Principles for Designing and Developing a Workflow Monitoring Tool to Enable and Enhance Clinical Workflow Automation.

BACKGROUND: Automation of health care workflows has recently become a priority. This can be enabled and enhanced by a workflow monitoring tool (WMOT). OBJECTIVES: We shared our experience in clinical workflow analysis via three cases studies in health care and summarized principles to design and develop such a WMOT. METHODS: The case studies were conducted in different clinical settings with distinct goals. Each study used at least two types of workflow data to create a more comprehensive picture of work processes and identify bottlenecks, as well as quantify them. The case studies were synthesized using a data science process model with focuses on data input, analysis methods, and findings. RESULTS: Three case studies were presented and synthesized to generate a system structure of a WMOT. When developing a WMOT, one needs to consider the following four aspects: (1) goal orientation, (2) comprehensive and resilient data collection, (3) integrated and extensible analysis, and (4) domain experts. DISCUSSION: We encourage researchers to investigate the design and implementation of WMOTs and use the tools to create best practices to enable workflow automation and improve workflow efficiency and care quality.

Improving Care Delivery: Location Timestamps to Enhance Process Measurement of a Clinical Workflow.

Traditional quality improvement (QI) strategies to describe workflow processes rely primarily upon qualitative methods or human-driven observations. These methods may be limited in scope and accuracy when applied to time-based workflow processes. This study sought to evaluate the utility of integrating objective time measurements to augment traditional QI strategies using procedural sedation workflow in a pediatric emergency department as an archetype. METHODS: We applied the FOCUS-Plan-Do-Check-Act framework to reduce the time from arrival to sedation for long-bone fractures. First, we added supplementary framework-defining steps to repeat the Clarifying and Understanding steps. We then extracted objective time-based data from an electronic health record (EHR) system and a real-time locating system (RTLS). We then compared and contrasted the findings of traditional surveys with analyses of timed steps within the sedation workflow. RESULTS: When identifying the source of delays, traditional survey techniques yielded ambiguous and even conflicting results based on clinical roles. The timestamps supported 5 measurable clinical role of subworkflows. By measuring the time to completion for 54 sedation cases, workflow patterns and significant bottlenecks were identified. CONCLUSIONS: Analyzing the time to complete individual tasks provided a more nuanced description of workflow delays and clarity when traditional survey results conflicted. Augmenting traditional QI process maps with EHR and RTLS timestamps better explained workflow bottlenecks, informing the QI team when selecting targets for subsequent Plan-Do-Check-Act work.

Keep your distance! Measuring staff physical distancing during the Sars-Cov-2 pandemic using a real-time locating system.

INTRODUCTION: Staff-to-staff transmission of SARS-CoV-2 poses a significant risk to the Emergency Department (ED) workforce. We measured close (<6 ft), prolonged (>10 min) staff interactions in a busy pediatric Emergency Department in common work areas over time as the pandemic unfolded, measuring the effectiveness of interventions meant to discourage such close contact. METHODS: We used a Real-Time Locating System to measure staff groupings in crowded common work areas lasting ten or more minutes. We compared the number of these interactions pre-pandemic with those occurring early and then later in the pandemic, as distancing interventions were suggested and then formalized. Nearly all healthcare workers in the ED were included, and the duration of interactions over time were evaluated as well. RESULTS AND CONCLUSIONS: This study included a total of 12,386 pairs of staff-to-staff encounters over three time periods including just prior to the pandemic, early in the pandemic response, and later in the steady-state pandemic response. Pairs of staff averaged 0.89 high-risk interactions hourly prior to the pandemic, and this continued early in the pandemic with informal recommendations (0.80 high-risk pairs hourly). High-risk staff encounters fell significantly to 0.47 interactions per hour in the steady-state pandemic with formal distancing guidelines in place and decreased patient and staffing volumes. The duration of these encounters remained stable, near 16 min. Close contact between healthcare staff workers did significantly decrease with formal distancing guidelines, though some high-risk interactions remained, warranting additive protective measures such as universal masking.

Improving Documentation Using a Real-Time Location System in a Pediatric Emergency Department.

BACKGROUND: Appropriate documentation of critical care services, including key time-based parameters, is critical to accurate severity of illness metrics and proper reimbursement. Documentation of time-based elements for critical care services performed in emergency departments (ED) remains inconsistent. We integrated electronic medical record and real-time location system (RTLS)-derived data to augment quality improvement methodology. OBJECTIVE: We aimed to increase the proportion of patient encounters with critical care services performed at a pediatric ED that had appropriate documentation from a baseline of 76 to 90% within 6 weeks. METHODS: The team formulated a framework of improvement and performed multiple plan-do-study-act cycles focused on key drivers. We integrated the capabilities of an RTLS for precise location tracking to identify patient encounters in which critical care services were performed and to minimize unnecessary audits and feedback. We developed an intervention using iterative revisions to address key drivers and improve documentation. The primary outcome was the proportion of patient encounters for which critical care services were performed for which a time-based attestation was documented in the medical record. RESULTS: We analyzed 92 encounters between March 2020 and April 2020. While the proportion of eligible patient encounters with critical care documentation improved from 76 to 85%, this change was unable to be directly attributed to improvement efforts. Patients with respiratory complaints encompassed the majority of eligible encounters without appropriate documentation. CONCLUSION: Utilizing improvement methodology and a novel application of RTLS, we successfully identified the co-location of physicians with patients receiving critical care services and designed interventions to improve documentation of critical care services provided in a pediatric ED. While changes were not able to be attributed to improvement efforts in this project, this project demonstrates the utility of RTLS to augment and inform systematic improvement efforts.

Real-time locating systems to improve healthcare delivery: A systematic review.

OBJECTIVE: Modern health care requires patients, staff, and equipment to navigate complex environments to deliver quality care efficiently. Real-time locating systems (RTLS) are local tracking systems that identify the physical locations of personnel and equipment in real time. Applications and analytic strategies to utilize RTLS-produced data are still under development. The objectives of this systematic review were to describe and analyze the key features of RTLS applications and demonstrate their potential to improve care delivery. MATERIALS AND METHODS: We searched MEDLINE, SCOPUS, and IEEE following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were articles that utilize RTLS to evaluate or influence workflow in a healthcare setting. We summarized aspects of relevant articles, identified key themes in the challenges of applying RTLS to workflow improvement, and thematically reviewed the state of quantitative analytic methodologies. RESULTS: We included 42 articles in the final qualitative synthesis. The most frequent study design was observational (n = 24), followed by descriptive (n = 12) and experimental (n = 6). The most common clinical environment for study was the emergency department (n = 12), followed by entire hospital (n = 7) and surgical ward (n = 6). DISCUSSION: The focus of studies changed over time from early experience to optimization to evaluation of an established system. Common narrative themes highlighted lessons learned regarding evaluation, implementation, and information visibility. Few studies have developed quantitative techniques to effectively analyze RTLS data. CONCLUSIONS: RTLS is a useful and effective adjunct methodology in process and quality improvement, workflow analysis, and patient safety. Future directions should focus on developing enhanced analysis to meaningfully interpret RTLS data.

National Imaging Trends of Recurrent Pediatric Urolithiasis.

OBJECTIVES: The aim of this study was to examine computed tomography (CT) and ultrasound (US) utilization trends in incident and prevalent pediatric emergency department (ED) urolithiasis patients before and after imaging guideline release. METHODS: We reviewed imaging modalities for children with 2 or more ED encounters between January 1, 2006, and September 1, 2013, for urolithiasis using the Pediatric Health Information System database. Z scores compared the proportion of patient encounters receiving CT and US before (January 1, 2006, to December 31, 2010) and after (January 1, 2011, to September 1, 2013) the release of imaging guidelines. McNemar test for paired proportions compared the percentage of US and CT use between initial versus subsequent visits. Piecewise logistic regression was used to determine the probability of US use and CT use over time before and after the implementation of imaging guidance. RESULTS: Analysis was completed on 2041 patients with 4930 unique encounters for urolithiasis. During 1758 encounters (35.7%), CT was performed initially. Ultrasound was performed 1585 times (32.2%). Fourteen percent fewer CT procedures were performed during first urolithiasis visits after guideline release (P < 0.01), whereas US use increased by 15% (P < 0.01). Fewer CT procedures were performed at later visits compared with the first (P < 0.05), and US was used more during second or later visits than the first (P < 0.05). CONCLUSIONS: Medical providers at large academic pediatric EDs have decreased use of CT and increased use of US over the study time frame to diagnose urolithiasis and are now similar during initial visits (US 36.4% vs CT 36.2%, P = 0.94). Physicians are still more likely to use US as the initial urolithiasis imaging modality during second and later encounters.

Pregnancy intention and antenatal care use in two rural north Indian States.

OBJECTIVES: Many studies have shown strong effects of pregnancy intention on antenatal care (ANC) behaviour in developed countries, but studies from developing settings have shown mixed results. Few investigators have utilized a prospective measure of pregnancy intention. This paper will analyze the association of pregnancy intention and the utilization of antenatal services in two states in northern India, using a prospective measure of whether a future pregnancy would be wanted or unwanted. METHODS: A prospective cohort study was conducted between 1998 and 2003 in Jharkhand and Bihar, India, of 2028 women with one or two pregnancies resulting in the live births of singleton infants during the study period. RESULTS: Antenatal care utilization was not found to be significantly associated with prospective pregnancy intention (OR=1.18 [95% CI 0.91, 1.52]). Among women who received ANC (N = 701), initiation of care was not delayed in unwanted pregnancies. Significant differences existed between the numbers of women who reported their pregnancy unwanted retrospectively compared with prospectively. These differences were not associated with the utilization of antenatal care services or timing of care initiation. The exception to these findings were women who consistently reported their pregnancies unwanted both before and after conception, who were twice as likely to delay ANC initiation as women with consistently wanted pregnancies. CONCLUSIONS: Demographic characteristics of reproductive-age women, such as age and parity, seem to predict more closely the use of ANC services than pregnancy intention in Bihar and Jharkhand. Delayed ANC initiation may be significantly associated with unwanted pregnancy, but only when pregnancies were most decisively identified as unwanted.