A Pilot of Digital Whiteboards for Improving Patient Satisfaction in the Emergency Department: Nonrandomized Controlled Trial.

BACKGROUND: Electronic paper (E-paper) screens use electrophoretic ink to provide paper-like low-power displays with advanced networking capabilities that may potentially serve as an alternative to traditional whiteboards and television display screens in hospital settings. E-paper may be leveraged in the emergency department (ED) to facilitate communication. Providing ED patient status updates on E-paper screens could improve patient satisfaction and overall experience and provide more equitable access to their health information. OBJECTIVE: We aimed to pilot a patient-facing digital whiteboard using E-paper to display relevant orienting and clinical information in real time to ED patients. We also sought to assess patients' satisfaction after our intervention and understand our patients' overall perception of the impact of the digital whiteboards on their stay. METHODS: We deployed a 41-inch E-paper digital whiteboard in 4 rooms in an urban, tertiary care, and academic ED and enrolled 110 patients to understand and evaluate their experience. Participants completed a modified Hospital Consumer Assessment of Health Care Provider and Systems satisfaction questionnaire about their ED stay. We compared responses to a matched control group of patients triaged to ED rooms without digital whiteboards. We designed the digital whiteboard based on iterative feedback from various departmental stakeholders. After establishing IT infrastructure to support the project, we enrolled patients on a convenience basis into a control and an intervention (digital whiteboard) group. Enrollees were given a baseline survey to evaluate their comfort with technology and an exit survey to evaluate their opinions of the digital whiteboard and overall ED satisfaction. Statistical analysis was performed to compare baseline characteristics as well as satisfaction. RESULTS: After the successful prototyping and implementation of 4 digital whiteboards, we screened 471 patients for inclusion. We enrolled 110 patients, and 50 patients in each group (control and intervention) completed the study protocol. Age, gender, and racial and ethnic composition were similar between groups. We saw significant increases in satisfaction on postvisit surveys when patients were asked about communication regarding delays (P=.03) and what to do after discharge (P=.02). We found that patients in the intervention group were more likely to recommend the facility to family and friends (P=.04). Additionally, 96% (48/50) stated that they preferred a room with a digital whiteboard, and 70% (35/50) found the intervention "quite a bit" or "extremely" helpful in understanding their ED stay. CONCLUSIONS: Digital whiteboards are a feasible and acceptable method of displaying patient-facing data in the ED. Our pilot suggested that E-paper screens coupled with relevant, real-time clinical data and packaged together as a digital whiteboard may positively impact patient satisfaction and the perception of the facility during ED visits. Further study is needed to fully understand the impact on patient satisfaction and experience. TRIAL REGISTRATION: ClinicalTrials.gov NCT04497922; https://clinicaltrials.gov/ct2/show/NCT04497922.

Electronic Paper Displays in Hospital Operations: Proposal for Deployment and Implementation.

BACKGROUND: Display signage is ubiquitous and essential in hospitals to serve several clerical, operational, and clinical functions, including displaying notices, providing directions, and presenting clinical information. These functions improve efficiency and patient engagement, reduce errors, and enhance the continuity of care. Over time, signage has evolved from analog approaches such as whiteboards and handwritten notices to digital displays such as liquid crystal displays, light emitting diodes, and, now, electronic ink displays. Electronic ink displays are paper-like displays that are not backlit and show content by aligning microencapsulated color beads in response to an applied electric current. Power is only required to generate content and not to retain it. These displays are very readable, with low eye strain; minimize the emission of blue light; require minimal power; and can be driven by several data sources, ranging from virtual servers to electronic health record systems. These attributes make adapting electronic ink displays to hospitals an ideal use case. OBJECTIVE: In this paper, we aimed to outline the use of signage and displays in hospitals with a focus on electronic ink displays. We aimed to assess the advantages and limitations of using these displays in hospitals and outline the various public-facing and patient-facing applications of electronic ink displays. Finally, we aimed to discuss the technological considerations and an implementation framework that must be followed when adopting and deploying electronic ink displays. METHODS: The public-facing applications of electronic ink displays include signage and way-finders, timetables for shared workspaces, and noticeboards and bulletin boards. The clinical display applications may be smaller form factors such as door signs or bedside cards. The larger, ≥40-inch form factors may be used within patient rooms or at clinical command centers as a digital whiteboard to display general information, patient and clinician information, and care plans. In all these applications, such displays could replace analog whiteboards, noticeboards, and even other digital screens. RESULTS: We are conducting pilot research projects to delineate best use cases and practices in adopting electronic ink displays in clinical settings. This will entail liaising with key stakeholders, gathering objective logistical and feasibility data, and, ultimately, quantifying and describing the effect on clinical care and patient satisfaction. CONCLUSIONS: There are several use cases in a clinical setting that may lend themselves perfectly to electronic ink display use. The main considerations to be studied in this adoption are network connectivity, content management, privacy and security robustness, and detailed comparison with existing modalities. Electronic ink displays offer a superior opportunity to future-proof existing practices. There is a need for theoretical considerations and real-world testing to determine if the advantages outweigh the limitations of electronic ink displays.

Clinical Decision Support Reduces Unnecessary Tetanus Vaccinations in the Emergency Department.

STUDY OBJECTIVE: Tetanus is the most common vaccination given in the emergency department; yet, administrations of tetanus vaccine boosters in the ED may not comply with the US Centers for Disease Control and Prevention's recommended vaccination schedule. We implemented a clinical decision support alert in the electronic health record that warned providers when ordering a tetanus vaccine if a prior one had been given within 10 years and studied its efficacy to reduce potentially unnecessary vaccines in the ED. METHODS: This was a retrospective, quasi-experimental, 1-group, pretest-posttest study in 3 hospital EDs in Boston, MA. We studied adult patients for whom tetanus vaccines were ordered despite a history of vaccination within the prior 10 years. We compared the number of potentially unnecessary tetanus vaccine administrations in a baseline phase (when the clinical decision support alert was not visible) versus an intervention phase. RESULTS: Of eligible patients, 22.1% (95% confidence interval [CI] 21.8% to 22.4%) had prior tetanus vaccines within 5 years, 12.8% (95% CI 12.5% to 13.0%) within 5 to 10 years, 3.8% (95% CI 3.6% to 3.9%) more than 10 years ago, and 61.3% (95% CI 60.9% to 61.7%) had no prior tetanus vaccination documentation. Of 60,983 encounters, 337 met the inclusion criteria. A tetanus vaccination was administered in 91% (95% CI 87% to 96%) of encounters in the baseline phase, compared to 55% (95% CI 47% to 62%) during the intervention. The absolute risk reduction was 36.7% (95% CI 28.0% to 45.4%), and the number of encounters needed to alert to avoid 1 potentially unnecessary tetanus vaccine (number needed to treat) was 2.7 (95% CI 2.2% to 3.6%). For patients with tetanus vaccines within the prior 5 years, the absolute risk reduction was 47.9% (95% CI 35.5 % to 60.3%) and the number needed to treat was 2.1 (95% CI 1.7% to 2.8%). CONCLUSION: A clinical decision support alert that warns ED clinicians that a patient may have an up-to-date tetanus vaccination status reduces potentially unnecessary vaccinations.

Internet of Things Buttons for Real-Time Notifications in Hospital Operations: Proposal for Hospital Implementation.

BACKGROUND: Hospital staff frequently performs the same process hundreds to thousands of times a day. Customizable Internet of Things buttons are small, wirelessly-enabled devices that trigger specific actions with the press of an integrated button and have the potential to automate some of these repetitive tasks. In addition, IoT buttons generate logs of triggered events that can be used for future process improvements. Although Internet of Things buttons have seen some success as consumer products, little has been reported on their application in hospital systems. OBJECTIVE: We discuss potential hospital applications categorized by the intended user group (patient or hospital staff). In addition, we examine key technological considerations, including network connectivity, security, and button management systems. METHODS: In order to meaningfully deploy Internet of Things buttons in a hospital system, we propose an implementation framework grounded in the Plan-Do-Study-Act method. RESULTS: We plan to deploy Internet of Things buttons within our hospital system to deliver real-time notifications in public-facing tasks such as restroom cleanliness and critical supply restocking. We expect results from this pilot in the next year. CONCLUSIONS: Overall, Internet of Things buttons have significant promise; future rigorous evaluations are needed to determine the impact of Internet of Things buttons in real-world health care settings.

Differentiable contributions of human amygdalar subregions in the computations underlying reward and avoidance learning.

To understand how the human amygdala contributes to associative learning, it is necessary to differentiate the contributions of its subregions. However, major limitations in the techniques used for the acquisition and analysis of functional magnetic resonance imaging (fMRI) data have hitherto precluded segregation of function with the amygdala in humans. Here, we used high-resolution fMRI in combination with a region-of-interest-based normalization method to differentiate functionally the contributions of distinct subregions within the human amygdala during two different types of instrumental conditioning: reward and avoidance learning. Through the application of a computational-model-based analysis, we found evidence for a dissociation between the contributions of the basolateral and centromedial complexes in the representation of specific computational signals during learning, with the basolateral complex contributing more to reward learning, and the centromedial complex more to avoidance learning. These results provide unique insights into the computations being implemented within fine-grained amygdala circuits in the human brain.

Hippocampal dysfunction in patients with mild cognitive impairment: a functional neuroimaging study of a visuospatial paired associates learning task.

Mild cognitive impairment (MCI) patients report memory problems greater than those normally expected with ageing, but do not fulfil criteria for clinically probable Alzheimer's disease. Accumulating evidence demonstrates that impaired performance on the Paired Associates Learning (PAL) test from the Cambridge Neuropsychological Test Automated Battery (CANTAB) may be sensitive and specific for early and differential diagnosis of Alzheimer's disease. We adapted the basic CANTAB PAL task for functional magnetic resonance imaging (fMRI) in order to examine the functional brain deficits, at encoding and retrieval separately, in patients with MCI compared to healthy matched volunteers. As well as investigating the main effects of encoding and retrieval, we characterized neural responses in the two groups to increasing memory load. We focused on changes in BOLD response in the hippocampus and related structures, as an a priori region of interest based on what is known about the neuropathology of the early stages of Alzheimer's disease and previous information on the neural substrates of the PAL task. We also used structural MRI in the same patients to assess accompanying structural brain abnormalities associated with MCI. In terms of the BOLD response, the bilateral hippocampal activation in the MCI and control groups depended upon load, the MCI patients activating significantly more than controls at low loads and significantly less at higher loads. There were no other differences between MCI patients and controls in terms of the neural networks activated during either encoding or retrieval of the PAL task, including the prefrontal, cingulate and temporal cortex. The functional deficit in hippocampal activation in the MCI patients was accompanied by structural differences in the same location, suggesting that the decrease in hippocampal activation may be caused by a decrease in the amount of grey matter. This is one of the first studies to have used both encoding and retrieval phases of a memory paradigm for fMRI in MCI patients, and to have shown that the BOLD response in MCI patients can show both hyperactivation and hypoactivation in the same individuals as a function of memory load and encoding/retrieval. The findings suggest that performance on PAL might be a useful cognitive biomarker for early detection of Alzheimer's disease, especially when used in conjunction with neuroimaging.

Cranberry and grape seed extracts inhibit the proliferative phenotype of oral squamous cell carcinomas.

Proanthocyanidins, compounds highly concentrated in dietary fruits, such as cranberries and grapes, demonstrate significant cancer prevention potential against many types of cancer. The objective of this study was to evaluate cranberry and grape seed extracts to quantitate and compare their anti-proliferative effects on the most common type of oral cancer, oral squamous cell carcinoma. Using two well-characterized oral squamous cell carcinoma cell lines, CAL27 and SCC25, assays were performed to evaluate the effects of cranberry and grape seed extract on phenotypic behaviors of these oral cancers. The proliferation of both oral cancer cell lines was significantly inhibited by the administration of cranberry and grape seed extracts, in a dose-dependent manner. In addition, key regulators of apoptosis, caspase-2 and caspase-8, were concomitantly up-regulated by these treatments. However, cranberry and grape seed extracts elicited differential effects on cell adhesion, cell morphology, and cell cycle regulatory pathways. This study represents one of the first comparative investigations of cranberry and grape seed extracts and their anti-proliferative effects on oral cancers. Previous findings using purified proanthocyanidin from grape seed extract demonstrated more prominent growth inhibition, as well as apoptosis-inducing, properties on CAL27 cells. These observations provide evidence that cranberry and grape seed extracts not only inhibit oral cancer proliferation but also that the mechanism of this inhibition may function by triggering key apoptotic regulators in these cell lines. This information will be of benefit to researchers interested in elucidating which dietary components are central to mechanisms involved in the mediation of oral carcinogenesis and progression.

Folate supplementation induces differential dose-dependent modulation of proliferative phenotypes among cancerous and noncancerous oral cell lines in vitro.

Sufficient folate intake confers positive health benefits, while deficiency is linked with many health problems. Although the US policy of dietary folic acid fortification has reduced the incidence of these deficiency-related health problems, recent evidence has demonstrated an association between folic acid supplementation and increased colorectal cancer incidence. Few studies have explored the possibility that folate affects other slowly developing cancers. This study sought to determine whether folic acid supplementation is sufficient to alter the growth and development of existing oral cancers. A series of in vitro growth, viability, and adhesion assays were performed using the well-characterized human oral squamous cell carcinoma cell lines, CAL27 and SCC25, to determine the effects of folic acid supplementation. Folic acid administration significantly stimulated CAL27 and SCC25 proliferation in a dose-dependent manner, but it was not sufficient to increase proliferation at any concentration tested in the normal control cell line, HGF-1. Neither oral cancer cell line harbored the common C677T DNA polymorphism of the methylenetetrahydrofolate reductase (MTHFR) gene, which might reduce folate bioavailability. Overexpression of p53 mRNA was observed in both cancerous cell lines, but it was differentially altered by folic acid administration in only SCC25 cells. These findings suggest folic acid administration may significantly alter growth of oral cancers in vitro via p53-dependent and p53-independent pathways. As oral cancer rates continue to rise in specific geographic areas, and among specific subsets of the US population, understanding environmental mediators, such as folic acid supplementation, becomes increasingly important for nutrition and public health scientists.

Appetitive and aversive taste conditioning in a computer game influences real-world decision making and subsequent activation in insular cortex.

A stimulus, by virtue of its pairing with a rewarding or an aversive outcome, can acquire motivating properties reflecting that outcome. However, there is uncertainty concerning the extent to which such properties might be carried across contexts. In the current study we sought to determine whether conditioning-dependent motivational properties can transfer from a computer game to the real world and, further, whether this conditioning might be expressed in terms of brain responses measured using functional magnetic resonance imaging (fMRI). We studied healthy participants conditioned with aversive and appetitive drinks in the context of a virtual cycling race. Three days after conditioning, participants returned for a fMRI session. We took this opportunity to observe the impact of incidental presentation of conditioned stimuli on a real-world decision (seat choice). We found a significant influence of conditioning on seat choice and, moreover, noted that individual susceptibility to this influence was reflected in differential insula cortex responses during subsequent scanning. The choice was also predicted by participants' personality scores and, as a statistical trend (p=0.07), by their sense of immersion in the game environment. Our data show that motivational properties of stimuli can transfer from the virtual to the real world. While much concern has been expressed over the impact of virtual experience on general levels of aggression and mood, our data point to another important consideration: the fact that a stimulus in the virtual environment can acquire motivational properties that persist and modify behavior in the real world.