitudes Questionnaire to measure interprofessional staff perceptions of safety and teamwork climate and a retrospective, modified Global Trigger Tool chart review methodology to measure unit-level patient outcomes. Safety climate and teamwork did not have a statistically significant relationship with the frequency of adverse events identified by the Global Trigger Tool. Researchers may consider the Global Trigger Tool for detecting unit-level adverse events.

Patient-Provider Communication With Older Adults About Sleep Apnea Diagnosis and Treatment.

Patient-provider communication impacts adherence to therapy. We explored older adults' communication with their providers, preferences for communication, and views on communication attributes and decision aid characteristics, by conducting four focus groups. Several participants reported they had received insufficient information about their sleep apnea diagnosis and treatment options. Most participants felt that it would be helpful to have treatment information tailored to their needs, including information on the negative impact of treatment on comfort and convenience and disclosure about common barriers to adherence. Participants provided desired characteristics for a decision aid, including their preferred delivery method, content, and format. These findings have implications for how to design useful decision aids for older adults with newly diagnosed sleep apnea.

Safe Practice Recommendations for the Use of Copy-Forward with Nursing Flow Sheets in Hospital Settings.

BACKGROUND: In early 2016 the Partnership for Health IT Patient Safety released safe practice recommendations for the use of copy-paste for electronic health record (EHR) documentation. These recommendations do not directly address nurses' use of copy-forward to document patient assessments in flow sheet software in hospital settings. Similar to clinicians' use of copy-paste and copy-forward with progress notes, concerns exist about patient safety issues from the use of potential inaccurate or outdated information to achieve increased efficiency of documentation. METHODS: A multiple-methods approach-which included a literature review, litigation search, stakeholder analysis, and consensus opinion from experts from multiple disciplines-was employed. RESULTS: Four recommendations correspond closely with copy-paste guidance for EHR documentation from the Partnership: (1) Provide a mechanism to make copied-forward content easily identifiable, (2) Ensure that the provenance of copied-forward content is readily available, (3) Ensure adequate staff training and education regarding the appropriate and safe use of copy-forward in flow sheet software, if available, and (4) Ensure that copy-forward practices are regularly monitored, measured, and assessed. A fifth additional recommendation is made to improve the efficiency of data entry mechanisms, which may reduce patient safety risk. Emerging promising areas for innovation are to optimize interface usability and flow sheet content, use templates, use digital photographs, and eliminate work-flow steps with better methods for authentication and data entry. CONCLUSIONS: A thoughtful and measured approach to safe use of copy-forward in flow sheets by nurses in hospital settings is expected to result in improvements in efficiency of documentation, work flow, and accuracy of information.

A Multimodal Intervention Improves Postanesthesia Care Unit Handovers.

BACKGROUND: Failures of communication are a major contributor to perioperative adverse events. Transitions of care may be particularly vulnerable. We sought to improve postoperative handovers. METHODS: We introduced a multimodal intervention in an adult and a pediatric postanesthesia care unit (PACU) to improve postoperative handovers between anesthesia providers (APs) and PACU registered nurses (RNs). The intervention included a standardized electronic handover report form, a didactic webinar, mandatory simulation training focused on improving interprofessional communication, and post-training performance feedback. Trained, blinded nurse observers scored PACU handovers during 17 months using a structured tool consisting of 8 subscales and a global score (1-5 scale). Multivariate logistic regression assessed the effect of the intervention on the proportion of observed handovers receiving a global effectiveness rating of ≥3. RESULTS: Four hundred fifty-two clinicians received the simulation-based training, and 981 handovers were observed and rated. In the adult PACU, the estimated percentages of acceptable handovers (global ratings ≥3) among AP-RN pairs, where neither received simulation-based training (untrained dyads), was 3% (95% confidence interval, 1%-11%) at day 0, 10% (5%-19%) at training initiation (day 40), and 57% (33%-78%) at 1-year post-training initiation (day 405). For AP-RN pairs where at least one received the simulation-based training (trained dyads), these percentages were estimated to be 18% (11%-28%) and 68% (57%-76%) on days 40 and 405, respectively. The percentage of acceptable handovers was significantly greater on day 405 than it was on day 40 for both untrained (P < 0.001) and trained dyads (P < 0.001). Similar patterns were observed in the pediatric PACU. Three years later, the unadjusted estimate of the probability of an acceptable handover was 87% (72%-95%) in the adult PACU and 56% (40%-72%) in the pediatric PACU. CONCLUSIONS: A multimodal intervention substantially improved interprofessional PACU handovers, including those by clinicians who had not undergone formal simulation training. An effect appeared to be present >3 years later.

Factors associated with longer length of stay for mental health emergency department patients.

BACKGROUND: Mental health patients can experience long lengths of stay in the emergency department (ED). Reducing boarding times for mental health patients might improve care for all ED patients. OBJECTIVE: The objective of this study was to identify patient factors that are correlated with extremely long lengths of stay (EL-LOS) for mental health patients in the ED. METHODS: A retrospective, case-control study compared mental health patients experiencing lengths of stay longer than 24 h to those with lengths of stay <24 h. The study was conducted at an urban, academic ED and Level I trauma center. Sequential chi-squared tests were used to detect significant differences on the outcome measure. Logistic regression was used to determine factors that made significant contributions to predicting EL-LOS. The outcome measure was patients' length of stay in the ED. The factors analyzed were patient demographics, insurance status, day of arrival and departure, placement (admitted locally, admitted remotely, or discharged), chief complaint, and diagnostic category. RESULTS: Patient-level factors associated with EL-LOS were self-pay status, admission to inpatient care, transfer to a remote facility, and suicidal ideation. Admission to inpatient care and self-pay status made significant nonredundant contributions to predicting EL-LOS. In addition, mental health patients arriving on a weekday were significantly more likely to be admitted to inpatient care than those arriving on weekends. CONCLUSIONS: Factors were identified that correlated with long lengths of stay in the ED for mental health patients. Increasing timely access to inpatient beds for mental health patients, in particular by improving access to insurance that covers inpatient psychiatric care and eliminating unique mental health requirements to obtain prior authorization for placement, would likely reduce these patients' lengths of stay.

A survey study of benefits and limitations of using CellaVision DM96 for peripheral blood differentials.

In most clinical laboratories, hematologists rely on the microscopic analysis of stained blood films to accurately classify cells, aiding in the diagnosis and monitoring of a variety of disorders and conditions. Use of the microscope, although considered the gold standard in performing white blood cell differentials, presents a variety of limitations Digital image technology can facilitate a variety of essential job functions in clinical hematology such as: consulting with colleagues, improving training, referencing an abnormal cell, and utilizing archived images for quality assurance and competency assessment. A questionnaire was developed to survey medical laboratory professionals about their perceptions regarding the benefits and limitations for using digital images in clinical hematology. The questionnaire was sent in March 2012 to an entire list of 81 current CellaVision DM96 (CellaVision AB, Sweden) consumers. A response rate of 46% was obtained. Background information on participants, 5-point Likert scale averages, percentage agreement (strongly agree and agree), and disagreement (strongly disagree and disagree) were calculated and analyzed. The benefits of using the CellaVision DM96 rated the strongest by respondents included: decreased eyestrain, consistency among patient results and advantages in training personnel. Respondents reported notable limitations as being: restrictions with accurately estimating platelets and red cell morphology. Digital image software is currently being utilized in preclinical and clinical hematology and offers potential benefits. With upgrades in slide scanning features and improved capabilities to view platelet and red cell morphology, a transition to digital image technology from the conventional method for performing peripheral blood cell differentials is possible.

Feasibility of interdisciplinary evaluation in non-arthritic hip pain: A randomized trial.

BACKGROUND: Physical therapy and orthopaedic surgery are two common treatments for non-arthritic hip pain. Interdisciplinary evaluation across these disciplines may produce a more supportive treatment-planning process; however, the feasibility of such an evaluation remains unknown. HYPOTHESIS OBJECTIVE: To assess the feasibility of an interdisciplinary evaluation with an orthopaedic surgeon and physical therapist for non-arthritic hip pain. STUDY DESIGN: Observational feasibility study of a randomized controlled trial. METHODS: Participants were randomized to an interdisciplinary (surgeon + physical therapist) or standard (surgeon) evaluation in a hip preservation clinic. Recruitment rate was recorded. Retention rate was calculated for all variables of interest. Enrollment and refusal reasons were recorded as patient quotes and categorized by a single grader. Time spent in clinic was compared across groups using Mann Whitney U tests (P ≤ 0.05). Study clinicians were interviewed, and responses were categorized based on pre-determined themes. RESULTS: Eighty-one percent of eligible patients enrolled over a 15-month recruitment period. Willingness(n = 16), urgency to resolve pain(n = 10), financial compensation(n = 1), interest in research(n = 42), physical therapy(n = 6), or multiple-provider care(n = 15) were participants' enrollment reasons; reason was not recorded for 22 participants. Time(n = 11), preference for single-provider care(n = 6), current physical therapy treatment(n = 1), and disinterest in physical therapy(n = 7) or research(n = 2) were refusal reasons of patients who did not enroll. Retention for primary variables of interest was 100% in both groups. Participants spent, on average, 23.5 min more time in clinic for the interdisciplinary evaluation compared to the standard (P < 0.001). CONCLUSIONS: An interdisciplinary evaluation for patients with non-arthritic hip pain that included a physical therapist and orthopaedic surgeon in a hip preservation clinic was feasible and may better inform the treatment planning process.

Strategies for case-based training with virtual patients: An experimental study of the impact of integrating mental model articulation and self-reflection.

Resilient system performance in high-stakes settings, which includes the ability to monitor, respond, anticipate, and learn, can be enhanced for trainees through simulation of realistic scenarios enhanced by augmented reality. Active learning strategies can enhance simulation-based training, particularly the mental model articulation principle where students are prompted to anticipate what will happen next and the reflection principle where students self-assess their performance compared to a gold standard expert model. In this paper, we compared simulation-based training for trauma care with and without active learning strategies during pauses in the simulated action for progressively deteriorating patients. The training was conducted online and real-time without a facilitator, with 42 medical students viewing training materials and then immediately taking an online quiz for three types of trauma cases: hemorrhage, airway obstruction, and tension pneumothorax. Participants were randomly assigned to either the experimental or control condition in a between-subjects design. We compared performance in the control and experimental conditions based on: A) the proportion of cues correctly recognized, B) the proportion of accurate diagnoses, C) the proportion of appropriate treatment interventions, and D) verbal briefing quality on a 1-5 scale. We found that the training intervention increased recognition of subtle cues critical for accurate diagnosis and appropriate treatment interventions; the training did not improve the accuracy of diagnoses or the quality of the verbal briefing. We conclude that incorporating active learning strategies in simulation-based training improved foundational capabilities in detecting subtle cues and intervening to rescue deteriorating patients that can increase the readiness for trainees to contribute to resilient system performance in the high-stakes setting of emergency care in hospitals.

Enhancing electronic health record usability in pediatric patient care: a scenario-based approach.

BACKGROUND: Usability of electronic health records (EHRs) is an important factor affecting patient safety and the EHR adoption rate for both adult and pediatric care providers. A panel of interdisciplinary experts (the authors) was convened by the National Institute of Standards and Technology to generate consensus recommendations to improve EHR usefulness, usability, and patient safety when supporting pediatric care, with a focus on critical user interactions. METHODS: The panel members represented expertise in the disciplines of human factors engineering (HFE), usability, informatics, and pediatrics in ambulatory care and pediatric intensive care. An iterative, scenario-based approach was used to identify unique considerations in pediatric care and relevant human factors concepts. A draft of the recommendations were reviewed by invited experts in pediatric informatics, emergency medicine, neonatology, pediatrics, HFE, nursing, usability engineering, and software development and implementation. RECOMMENDATIONS: Recommendations for EHR developers, small-group pediatric medical practices, and children's hospitals were identified out of the original 54 recommendations, in terms of nine critical user interaction categories: patient identification, medications, alerts, growth chart, vaccinations, labs, newborn care, privacy, and radiology. CONCLUSION: Pediatric patient care has unique dimensions, with great complexity and high stakes for adverse events. The recommendations are anticipated to increase the rate of EHR adoption by pediatric care providers and improve patient safety for pediatric patients. The described methodology might be useful for accelerating adoption and increasing safety in a variety of clinical areas where the adoption of EHRs is lagging or usability issues are believed to reduce potential patient safety, efficiency, and quality benefits.