Evaluating Digital Maturity and Patient Acceptability of Real-Time Patient Experience Feedback Systems: Systematic Review.

BACKGROUND: One of the essential elements of a strategic approach to improving patients' experience is to measure and report on patients' experiences in real time. Real-time feedback (RTF) is increasingly being collected using digital technology; however, there are several factors that may influence the success of the digital system. OBJECTIVE: The aim of this review was to evaluate the digital maturity and patient acceptability of real-time patient experience feedback systems. METHODS: We systematically searched the following databases to identify papers that used digital systems to collect RTF: The Cochrane Library, Global Health, Health Management Information Consortium, Medical Literature Analysis and Retrieval System Online, EMBASE, PsycINFO, Web of Science, and CINAHL. In addition, Google Scholar and gray literature were utilized. Studies were assessed on their digital maturity using a Digital Maturity Framework on the basis of the following 4 domains: capacity/resource, usage, interoperability, and impact. A total score of 4 indicated the highest level of digital maturity. RESULTS: RTF was collected primarily using touchscreens, tablets, and Web-based platforms. Implementation of digital systems showed acceptable response rates and generally positive views from patients and staff. Patient demographics according to RTF responses varied. An overrepresentation existed in females with a white predominance and in patients aged ≥65 years. Of 13 eligible studies, none had digital systems that were deemed to be of the highest level of maturity. Three studies received a score of 3, 2, and 1, respectively. Four studies scored 0 points. While 7 studies demonstrated capacity/resource, 8 demonstrated impact. None of the studies demonstrated interoperability in their digital systems. CONCLUSIONS: Patients and staff alike are willing to engage in RTF delivered using digital technology, thereby disrupting previous paper-based feedback. However, a lack of emphasis on digital maturity may lead to ineffective RTF, thwarting improvement efforts. Therefore, given the potential benefits of RTF, health care services should ensure that their digital systems deliver across the digital maturity continuum.

The Prevention of Venous Thromboembolism in Surgical Patients.

Patients undergoing surgery are at an increased risk of VTE. Since the early 1990s the prevention of VTE has been dominated by the administration of low-molecular weight heparin during admission. New oral anticoagulants have been extensively researched and have increased in popularity. This chapter reviews why surgical patients are at increased risk of VTE and summaries both the pharmacological and mechanical methods of prophylaxis available.

The Diagnosis and Management of Early Deep Vein Thrombosis.

The diagnosis and management of an acute DVT is difficult and mistakes are often made. The cost to the National Health Service (NHS) of litigation arising from failure to diagnose and treat DVT early is substantial. Clinical diagnosis alone is often unreliable and a large proportion of DVT occurring in hospital are asymptomatic. In the United Kingdom, clinical scoring systems, D-dimer and ultrasound (US) imaging have all been adopted to aid diagnosis via DVT pathways. These pathways aim to exclude DVT only and often fail to actually address the cause of the symptoms once DVT is eventually cleared.

The role of compression in the management of soft tissue ankle injuries: a systematic review.

BACKGROUND: Ankle sprains are very common injuries which can lead to long-term pain, swelling and instability. Compression is often used in the treatment of these common injuries but is it effective and how best is it delivered? METHODS: MEDLINE (1966-current), EMBASE (1980-current), Cochrane Library (2011:1) and MEDION were included in our search. Studies evaluating compression in the treatment of ankle sprains were included. Two authors independently reviewed potential studies according to a set eligibility criteria. RESULTS: Twelve studies including 1,701 patients with ankle sprains were identified (level of evidence: four grade 1b; five grade 2b; three grade 4). Intermittent pneumatic compression (IPC), elastic tubular bandage and compression bandaging were all evaluated. Five of the 12 studies reported that compression therapy improves recovery after ankle injury, of which one evaluated IPC, and the remaining four elastic bandages (Elastoplast, class II elastic stockings, wool and crepe, focal compression with air stirrup). Five studies evaluating Tubigrip in ankle sprains concluded that Tubigrip has no positive effect on functional recovery and may increase the requirement for analgesia compared with no intervention. CONCLUSION: Compression may be an effective tool in the management of ankle injuries and has been shown to reduce swelling and improve quality of life in single studies. Definitive conclusions are hampered by the poor quality of evidence and the variety of treatments used. The most effective form of compression to treat ankle sprains or is yet to be determined. Adequately designed randomized control trials are clearly needed.

Using natural language processing to understand, facilitate and maintain continuity in patient experience across transitions of care.

BACKGROUND: Patient centred care necessitates that healthcare experiences and perceived outcomes be considered across all transitions of care. Information encoded within free-text patient experience comments relating to transitions of care are not captured in a systematic way due to the manual resource required. We demonstrate the use of natural language processing (NLP) to extract meaningful information from the Friends and Family Test (FFT). METHODS: Free-text fields identifying favourable service ("What did we do well?") and areas requiring improvement ("What could we do better?") were extracted from 69,285 FFT reports across four care settings at a secondary care National Health Service (NHS) hospital. Sentiment and patient experience themes were coded by three independent coders to produce a training dataset. The textual data was standardised with a series of pre-processing techniques and the performance of six machine learning (ML) models was obtained. The best performing ML model was applied to predict the themes and sentiment from the remaining reports. Comments relating to transitions of care were extracted, categorised by sentiment, and care setting to identify the most frequent words/combinations presented as tri-grams and word clouds. RESULTS: The support vector machine (SVM) ML model produced the highest accuracy in predicting themes and sentiment. The most frequent single words relating to transition and continuity with a negative sentiment were "discharge" in inpatients and Accident and Emergency, "appointment" in outpatients, and "home' in maternity. Tri-grams identified from the negative sentiments such as 'seeing different doctor', 'information aftercare lacking', 'improve discharge process' and 'timing discharge letter' have highlighted some of the problems with care transitions. None of this information was available from the quantitative data. CONCLUSIONS: NLP can be used to identify themes and sentiment from patient experience survey comments relating to transitions of care in all four healthcare settings. With the help of a quality improvement framework, findings from our analysis may be used to guide patient-centred interventions to improve transitional care processes.

Enriching the Value of Patient Experience Feedback: Web-Based Dashboard Development Using Co-design and Heuristic Evaluation.

BACKGROUND: There is an abundance of patient experience data held within health care organizations, but stakeholders and staff are often unable to use the output in a meaningful and timely way to improve care delivery. Dashboards, which use visualized data to summarize key patient experience feedback, have the potential to address these issues. OBJECTIVE: The aim of this study is to develop a patient experience dashboard with an emphasis on Friends and Family Test (FFT) reporting, as per the national policy drive. METHODS: A 2-stage approach was used-participatory co-design involving 20 co-designers to develop a dashboard prototype, followed by iterative dashboard testing. Language analysis was performed on free-text patient experience data from the FFT, and the themes and sentiments generated were used to populate the dashboard with associated FFT metrics. Heuristic evaluation and usability testing were conducted to refine the dashboard and assess user satisfaction using the system usability score. RESULTS: The qualitative analysis from the co-design process informed the development of the dashboard prototype with key dashboard requirements and a significant preference for bubble chart display. The heuristic evaluation revealed that most cumulative scores had no usability problems (18/20, 90%), had cosmetic problems only (7/20, 35%), or had minor usability problems (5/20, 25%). The mean System Usability Scale score was 89.7 (SD 7.9), suggesting an excellent rating. CONCLUSIONS: The growing capacity to collect and process patient experience data suggests that data visualization will be increasingly important in turning feedback into improvements to care. Through heuristic usability, we demonstrated that very large FFT data can be presented in a thematically driven, simple visual display without the loss of the nuances and still allow for the exploration of the original free-text comments. This study establishes guidance for optimizing the design of patient experience dashboards that health care providers find meaningful, which in turn drives patient-centered care.

Identifying factors that promote and limit the effective use of real-time patient experience feedback: a mixed-methods study in secondary care.

OBJECTIVES: The Friends and Family Test (FFT) is commissioned by the National Health Service (NHS) in England to capture patient experience as a real-time feedback initiative for patient-centred quality improvement (QI). The aim of this study was to create a process map in order to identify the factors that promote and limit the effective use of FFT as a real-time feedback initiative for patient-centred QI. SETTING: This study was conducted at a large London NHS Trust. Services include accident and emergency, inpatient, outpatient and maternity, which routinely collect FFT patient experience data. PARTICIPANTS: Healthcare staff and key stakeholders involved in FFT. INTERVENTIONS: Semi-structured interviews were conducted on 15 participants from a broad range of professional groups to evaluate their engagement with the FFT. Interview data were recorded, transcribed and analysed for using deductive thematic analysis. RESULTS: Concerns related to inefficiency in the flow of FFT data, lack of time to analyse FFT reports (with emphasis on high level reporting rather than QI), insufficient access to FFT reports and limited training provided to understand FFT reports for frontline staff. The sheer volume of data received was not amenable to manual thematic analysis resulting in inability to acquire insight from the free text. This resulted in staff ambivalence towards FFT as a near real-time feedback initiative. CONCLUSIONS: The results state that there is too much FFT free text for meaningful analysis, and the output is limited to the provision of sufficient capacity and resource to analyse the data, without consideration of other options, such as text analytics and amending the data collection tool.

Applying natural language processing and machine learning techniques to patient experience feedback: a systematic review.

OBJECTIVES: Unstructured free-text patient feedback contains rich information, and analysing these data manually would require a lot of personnel resources which are not available in most healthcare organisations.To undertake a systematic review of the literature on the use of natural language processing (NLP) and machine learning (ML) to process and analyse free-text patient experience data. METHODS: Databases were systematically searched to identify articles published between January 2000 and December 2019 examining NLP to analyse free-text patient feedback. Due to the heterogeneous nature of the studies, a narrative synthesis was deemed most appropriate. Data related to the study purpose, corpus, methodology, performance metrics and indicators of quality were recorded. RESULTS: Nineteen articles were included. The majority (80%) of studies applied language analysis techniques on patient feedback from social media sites (unsolicited) followed by structured surveys (solicited). Supervised learning was frequently used (n=9), followed by unsupervised (n=6) and semisupervised (n=3). Comments extracted from social media were analysed using an unsupervised approach, and free-text comments held within structured surveys were analysed using a supervised approach. Reported performance metrics included the precision, recall and F-measure, with support vector machine and Naïve Bayes being the best performing ML classifiers. CONCLUSION: NLP and ML have emerged as an important tool for processing unstructured free text. Both supervised and unsupervised approaches have their role depending on the data source. With the advancement of data analysis tools, these techniques may be useful to healthcare organisations to generate insight from the volumes of unstructured free-text data.

The early management of DVT in the North West of England: A nation-wide problem?

BACKGROUND: Despite NICE guidelines, the early management of deep vein thrombosis (DVT) in UK hospitals varies widely. We investigated the variation in clinical pathways used in NHS hospitals in North West England. METHODS: A detailed questionnaire was sent to seventeen University or District General hospitals with an Accident and Emergency department. Copies of protocols or patient pathways were requested. RESULTS: 15 hospitals responded despite our repeated requests for information. Of those, four hospitals did not provide any DVT protocol, guideline or service for DVT. In seven (63.6%) hospitals, possible DVT patients were assessed in A&E, and four (36.4%) in Acute Medical Admission Units. During the day, initial assessment was by a Specialist Nurse (SN)/Advance Nurse Practitioner (ANP) in 4 (36.4%) hospitals, by a doctor in 5 out of 11 hospitals (45.5%) and a combination of ANP and doctors in 2 out of 11 (18.2%) hospitals. Out of hours assessment was conducted by a doctor in all 11 hospitals (100%). Two (18.2%) hospitals used the 2003 Wells score, three (27.3%) used the 1997 Wells score and six (54.5%) hospitals used 'in house' modified Wells score. The score required to trigger further investigation varied between different hospitals. Only four (36.4%) hospitals could arrange US imaging within four hours of presentation. CONCLUSION: This lack of co-ordinated services for the management of DVT in the North West England is likely to reflect national practice. A national programme is urgently needed to ensure patients with suspected DVT are managed using standardised and consistent protocols.

Is cryoanalgesia effective for post-thoracotomy pain?

A best evidence topic was written according to a structured protocol. The question addressed was whether cryoanalgesia improves post-thoracotomy pain and recovery. Twelve articles were identified that provided the best evidence to answer the question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Reported measures were pain scores, additional opiate requirements, incidence of hypoesthesia and change in lung function. Half of the articles reviewed failed to demonstrate superiority of cryoanalgesia over other pain relief methods; however, additional opiate requirements were reduced in patients receiving cryoanalgesia. Change in lung function postoperatively was equivocal. Cryoanalgesia potentiated the incidence of postoperative neuropathic pain. Further analysis of the source of cryoanalgesia, duration, temperature obtained and extent of blockade revealed numerous discrepancies. Three studies utilized CO2 as the source of cryoanalgesia and four used nitrous oxide, but at differing temperatures and duration. Five studies did not reveal the source of cyroanalgesia. The number of intercostal nerves anaesthetized in each study varied. Seven articles anaesthetized three intercostal nerves, three articles used five intercostal nerves, one article used four intercostal nerves and one used one intercostal nerve at the thoracotomy site. Thoracotomy closure and site of area of chest drain insertion may have a role in postoperative pain; but only one article explained method of closure, and two articles mentioned placement of chest drain through blocked dermatomes. No causal inferences can be made by the above results as they are not directly comparable due to confounding variables between studies. Currently, the evidence does not support the use of cryoanalgesia alone as an effective method for relieving post-thoracotomy pain.

Type B aortic dissection after standard endovascular repair of abdominal aortic aneurysm.

Dissection of the aorta is a rare yet potentially serious complication following endovascular abdominal aortic aneurysm (EVAR). These can lead to visceral branch hypoperfusion, compromise of aneurysm exclusion, arterial dilation or rupture. Intimal injury and dissection in the context of EVAR may be associated with a number of risk factors that include adverse infrarenal neck morphology, device oversizing, barbed fixation and wire manipulation in the proximal aorta. Herein, we describe three cases of type B aortic dissection following EVAR and discuss possible causes. As the applicability of endovascular technology widens, clinicians are reminded of the importance of early recognition and detection of unusual sequelae following EVAR.

Dissection of the pulmonary ligament during upper lobectomy: is it necessary?

A best evidence topic was written according to a structured protocol. The question addressed was whether dissection of the pulmonary ligament during an upper lobectomy would result in improved outcomes. A total of 85 articles were found using the reported search, of which eight represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Reported measures were complications associated with dissection (atelectasis, bronchial stenosis, bronchial obstruction and bronchial deformation) and preservation (insufficient lung expansion, pooling of effusion and atelectasis) of the pulmonary ligament, ratio (%) of dead space in longitudinal axis (movement of nonoperated lobes), change in the angle (degrees) of main bronchus on the operated side, overall morbidity and mortality, overall survival and conversion rates. In a randomized control trial, the dissection of the pulmonary ligament revealed no significant difference in the dead space ratio or change in the angle of the main bronchus when compared with preservation. Dissection of the ligament, in theory, reduces the free space in the upper thorax by increasing the mobility of the residual lobes. Dissection of the ligament may lead to bronchial deformation, stenosis, obstruction or lobar torsion. Preservation of the ligament may prevent this complication by suppressing the upward movement of residual lobes. However, this may result in pleural effusion in the free thoracic space that may potentially become infected resulting in an empyema or bronchial fistula. Five large case series were analysed; three routinely dissected the pulmonary ligament and two did not. There was no observed difference in clinical outcomes between the two groups. There is no convincing evidence that dissection of the pulmonary ligament in an upper lobectomy significantly improves outcomes and reduces complications.