Transversus Abdominis Plane Block in Laparoscopic Colorectal Surgery: A Systematic Review.

BACKGROUND: Multimodal analgesia is important for postoperative recovery in laparoscopic colorectal surgery. Multiple randomized controlled trials have investigated the use of transversus abdominis plane local anesthetic infiltration as a method of decreasing postoperative pain and opioid consumption, with variable results. OBJECTIVE: This study aimed to examine the overall effect of transversus abdominis plane block in postoperative pain, opioid use, and speed of recovery in laparoscopic colorectal surgery. DATA SOURCES: A literature search was done with PubMed, EMBASE, Web of Knowledge, and Cochrane Library. Only randomized controlled trials were selected for review. INTERVENTIONS: Transversus abdominis plane local anesthetic infiltration versus no intervention, saline, or other techniques in laparoscopic colorectal surgeries was investigated. MAIN OUTCOME MEASURES: The primary outcome measured was postoperative pain on day 1, at rest or with activity. The secondary outcomes measured were postoperative pain beyond day 1, consumptions of opioid, and length of hospital stay. RESULTS: Eight clinical trials including 649 patients between 2013 and 2018 were included. Resting pain scores within 2 hours (standardized mean difference, -0.53; p = 0.01), 4 hours (standardized mean difference, -0.42; p = 0.004), and 6 hours (standardized mean difference, -0.47; p = 0.03) showed statistically significant reduction. Six studies including 413 patients demonstrated lower cumulative opioid consumption within 24 hours after surgery (standardized mean difference, -0.82; p = 0.01). Five studies including 357 patients did not show a significant difference in length of stay (standardized mean difference, -0.04; p = 0.82). LIMITATIONS: Local anesthetic used in block varied in type and quantity across different studies. There were heterogeneities in pain score measurements and opioid consumption. Patient populations may be different among studies. CONCLUSIONS: Transversus abdominis block can lead to a lower pain score at rest within the first 6 hours and reduce opioid consumption within the first 24 hours. See Video Abstract at http://links.lww.com/DCR/A997.

Dynamic article: combined endoscopic-laparoscopic surgery for complex colonic polyps: postoperative outcomes and video demonstration of 3 key operative techniques.

BACKGROUND: Combined endoscopic-laparoscopic surgery is a novel technique that can be used to avoid bowel resection for complex colon polyps that are not amenable to colonoscopic resection. OBJECTIVE: The aim of this study was to evaluate the safety and outcomes of combined endoscopic-laparoscopic surgery for complex colonic polyps. DESIGN: This study is a retrospective review of consecutive combined endoscopic-laparoscopic surgeries. SETTING: This study was conducted at a single institution. PATIENTS: All patients that underwent combined endoscopic-laparoscopic surgery for a complex colonic polyp at our center from October 2009 to October 2013 were followed. Each patient's lesion was assessed by a therapeutic endoscopist before referral for combined endoscopic-laparoscopic surgery, and was deemed unresectable based on size, broad base, or location of the polyp. MAIN OUTCOME MEASURES: Intraoperative and postoperative complications, length of hospital stay, and recurrence were the primary outcomes measured. RESULTS: Thirty consecutive patients underwent combined endoscopic-laparoscopic surgery. Twenty (66.7%) patients underwent laparoscopic-assisted colonoscopic polyp excision (10 of these excisions were facilitated by Endoloop placement at the polyp base), 9 (30%) patients underwent colonoscopic-assisted laparoscopic cecectomy, and 1 (3.3%) patient was converted from a colonoscopic-assisted laparoscopic cecectomy to a laparoscopic ileocolic resection. The median length of hospital stay was 2 days (range, 1-16). Twenty-nine (96.7%) of the final pathology results were benign, with 10 (33.3%) showing high-grade dysplasia. One (3.3%) final pathology result was positive for a well-differentiated adenocarcinoma. This patient subsequently underwent a laparoscopic right hemicolectomy and chemotherapy for node-positive disease. One (3.3%) patient experienced a recurrent benign polyp at the previous excision site, which was removed by colonoscopy. The time to detection of recurrence was 274 days. LIMITATIONS: This study looked at a small group of patients, over a short follow-up period. However, all consecutive patients were captured, and there were no losses to follow-up. CONCLUSIONS: Combined endoscopic-laparoscopic surgery for complex benign colonic polyps is a safe procedure, with good clinical outcomes and low recurrence rates.

Evaluation of the accuracy of smartphone medical calculation apps.

BACKGROUND: Mobile phones with operating systems and capable of running applications (smartphones) are increasingly being used in clinical settings. Medical calculating applications are popular mhealth apps for smartphones. These include, for example, apps that calculate the severity or likelihood of disease-based clinical scoring systems, such as determining the severity of liver disease, the likelihood of having a pulmonary embolism, and risk stratification in acute coronary syndrome. However, the accuracy of these apps has not been assessed. OBJECTIVE: The objective of this study was to evaluate the accuracy of smartphone-based medical calculation apps. METHODS: A broad search on Google Play, BlackBerry World, and the iTunes App Store was conducted to find medical calculation apps for smartphones. The list of apps was narrowed down based on inclusion and exclusion criteria focusing on functions thought to be relevant by a panel of general internists (number of functions =13). Ten case values were inputted for each function and were compared to manual calculations. For each case, the correct answer was assigned a score of 1. A score for the 10 cases was calculated based on the accuracy of the results for each function on each app. RESULTS: We tested 14 apps and 13 functions for each app if that function was available. We conducted 10 cases for each function for a total of 1240 tests. Most functions tested on the apps were accurate in their results with an overall accuracy of 98.6% (17 errors in 1240 tests). In all, 6 of 14 (43%) apps had 100% accuracy. Although 11 of 13 (85%) functions had perfect accuracy, there were issues with 2 functions: the Child-Pugh scores and Model for End-Stage Liver Disease (MELD) scores on 8 apps. Approximately half of the errors were clinically significant resulting in a significant change in prognosis (8/17, 47%). CONCLUSIONS: The results suggest that most medical calculating apps provide accurate and reliable results. The free apps that were 100% accurate and contained the most functions desired by internists were CliniCalc, Calculate by QxMD, and Medscape. When using medical calculating apps, the answers will likely be accurate; however, it is important to be careful when calculating MELD scores or Child-Pugh scores on some apps. Despite the few errors found, greater scrutiny is warranted to ensure full accuracy of smartphone medical calculator apps.

Medical students and personal smartphones in the clinical environment: the impact on confidentiality of personal health information and professionalism.

BACKGROUND: Smartphones are becoming ubiquitous in health care settings. The increased adoption of mobile technology such as smartphones may be attributed to their use as a point-of-care information source and to perceived improvements in clinical communication and efficiency. However, little is known about medical students' use of personal smartphones for clinical work. OBJECTIVE: The intent of the study was to examine final-year medical students' experience with and attitudes toward using personal mobile technology in the clinical environment, with respect to the perceived impact on patient confidentiality and provider professionalism. METHODS: Cross-sectional surveys were completed by final-year medical students at the University of Toronto. Respondents were asked about the type of personal mobile phone they use, security features on their personal phone, experiences using their personal phone during clinical rotations, and attitudes about using their personal phone for clinical work purposes. RESULTS: The overall response rate was 45.4% (99/218). Smartphone ownership was prevalent (98%, 97/99) with the majority (86%, 85/99) of participants using their personal phones for patient-related communication during clinical rotations. A total of 26% (26/99) of participants reported not having any type of security feature on their personal phone, 94% (90/96) of participants agreed that using their personal phone for clinical work makes them more efficient, and 86% (82/95) agreed that their personal phone allows them to provide better patient care. Although 68% (65/95) of participants believe that the use of personal phones for patient-related communication with colleagues poses a risk to the privacy and confidentiality of patient health information, 22% (21/96) of participants still use their personal phone to text or email identifiable patient data to colleagues. CONCLUSIONS: Our findings suggest that the use of personal smartphones for clinical work by medical students is prevalent. There is a need to more fully address the threat to patient confidentiality posed by the use of unsecured communication devices such as smartphones.

Advance Directives Change Frequently in Nursing Home Residents.

OBJECTIVES: To describe the rate, timing, and pattern of changes in advance directives (ADs) of do not resuscitate (DNR) and do not hospitalize (DNH) orders among new admissions to nursing homes (NHs). DESIGN: A retrospective cohort study. SETTING AND PARTICIPANTS: Admissions to all publicly funded NHs in Ontario, Canada, between January 1, 2013, and December 31, 2017. METHODS: Residents were followed until discharged from incident NH stay, death, or were still present at the end of study (December 31, 2019). They were categorized into 3 mutually exclusive baseline composite AD groups: Full Code, DNR Only, and DNR+DNH. We used Poisson regression models to estimate the incidence rate ratios of AD change between different AD groups and different decision makers for personal care, adjusted for baseline clinical and sociodemographic variables. RESULTS: A total of 102,541 NH residents were eligible for inclusion. Residents with at least 1 AD change accounted for 46% of Full Code, 30% of DNR Only, and 25% of DNR+DNH group. Median time to first AD change ranged between 26 and 55 weeks. For Full Code and DNR Only residents, the most frequent change was to an AD 1 level lower in aggressiveness or intervention, whereas for DNR+DNH residents the most frequent change was to DNR Only. About 16% of residents had 2 or more AD changes during their stay. After controlling for covariates, residents with a DNR-only order or DNR+DNH orders at admission and those with a surrogate decision maker were associated with lower AD change rates. CONCLUSIONS AND IMPLICATIONS: Measuring AD adherence rates that are documented only at a particular time often underestimates the dynamics of AD changes during a resident's stay and results in an inaccurate measure of the effectiveness of AD on resident care. There should be more frequent reviews of ADs as they are quite dynamic. Mandatory review after an acute change in a resident's health would ensure that ADs are current.

The use of smartphones in general and internal medicine units: a boon or a bane to the promotion of interprofessional collaboration?

Effective communication and coordination are critical components for improving collaborative care delivery among different healthcare providers who work in mobile and time-pressured environments. Increasingly, healthcare providers are exploring alternative communication technologies to help bridge the temporal and spatial issues that are often inherent in the clinical communication conundrum. Our study examined perceptions of General Internal Medicine (GIM) staff on the usage of Smartphone devices and a Webpaging system, which were implemented on the inpatient GIM units at two teaching hospitals in North America. An exploratory case study approach was employed and in-depth interviews with 31 clinicians were conducted. This data-set serves as a subset and prelude to a larger research study that examined and compared the impacts of different types of communication technologies used in five teaching hospitals. Findings from our study indicate that the use of Smartphone technology was well received among clinicians. Specifically, healthcare professionals valued the use of emails when communicating nonurgent issues and the availability of the phone function that enabled access to clinicians especially in urgent situations. Dissatisfaction, however, was expressed over the suitability of these smartphone features in different communication contexts as well as discrepancies between clinicians over the appropriate use of the communication modes. Future interventions in communication technology should take into considerations how communication mediums and situational contexts (e.g. urgent and nonurgent patient issues) impact interprofessional interactions.

An evidence-based case for the value of social workers in efficient hospital discharge.

A study was undertaken to make an evidence-based case for the value of social workers in efficient discharge of patients from acute care hospitals and to assist hospital managers in making informed staffing decisions. Hospital administrative databases from March 1 to November 30, 2008, were used for the analysis of inpatient discharges on days when social workers were on vacation compared with days fully staffed with social workers. Two performance measures, daily discharge rate and average length of stay, were evaluated. During the study period, 1825 patients were discharged from the General Internal Medicine inpatient service. Team discharge rates were significantly lower on social work vacation Fridays versus regular Fridays. In contrast, the average length of stay for patients discharged on social work vacation Fridays was significantly shorter than that for patients discharged on regular Fridays. It was concluded that daily discharge rate better quantified the role of social work in patient discharge. More generally, these results provide preliminary support for the need for adequate social work staffing in timely and efficient patient discharge.

Impact of an internal medicine nocturnist service on care of patients with cancer at a large Canadian teaching hospital: a quality-improvement study.

BACKGROUND: Nocturnists (overnight hospitalists) are commonly implemented in US teaching hospitals to adhere to per-resident patient caps and improve care but are rare in Canada, where patient caps and duty hours are comparatively flexible. Our objective was to assess the impact of a newly implemented nocturnist program on perceived quality of care, code status documentation and patient outcomes. METHODS: Nocturnists were phased in between June 2018 and December 2019 at Toronto General Hospital, a large academic teaching hospital in Toronto, Ontario. We performed a quality-improvement study comparing rates of code status entry into the electronic health record at admission, in-hospital mortality, the 30-day readmission rate and hospital length of stay for patients with cancer admitted by nocturnists and by residents. Surveys were administered in June 2019 to general internal medicine faculty and residents to assess their perceptions of the impact of the nocturnist program. RESULTS: From July 2018 to June 2019, 30 nocturnists were on duty for 241/364 nights (66.5%), reducing the mean maximum overnight per-resident patient census from 40 (standard deviation [SD] 4) to 25 (SD 5) (p < 0.001). The rate of admission code status entry was 35.3% among patients admitted by residents (n = 133) and 54.9% among those admitted by nocturnists (n = 339) (p < 0.001). The mortality rate was 10.5% among patients admitted by residents and 5.6% among those admitted by nocturnists (p = 0.06), the 30-day readmission rate was 8.3% and 5.9%, respectively (p = 0.4), and the mean acute length of stay was 7.2 (SD 7.0) days and 6.4 (SD 7.8) days, respectively (p = 0.3). Surveys were completed by 15/24 faculty (response rate 62%), who perceived improvements in patient safety, efficiency and trainee education; however, only 30/102 residents (response rate 29.4%) completed the survey. INTERPRETATION: Although implementation of a nocturnist program did not affect patient outcomes, it reduced residents' overnight patient census, and improved faculty perceptions of quality of care and education, as well as documentation of code status. Our results support nocturnist implementation in Canadian teaching hospitals.

Smoothing inpatient discharges decreases emergency department congestion: a system dynamics simulation model.

BACKGROUND: Timely access to emergency patient care is an important quality and efficiency issue. Reduced discharges of inpatients at weekends are a reality to many hospitals and may reduce hospital efficiency and contribute to emergency department (ED) congestion. OBJECTIVE: To evaluate the daily number of ED beds occupied by inpatients after evenly distributing inpatient discharges over the course of the week using a computer simulation model. METHODS: Simulation modelling study from an academic care hospital in Toronto, Canada. Daily historical data from the general internal medicine (GIM) department between 15 January and 15 December for two years, 2005 and 2006, were used for model building and validation, respectively. RESULTS: There was good agreement between model simulations and historical data for both ED and ward censuses and their respective lengths of stay (LOS), with the greatest difference being +7.8% for GIM ward LOS (model: 9.3 days vs historical: 8.7 days). When discharges were smoothed across the 7 days, the number of ED beds occupied by GIM patients decreased by approximately 27-57% while ED LOS decreased 7-14 hours. The model also demonstrated that patients occupying hospital beds who no longer require acute care have a considerable impact on ED and ward beds. CONCLUSIONS: Smoothing out inpatient discharges over the course of a week had a positive effect on decreasing the number of ED beds occupied by inpatients. Despite the particular challenges associated with weekend discharges, simulation experiments suggest that discharges evenly spread across the week may significantly reduce bed requirements and ED LOS.

Melatonin Increasingly Used in Hospitalized Patients.

The frequency of melatonin use for insomnia in hospitalized patients is unknown. This study assessed temporal trends of melatonin use in the hospital and compared them with those of use of zopiclone and lorazepam. We performed a retrospective observational study over 6 years from January 2013 to December 2018 at two academic urban hospitals in Toronto, Canada. We abstracted pharmacy dispensing data and standardized rates of medication use by inpatient days. Melatonin use increased from almost none to more than 70 doses per 1,000 inpatient days during 2013-2018, while zopiclone use decreased by 20 doses per 1,000 inpatient days. Melatonin use was twice as high at one hospital and was higher on internal medicine and critical care. Overall use of the three medications increased by 25.7%, which mainly reflects a marked increase in melatonin use. Melatonin is likely being used in a proportion of patients who would not otherwise have received a sleep medication.

How much do operational processes affect hospital inpatient discharge rates?

BACKGROUND: The objective of this study is to determine the effect of day of the week, holiday, team admission and rotation schedules, individual attending physicians and their length of coverage on daily team discharge rates. METHODS: We conducted a retrospective analysis of the General Internal Medicine (GIM) inpatient service at our institution for years 2005 and 2006, which included 5088 patients under GIM care. RESULTS: Weekend discharge rate was more than 50% lower compared with reference rates whereas Friday rates were 24% higher. Holiday Monday discharge rates were 65% lower than regular Mondays, with an increase in pre-holiday discharge rates. Teams that were on-call or that were on call the next day had 15% higher discharge rates compared with reference whereas teams that were post-call had 20% lower rates. Individual attending physicians and length of attending coverage contributed small variations in discharge rates. Resident scheduling was not a significant predictor of discharge rates. CONCLUSIONS: Day of the week and holidays followed by team organization and scheduling are significant predictors of daily variation in discharge rates. Introducing greater holiday and weekend capacity as well as reorganizing internal processes such as admitting and attending schedules may potentially optimize discharge rates.

Comparing administration of questionnaires via the internet to pen-and-paper in patients with heart failure: randomized controlled trial.

BACKGROUND: The use of the Internet to administer questionnaires has many potential advantages over the use of pen-and-paper administration. Yet it is important to validate Internet administration, as most questionnaires were initially developed and validated for pen-and-paper delivery. While some have been validated for use over the Internet, these questionnaires have predominately been used amongst the healthy general population. To date, information is lacking on the validity of questionnaires administered over the Internet in patients with chronic diseases such as heart failure. OBJECTIVES: To determine the validity of three heart failure questionnaires administered over the Internet compared to pen-and-paper administration in patients with heart failure. METHODS: We conducted a prospective randomized study using test-retest design comparing administration via the Internet to pen-and-paper administration for three heart failure questionnaires provided to patients recruited from a heart failure clinic in Toronto, Ontario, Canada: the Kansas City Cardiomyopathy Questionnaire (KCCQ), the Minnesota Living with Heart Failure Questionnaire (MLHFQ), and the Self-Care Heart Failure Index (SCHFI). RESULTS: Of the 58 subjects enrolled, 34 completed all three questionnaires. The mean difference and confidence intervals for the summary scores of the KCCQ, MLHFQ, and SCHFI were 1.2 (CI -1.5 to 4.0, scale from 0 to 100), 4.0 (CI -1.98 to 10.04, scale from 0 to 105), and 10.1 (CI 1.18 to 19.07, scale from 66.7 to 300), respectively. CONCLUSIONS: Internet administration of the KCCQ appears to be equivalent to pen-and-paper administration. For the MLHFQ and SCHFI, we were unable to demonstrate equivalence. Further research is necessary to determine if the administration methods are equivalent for these instruments.

Using wearables and self-management apps in patients with COPD: a qualitative study.

BACKGROUND: Technology such as wearable technology and self-management applications could improve the care of patients with chronic obstructive pulmonary disease (COPD) by real-time continuous monitoring, early detection of COPD and improved self-management. However, patients have not been willing to use technology when it is too difficult to use, interferes with their daily lives or threatens their identity, independence and self-care. METHODS: We conducted a qualitative study to determine what patients with COPD would like to see in a wearable device and a mobile application to help manage their condition. Semi-structured interviews were conducted, recorded and transcribed. Thematic analysis was used to identify themes and concepts. RESULTS: We interviewed 14 people with COPD with an average age of 69 years. Participants perceived that the technology could improve their ability to manage their condition both in daily life and during exacerbations by connecting how they feel and by knowing their oxygen saturation, heart rate and activity. The technology may help them address feelings of fear and panic associated with exacerbations and may provide reassurance and connectedness. Some people with COPD wanted their healthcare providers to have access to their data, while others were concerned about inundating them with too much information. Of note, people wanted to maintain control of the information; to make connections with the data, but also in order to be alerted when a possible exacerbation occurs. CONCLUSION: Patients perceived significant potential for wearables and apps to help manage their condition.

Cost-effectiveness of an electronic medication ordering and administration system in reducing adverse drug events.

OBJECTIVES: Adverse drug events (ADEs) are common and cause significant morbidity and mortality. Patient safety groups advocate the implementation of electronic medication order entry systems to reduce ADEs. However, these systems are costly, and there are limited data on their effectiveness. We conducted a study to examine the costs of introducing an electronic medication ordering and administration system and its potential impact on reducing ADEs. METHODS: An incremental cost-effectiveness analysis was performed comparing an electronic medication ordering and administration system to the standard system used at a large health care institution over a 10-year time horizon. Estimates of effect were obtained from the literature. Cost data were obtained from a health care institution in Toronto, Canada. RESULTS: The incremental cost-effectiveness of the new system was $12,700 (USD) per ADE prevented. The cost-effectiveness was found to be sensitive to the ADE rate, to the effectiveness of the new system, the cost of the system, and costs due to possible increase in doctor workload. CONCLUSIONS: An electronic medication order entry and administration system could improve care by reducing adverse events. Unfortunately there are limited data on effectiveness of these systems at reducing ADEs. Further research is required to determine more precisely the potential economic benefit of this technology.

Analysis of Smartphone Interruptions on Academic General Internal Medicine Wards. Frequent Interruptions may cause a 'Crisis Mode' Work Climate.

INTRODUCTION: Hospital-based medical services are increasingly utilizing team-based pagers and smartphones to streamline communications. However, an unintended consequence may be higher volumes of interruptions potentially leading to medical error. There is likely a level at which interruptions are excessive and cause a 'crisis mode' climate. METHODS: We retrospectively collected phone, text messaging, and email interruptions directed to hospital-assigned smartphones on eight General Internal Medicine (GIM) teams at two tertiary care centres in Toronto, Ontario from April 2013 to September 2014. We also calculated the number of times these interruptions exceeded a pre-specified threshold per hour, termed 'crisis mode', defined as at least five interruptions in 30 minutes. We analyzed the correlation between interruptions and date, site, and patient volumes. RESULTS: A total of 187,049 interruptions were collected over an 18-month period. Daily weekday interruptions rose sharply in the morning, peaking between 11 AM to 12 PM and measuring 4.8 and 3.7 mean interruptions/hour at each site, respectively. Mean daily interruptions per team totaled 46.2 ± 3.6 at Site 1 and 39.2 ± 4.2 at Site 2. The 'crisis mode' threshold was exceeded, on average, 2.3 times/day per GIM team during weekdays. In a multivariable linear regression analysis, site (ß6.43 CI95% 5.44 - 7.42, p<0.001), day of the week (with Friday having the most interruptions) (ß0.481 CI95% 0.236 - 0.730, p<0.05) and patient census (ß1.55 CI95% 1.42 - 1.67, p<0.05) were all predictive of daily interruption volume although there was a significant interaction effect between site and patient census (ß-0.941 CI95% -1.18 - -0.703, p<0.05). CONCLUSION: Interruptions were related to site-specific features, including volume, suggesting that future interventions should target the culture of individual hospitals. Excessive interruptions may have implications for patient safety especially when exceeding a maximal threshold over short periods of time.

An analysis of messages sent between nurses and physicians in deteriorating internal medicine patients to help identify issues in failures to rescue.

OBJECTIVE: To evaluate in patients who deteriorate and require transfer to the intensive care unit (ICU), how many have a critical text message communicating deterioration and what is the quality of this message? Is message quality, message response or the timeliness of rapid response team (RRT) activation related to death? METHODS: We conducted a retrospective chart review of all ICU transfers from General Internal Medicine (GIM) wards from January 2012 until August 2014. All critical messages (CM) in the 48h prior to ICU transfer were analyzed for RRT calling criteria, time to RRT activation, message quality, presence of vitals, and the quality and timeliness of physician response. RESULTS: Of the 236 patients in the study, 93 (39%) had a CM in the 48h prior to ICU transfer. Within this subset, 76 patients did not have prior RRT activation and the median times from CM to RRT activation and CM to ICU transfer were 8.9 [IQR 2.9, 20.7] and 15.6 [IQR 9.0, 28.7] hours, respectively. Only 45% of messages contained 2 or more vitals and only 3% of messages contained Situation, Background, Assessment, and Recommendations (SBAR). Physician response was timely (3 [IQR 2, 17] min) but response quality was poor; nearly one quarter of responses only acknowledged receipt. Among message characteristics, only the number of SBAR elements was correlated with in-hospital survival (p=0.047). CONCLUSION: Communication between nurses and physicians about critically ill patients could be improved. There appear to be significant gaps in the quality of messages, their responses, and delays in RRT activation.

Hospital-Based Clinicians' Use of Technology for Patient Care-Related Communication: A National Survey.

OBJECTIVE: To characterize current use of communication technologies, including standard text messaging and secure mobile messaging applications, for patient care-related (PCR) communication. METHODS: We used a Society of Hospital Medicine database to conduct a national cross-sectional survey of hospital-based clinicians. RESULTS: We analyzed data from 620 survey respondents (adjusted response rate, 11.0%). Pagers were provided by hospitals to 495 (79.8%) of these clinicians, and 304 (49%) of the 620 reported they received PCR messages most commonly by pager. Use of standard text messaging for PCR communication was common, with 300 (52.9%) of 567 clinicians reporting receipt of standard text messages once or more per day. Overall, 21.5% (122/567) of respondents received standard text messages that included individually identifiable information, 41.3% (234/567) received messages that included some identifiable information (eg, patient initials), and 21.0% (119/567) received messages for urgent clinical issues at least once per day. About one-fourth of respondents (26.6%, 146/549) reported their organization had implemented a secure messaging application that some clinicians were using, whereas few (7.3%, 40/549) reported their organization had implemented an application that most clinicians were using. DISCUSSION: Pagers remain the technology most commonly used by hospital-based clinicians, but a majority also use standard text messaging for PCR communication, and relatively few hospitals have fully implemented secure mobile messaging applications. CONCLUSION: The wide range of technologies used suggests an evolution of methods to support communication among healthcare professionals.

Evidence for handheld electronic medical records in improving care: a systematic review.

BACKGROUND: Handheld electronic medical records are expected to improve physician performance and patient care. To confirm this, we performed a systematic review of the evidence assessing the effects of handheld electronic medical records on clinical care. METHODS: To conduct the systematic review, we searched MEDLINE, EMBASE, CINAHL, and the Cochrane library from 1966 through September 2005. We included randomized controlled trials that evaluated effects on practitioner performance or patient outcomes of handheld electronic medical records compared to either paper medical records or desktop electronic medical records. Two reviewers independently reviewed citations, assessed full text articles and abstracted data from the studies. RESULTS: Two studies met our inclusion criteria. No other randomized controlled studies or non-randomized controlled trials were found that met our inclusion criteria. Both studies were methodologically strong. The studies examined changes in documentation in orthopedic patients with handheld electronic medical records compared to paper charts, and both found an increase in documentation. Other effects noted with handheld electronic medical records were an increase in time to document and an increase in wrong or redundant diagnoses. CONCLUSION: Handheld electronic medical records may improve documentation, but as yet, the number of studies is small and the data is restricted to one group of patients and a small group of practitioners. Further study is required to determine the benefits with handheld electronic medical records especially in assessing clinical outcomes.

Pilot study of an Internet patient-physician communication tool for heart failure disease management.

BACKGROUND: Internet disease management has the promise of improving care in patients with heart failure but evidence supporting its use is limited. We have designed a Heart Failure Internet Communication Tool (HFICT), allowing patients to enter messages for clinicians, as well as their daily symptoms, weight, blood pressure and heart rate. Clinicians review the information on the same day and provide feedback. OBJECTIVE: This pilot study evaluated the feasibility and patients' acceptability of using the Internet to communicate with patients with symptomatic heart failure. METHODS: Patients with symptomatic heart failure were instructed how to use the Internet communication tool. The primary outcome measure was the proportion of patients who used the system regularly by entering information on average at least once per week for at least 3 months. Secondary outcomes measures included safety and maintainability of the tool. We also conducted a content analysis of a subset of the patient and clinician messages entered into the comments field. RESULTS: Between 3 May 1999 and 1 November 2002, 62 patients (mean age 48.7 years) were enrolled. At 3 months 58 patients were alive and without a heart transplant. Of those, 26 patients (45%; 95% Confidence Interval, 0.33-0.58) continued using the system at 3 months. In 97% of all entries by participants weight was included; 68% of entries included blood pressure; and 71% of entries included heart rate. In 3,386 entries out of all 5,098 patient entries (66%), comments were entered. Functions that were not used included the tracking of diuretics, medications and treatment goals. The tool appeared to be safe and maintainable. Workload estimates for clinicians for entering a response to each patient's entry ranged from less than a minute to 5 minutes or longer for a detailed response. Patients sent 3,386 comments to the Heart Function Clinic. Based on the content analysis of 100 patient entries, the following major categories of communication were identified: patient information; patient symptoms; patient questions regarding their condition; patient coordinating own care; social responses. The number of comments decreased over time for both patients and clinicians. CONCLUSIONS: While the majority of patients discontinued use, 45% of the patients used the system and continued to use it on average for 1.5 years. An Internet tool is a feasible method of communication in a substantial proportion of patients with heart failure. Further study is required to determine whether clinical outcomes, such as quality of life or frequency of hospitalization, are improved.

Implementation of a computerized physician order entry system of medications at the University Health Network--physicians' perspectives on the critical issues.

There are many reasons why most hospitals have not adopted physician order entry systems for medications. It is a costly endeavour (Kuperman and Gibson 2003) that can cause major disruptions to workflow for physicians, pharmacists and nurses. Yet, the technology can reduce medication errors, especially with sophisticated decision support. We have presented many of the lessons learned from our successful implementation experience. To date, over 90% of medication orders are entered by physicians. The technology must be ready for the implementation. System issues such as errors, slowness and freezing give ready opportunity for critics who will claim the system is just not ready for real-time. Through rigorous testing, we were able to avoid issues previously seen in our pilot study. Usability testing with end-users was also critical in both guiding decision-making as well as validating that the system was ready for implementation. Proper training and support were also necessary. To ensure ready adoption, decision support was optimized to reduce the volume of less important alerts. Most importantly, we found that active physician involvement at multiple levels was key. This ensured that physicians understood from a high-level perspective that this change was necessary. Planning for specific implementation details had the benefit of input from physicians working in the area. Day-to-day issues of our residents and staff were also addressed promptly.