Barriers to delirium screening and management during hospital admission: a qualitative analysis of inpatient nursing perspectives.

BACKGROUND: Delirium in hospitalized patients is a major public health issue, yet delirium is often unrecognized and missed during inpatient admission. The objective of this study was to identify barriers to delirium screening, identification, and management from a nursing perspective on inpatient, acute care units. METHODS: This was a pre-implementation, diagnostic evaluation study to determine current practice patterns and potential barriers to optimizing delirium care at a major university hospital. A qualitative approach was used, which included focus groups of inpatient nurses working on major medical and surgical acute care units. Focus groups were conducted until signs of thematic saturation were present, and data were analyzed via inductive thematic analysis, without predetermined theories or structures. A consensus approach was utilized for transcript coding, and final themes were generated after multiple reviews of initial themes against transcript datasets. RESULTS: Focus group sessions (n = 3) were held with 18 nurses across two major inpatient units. Nurses reported several barriers to successful delirium screening and management. Specific challenges included difficulty with using delirium screening tools, an organizational culture not conducive to delirium prevention, and competing clinical priorities. Proposed solutions were also discussed, including decision-support systems with automated pager alerts and associated delirium order sets, which may help improve delirium care coordination and standardization. CONCLUSION: At a major university hospital, nurses affirm the difficulty experienced with delirium screening and identification, particularly due to screening tool challenges, cultural barriers, and clinical workload. These impediments may serve as targets for a future implementation trial to improve delirium screening and management.

Exploring the MAPPING application to facilitate risk communication and shared decision-making between physicians and patients with gynaecological cancer.

This is an observational study in which we evaluated current levels of risk communication (RC) among gynaecological oncologists and their view on the Mapping All Patient Probabilities in Numerical Graphs (MAPPING) application as a possible tool to facilitate RC and shared decision-making (SDM). In part A, we audio-recorded 29 conversations between gynaecological oncologists and patients when discussing treatment options. In part B, interviews were performed with eight gynaecological oncologists.RC and SDM were measured using two observer-based measures, that is, the RC content (RCC) tool (scale 0-2) and the OPTION-5 instrument (scale 0-100). We used CollaboRATE questionnaire (scale 0-10) and a self-developed survey to assess patient-reported RC and SDM. In part B, we evaluated physicians' attitudes regarding the use of the MAPPING application to support RC. Patients were minimally involved in the decision-making process (OPTION-5 25.9%±13.4 RCC 0.21±0.18). Patient-reported SDM was high (mean collaboRATE score 9.19±1.79) and patients preferred receiving numeric information, whereas most physicians used qualitative risk terms rather than exact numbers. In part B, gynaecologists had a positive attitude towards the MAPPING application. However, they stated that the app was difficult to use improvement of layout and better implementations are needed.

Feasibility, acceptability and impact of a clinical decision support tool among primary care providers in an urban, rural and remote site in the Philippines.

INTRODUCTION: Strengthening primary care helps address health inequities that continue to persist in the Philippines. The Philippine Primary Care Studies pilot-tested interventions to improve the primary care system. One intervention was the provision of a free subscription to an electronic decision support application called UpToDate (UTD) for primary care providers (PCPs), including doctors, nurses, midwives and community health workers (CHWs). This study aimed to (1) assess the feasibility of using UTD as information source for PCPs in urban, rural and remote settings, (2) determine the acceptability of UTD as an information source for PCPs and (3) examine the impact of UTD access on PCP clinical decision-making. METHODS: Four focus group discussions (FGDs) and two key informant interviews (KII) were conducted to gather insights from 30 PCPs. Thematic analysis through coding in NVivo V.12 was done using the technology acceptance model (TAM) as a guiding framework. RESULTS: All PCPs had positive feedback regarding UTD use because of its comprehensiveness, accessibility, mobility and general design. The participants relayed UTD's benefit for point-of-contact use, capacity-building and continuing professional development. PCPs across the three sites, including CHWs with no formal medical education, were able to provide evidence-based medical advice to patients through UTD. However, external factors in these settings impeded the full integration of UTD in the PCPs' workflow, including poor internet access, unstable sources of electricity, lack of compatible mobile devices and the need for translation to the local language. CONCLUSION: UTD was a feasible and acceptable clinical decision support tool for the PCPs. Factors affecting the feasibility of using UTD include technological and environmental factors (ie, internet access and the lack of translation to the local language), as well as the organisational structure of the primary care facility which determines the roles of the PCPs. Despite the difference in roles and responsibilities of the PCPs, UTD positively impacted decision-making and patient education for all PCPs through its use as a point-of-contact tool and a tool for capacity-building.

When do medical operators choose to use, or not use, video in emergency calls? A case study.

BackgroundAn evaluation report for a pilot project on the use of video in medical emergency calls between the caller and medical operator indicates that video is only used in 4% of phone calls to the emergency medical communication centre (EMCC). Furthermore, the report found that in half of these cases, the use of video did not alter the assessment made by the medical operator at the EMCC.We aimed to describe the reasons for when and why medical operators choose to use or not use video in emergency calls. METHOD: The study was conducted in a Norwegian EMCC, employing a thematic analysis of notes from medical operators responding to emergency calls regarding the use of video. RESULT: Informants reported 19 cases where video was used and 46 cases where it was not used. When video was used, three main themes appeared: 'unclear situation or patient condition', 'visible problem' and 'children'. When video was not used the following themes emerged: 'cannot be executed/technical problems', 'does not follow instructions', 'perceived as unnecessary'. Video was mostly used in cases where the medical operators were uncertain about the situation or the patients' conditions. CONCLUSION: The results indicate that medical operators were selective in choosing when to use video. In cases where operators employed video, it provided a better understanding of the situation, potentially enhancing the basis for decision-making.

Using the Translating Research into Practice framework to develop a diabetes prevention intervention in primary care: a mixed-methods study.

BACKGROUND: Pre-diabetes affects one-third of US adults and increases the risk of type 2 diabetes. Effective evidence-based interventions, such as the Diabetes Prevention Program, are available, but a gap remains in effectively translating and increasing uptake of these interventions into routine care. METHODS: We applied the Translating Research into Practice (TRiP) framework to guide three phases of intervention design and development for diabetes prevention: (1) summarise the evidence, (2) identify local barriers to implementation and (3) measure performance. In phase 1, we conducted a retrospective cohort analysis of linked electronic health record claims data to evaluate current practices in the management of pre-diabetes. In phase 2, we conducted in-depth interviews of 16 primary care physicians, 7 payor leaders and 31 patients to elicit common barriers and facilitators for diabetes prevention. In phase 3, using findings from phases 1 and 2, we developed the core elements of the intervention and performance measures to evaluate intervention uptake. RESULTS: In phase 1 (retrospective cohort analysis), we found few patients with pre-diabetes received diabetes prevention interventions. In phase 2 (stakeholder engagement), we identified common barriers to include a lack of knowledge about pre-diabetes among patients and about the Diabetes Prevention Program among clinicians. In phase 3 (intervention development), we developed the START Diabetes Prevention Clinical Pathway as a systematic change package to address barriers and facilitators identified in phases 1 and 2, performance measures and a toolkit of resources to support the intervention components. CONCLUSIONS: The TRiP framework supported the identification of evidence-based care practices for pre-diabetes and the development of a well-fitted, actionable intervention and implementation plan designed to increase treatment uptake for pre-diabetes in primary care settings. Our change package can be adapted and used by other health systems or clinics to target prevention of diabetes or other related chronic conditions.

Health information technology tools to accelerate gastrointestinal evaluation in patients with iron deficiency anaemia: a cluster randomised controlled trial.

OBJECTIVE: System-level safety measures do not exist to ensure that patients with iron deficiency anaemia (IDA) undergo proper diagnostic evaluations. We sought to determine if a set of EHR (electronic health record) tools and an expedited referral workflow increase short-term completion of bidirectional endoscopy in higher risk patients with IDA. MATERIALS AND METHODS: We conducted a pragmatic, cluster-randomised trial randomised by primary care physician (PCP) that included 16 PCPs and 316 patients with IDA. Physicians were randomised to intervention or control groups. Intervention components included a patient registry visible within the EHR, point-of-care alert and expedited diagnostic evaluation workflow for IDA. Outcomes were assessed at 120 days. The primary outcome was completion of bidirectional endoscopy. Secondary outcomes were any endoscopy completed or scheduled, gastroenterology consultation completed, and gastroenterology referral or endoscopy ordered or completed. RESULTS: There were no differences in the primary or secondary outcomes. At 120 days, the primary outcome had occurred for 7 (4%) of the intervention group and 5 (3.5%) of the control group. For the three secondary outcomes, rates were 15 (8.6%), 12 (6.9%) and 39 (22.4%) for the immediate intervention group and 10 (7.0%), 9 (6.3%) and 25 (17.6%) for the control group, respectively, p>0.2. Lack of physician time to use the registry tools was identified as a barrier. DISCUSSION AND CONCLUSION: Providing PCPs with lists of patients with IDA and a pathway for expedited evaluation did not increase rates of completing endoscopic evaluation in the short term. TRIAL REGISTRATION NUMBER: NCT05365308.

Crowdsourcing a diagnosis? Exploring the accuracy of the size and type of group diagnosis: an experimental study.

BACKGROUND: The consultation process, where a clinician seeks an opinion from another clinician, is foundational in medicine. However, the effectiveness of group diagnosis has not been studied. OBJECTIVE: To compare individual diagnosis to group diagnosis on two dimensions: group size (n=3 or 6) and group process (interactive or artificial groups). METHODOLOGY: Thirty-six internal or emergency medicine residents participated in the study. Initially, each resident worked through four written cases on their own, providing a primary diagnosis and a differential diagnosis. Next, participants formed into groups of three. Using a videoconferencing platform, they worked through four additional cases, collectively providing a single primary diagnosis and differential diagnosis. The process was repeated using a group of six with four new cases. Cases were all counterbalanced. Retrospectively, nominal (ie, artificial) groups were formed by aggregating individual participant data into subgroups of three and six and analytically computing scores. Presence of the correct diagnosis as primary diagnosis or included in the differential diagnosis, as well as the number of diagnoses mentioned, was calculated for all conditions. Means were compared using analysis of variance. RESULTS: For both authentic and nominal groups, the diagnostic accuracy of group diagnosis was superior to individual for both the primary diagnosis and differential diagnosis. However, there was no improvement in diagnostic accuracy when comparing a group of three to a group of six. Interactive and nominal groups were equivalent; however, this may be an artefact of the method used to combine data. CONCLUSIONS: Group diagnosis improves diagnostic accuracy. However, a larger group is not necessarily superior to a smaller group. In this study, interactive group discussion does not result in improved diagnostic accuracy.

Deployment of a human-centred clinical decision support system for pulmonary embolism: evaluation of impact on quality of diagnostic decisions.

Pulmonary embolism (PE) is a serious condition that presents a diagnostic challenge for which diagnostic errors often happen. The literature suggests that a gap remains between PE diagnostic guidelines and adherence in healthcare practice. While system-level decision support tools exist, the clinical impact of a human-centred design (HCD) approach of PE diagnostic tool design is unknown. DESIGN: Before-after (with a preintervention period as non-concurrent control) design study. SETTING: Inpatient units at two tertiary care hospitals. PARTICIPANTS: General internal medicine physicians and their patients who underwent PE workups. INTERVENTION: After a 6-month preintervention period, a clinical decision support system (CDSS) for diagnosis of PE was deployed and evaluated over 6 months. A CDSS technical testing phase separated the two time periods. MEASUREMENTS: PE workups were identified in both the preintervention and CDSS intervention phases, and data were collected from medical charts. Physician reviewers assessed workup summaries (blinded to the study period) to determine adherence to evidence-based recommendations. Adherence to recommendations was quantified with a score ranging from 0 to 1.0 (the primary study outcome). Diagnostic tests ordered for PE workups were the secondary outcomes of interest. RESULTS: Overall adherence to diagnostic pathways was 0.63 in the CDSS intervention phase versus 0.60 in the preintervention phase (p=0.18), with fewer workups in the CDSS intervention phase having very low adherence scores. Further, adherence was significantly higher when PE workups included the Wells prediction rule (median adherence score=0.76 vs 0.59, p=0.002). This difference was even more pronounced when the analysis was limited to the CDSS intervention phase only (median adherence score=0.80 when Wells was used vs 0.60 when Wells was not used, p=0.001). For secondary outcomes, using both the D-dimer blood test (42.9% vs 55.7%, p=0.014) and CT pulmonary angiogram imaging (61.9% vs 75.4%, p=0.005) was lower during the CDSS intervention phase. CONCLUSION: A clinical decision support intervention with an HCD improves some aspects of the diagnostic decision, such as the selection of diagnostic tests and the use of the Wells probabilistic prediction rule for PE.

What do clinical practice guidelines say about deprescribing? A scoping review.

INTRODUCTION: Deprescribing (medication dose reduction or cessation) is an integral component of appropriate prescribing. The extent to which deprescribing recommendations are included in clinical practice guidelines is unclear. This scoping review aimed to identify guidelines that contain deprescribing recommendations, qualitatively explore the content and format of deprescribing recommendations and estimate the proportion of guidelines that contain deprescribing recommendations. METHODS: Bibliographic databases and Google were searched for guidelines published in English from January 2012 to November 2022. Guideline registries were searched from January 2017 to February 2023. Two reviewers independently screened records from databases and Google for guidelines containing one or more deprescribing recommendations. A 10% sample of the guideline registries was screened to identify eligible guidelines and estimate the proportion of guidelines containing a deprescribing recommendation. Guideline and recommendation characteristics were extracted and language features of deprescribing recommendations including content, form, complexity and readability were examined using a conventional content analysis and the SHeLL Health Literacy Editor tool. RESULTS: 80 guidelines containing 316 deprescribing recommendations were included. Deprescribing recommendations had substantial variability in their format and terminology. Most guidelines contained recommendations regarding for who (75%, n=60), what (99%, n=89) and when or why (91%, n=73) to deprescribe, however, fewer guidelines (58%, n=46) contained detailed guidance on how to deprescribe. Approximately 29% of guidelines identified from the registries sample (n=14/49) contained one or more deprescribing recommendations. CONCLUSIONS: Deprescribing recommendations are increasingly being incorporated into guidelines, however, many guidelines do not contain clear and actionable recommendations on how to deprescribe which may limit effective implementation in clinical practice. A co-designed template or best practice guide, containing information on aspects of deprescribing recommendations that are essential or preferred by end-users should be developed and employed. TRIAL REGISTRATION NUMBER: osf.io/fbex4.

Comparison of static and rolling logistic regression models on predicting invasive mechanical ventilation or death from COVID-19-A retrospective, multicentre study.

INTRODUCTION: COVID-19 virus has undergone mutations, and the introduction of vaccines and effective treatments have changed its clinical severity. We hypothesized that models that evolve may better predict invasive mechanical ventilation or death than do static models. METHODS: This retrospective study of adult patients with COVID-19 from six Michigan hospitals analysed 20 demographic, comorbid, vital sign and laboratory factors, one derived factor and nine factors representing changes in vital signs or laboratory values with time for their ability to predict death or invasive mechanical ventilation within the next 4, 8 or 24 h. Static logistic regression was constructed on the initial 300 patients and tested on the remaining 6741 patients. Rolling logistic regression was similarly constructed on the initial 300 patients, but then new patients were added, and older patients removed. Each new construction model was subsequently tested on the next patient. Static and rolling models were compared with receiver operator characteristic and precision-recall curves. RESULTS: Of the 7041 patients, 534 (7.6%) required invasive mechanical ventilation or died within 14 days of arrival. Rolling models improved discrimination (0.865 ± 0.010, 0.856 ± 0.007 and 0.843 ± 0.005 for the 4, 8 and 24-h models, respectively; all p < 0.001 compared with the static logistic regressions with 0.827 ± 0.011, 0.794 ± 0.012 and 0.735 ± 0.012, respectively). Similarly, the areas under the precision-recall curves improved from 0.006, 0.010 and 0.021 with the static models to 0.030, 0.045 and 0.076 for the 4-, 8- and 24-h rolling models, respectively, all p < 0.001. CONCLUSION: Rolling models with contemporaneous data maintained better metrics of performance than static models, which used older data.

Safety implications of remote assessments for suspected COVID-19: qualitative study in UK primary care.

BACKGROUND: The introduction of remote triage and assessment early in the pandemic raised questions about patient safety. We sought to capture patients and clinicians' experiences of the management of suspected acute COVID-19 and generate wider lessons to inform safer care. SETTING AND SAMPLE: UK primary healthcare. A subset of relevant data was drawn from five linked in-pandemic qualitative studies. The data set, on a total of 87 participants recruited via social media, patient groups and snowballing, comprised free text excerpts from narrative interviews (10 survivors of acute COVID-19), online focus groups (20 patients and 30 clinicians), contributions to a Delphi panel (12 clinicians) and fieldnotes from an online workshop (15 patients, clinicians and stakeholders). METHODS: Data were uploaded onto NVivo. Coding was initially deductive and informed by WHO and Institute of Medicine frameworks of quality and safety. Further inductive analysis refined our theorisation using a wider range of theories-including those of risk, resilience, crisis management and social justice. RESULTS: In the early weeks of the pandemic, patient safety was compromised by the driving logic of 'stay home' and 'protect the NHS', in which both patients and clinicians were encouraged to act in a way that helped reduce pressure on an overloaded system facing a novel pathogen with insufficient staff, tools, processes and systems. Furthermore, patients and clinicians observed a shift to a more transactional approach characterised by overuse of algorithms and decision support tools, limited empathy and lack of holistic assessment. CONCLUSION: Lessons from the pandemic suggest three key strategies are needed to prevent avoidable deaths and inequalities in the next crisis: (1) strengthen system resilience (including improved resourcing and staffing; support of new tools and processes; and recognising primary care's role as the 'risk sink' of the healthcare system); (2) develop evidence-based triage and scoring systems; and (3) address social vulnerability.

Process improvement using telemedicine consultation to prevent unnecessary interfacility transfers for low-severity blunt head trauma.

OBJECTIVE: Mild traumatic brain injuries (MTBI) associated with intracranial haemorrhage are commonly transferred to tertiary care centres. Recent studies have shown that transfers for low-severity traumatic brain injuries may be unnecessary. Trauma systems can be overwhelmed by low acuity patients justifying standardisation of MTBI transfers. We sought to evaluate the impact of telemedicine services on mitigating unnecessary transfers for those presenting with low-severity blunt head trauma after sustaining a ground level fall (GLF). METHOD: A process improvement plan was developed by a task force of transfer centre (TC) administrators, emergency department physicians (EDP), trauma surgeons and neurosurgeons (NS) to facilitate the requesting EDP and the NS on-call to converse directly to mitigate unnecessary transfers. Consecutive retrospective chart review was performed on neurosurgical transfer requests between 1 January 2021 and 31 January 2022. A comparison of transfers preintervention and postintervention (1 January 2021 to 12 September 2021)/(13 September 2021 to 31 January 2022) was performed. RESULTS: The TC received 1091 neurological-based transfer requests during the study period (preintervention group: 406 neurosurgical requests; postintervention group: 353 neurosurgical requests). After consultation with the NS on-call, the number of MTBI patients remaining at their respective ED's with no neurological degradation more than doubled from 15 in the preintervention group to 37 in the postintervention group. CONCLUSION: TC-mediated telemedicine conversations between the NS and the referring EDP can prevent unnecessary transfers for stable MTBI patients sustaining a GLF if needed. Outlying EDPs should be educated on this process to increase efficacy.

History information management strategy for minimising biases and noise for improved medical diagnosis.

Despite measures for physicians' excellence in diagnosis, the need for improvement of medical history techniques has been pointed out as one of the critical elements for improving diagnosis. Specific and proactive frameworks related to methods of effective history acquisition are needed to minimise bias and optimise decision-making. Therefore, this paper uses Linear Sequential Unmasking- Expanded to develop and propose a structured medical history acquisition strategy. The strength of this lies in its reliance on cognitive psychological processes. Breaking information gatherings and decisions into smaller tasks and ordering them correctly reduces cognitive load as well as minimises noise and bias cascade. Additionally, this approach can help physicians develop diagnostic expertise regardless of specialty.

Implementing criteria-led discharge for acute admissions to facilitate the elective recovery from COVID-19: an example in acute tonsillitis.

BACKGROUND: Healthcare systems face unprecedented numbers of patients waiting for elective treatments in the wake of the COVID-19 pandemic. Hospitals must urgently optimise patient pathways and build capacity to meet the populations health needs. Criteria-led discharge (CLD) is frequently used to optimise elective care pathways but may hold potential in discharging patients at the end of an acute hospital admission. METHODS: We conducted a quality improvement project to design and introduce a novel inpatient pathway using CLD for patients with severe acute tonsillitis. Our analysis compared the standardisation of treatment, length of stay, discharge time and readmission rate between those treated on the novel pathway compared with standard treatment. RESULTS: The study population included 137 patients admitted to a tertiary centre with acute tonsillitis. Introduction of the tonsillitis pathway using CLD resulted in a significant reduction in median length of stay from 24 hours to 18 hours. Of those treated on the tonsillitis pathway, 52.2% were discharged prior to midday compared with 29.1% who received standard treatment. No patient discharged using CLD required readmission. CONCLUSION: CLD is safe and effective at reducing length of stay in patients requiring acute hospital admission for acute tonsillitis. CLD should be used and evaluated in further novel patient pathways across different areas of medicine to optimise care and build capacity for provision of elective healthcare services. Further research is required to investigate safe and optimal criteria which indicate patients are fit for discharge.

Reducing post-tonsillectomy haemorrhage: a multicentre quality improvement programme incorporating video-based cold technique instruction.

OBJECTIVE: Data from the Norwegian Tonsil Surgery Register (NTSR) showed large differences between the hospitals in Norway in the readmission rate due to post-tonsillectomy haemorrhage (rrPTH; range, 0%-25%; national average, 8%). Because of these large variations in the rrPTH, we conducted a quality improvement project involving hospitals with good and bad readmission rates. METHODS: Seven hospitals with readmission rates greater than 10% and four with rates lower than 5% participated in this project. We recorded videos of ear, nose and throat surgeons from the hospitals with low readmission rates when they performed extracapsular tonsillectomy, and these videos of cold dissection tonsillectomy were used as teaching material for examples of good surgical skills for the other hospitals. After a 2-day workshop, all participants from the hospitals went back to their institutions and prepared local plans to improve their results. We used the Plan-Do-Study-Act model. The primary outcome variable was the patient-reported rrPTH in the NTSR. As secondary goal, we aimed to identify aspects of the tonsillectomy procedure that could help achieve a lower rrPTH. RESULTS: The participating hospitals reduced their rrPTH from 18% at baseline (2017/2018) to 7% in 2020. Six of seven hospitals changed their dissection technique significantly to more use of cold dissection. CONCLUSION: By learning cold dissection tonsillectomy from surgeons with low rrPTH, it seems possible to decrease the rates of bleeding complications after tonsillectomy. A combination of videos as a teaching tool, new treatment plans, and focus on quality and improvement may effectively improve surgical results. The videos can show details that are difficult to convey in the literature. Quality registers can be used to identify areas requiring improvement and evaluate the effects of changes in practice.

Transitioning EPMA applications in a large multisite teaching hospital.

INTRODUCTION: University Hospitals of Leicester (UHL) has co-developed and deployed a novel Electronic Prescribing and Medicines Administration (EPMA) application as part of the trust electronic patient record (EPR) programme that meets specific clinical demands and interoperability standards of the National Health Service (NHS) despite clinical pressures from the COVID-19 pandemic. METHODS: Following an initial limited pilot deployment, a big-bang whole site-based approach allowed transition of 1844 acute adult inpatients beds from an existing standalone EMPA to the new system. This project used a frontline driven and agile management strategy. Clinical risk was managed using a combination of standard risk logs, robust clinical prototyping and robust disaster recovery plans. Early engagement with clinical teams allowed for advanced product configuration before live deployment and reduced the need for sustained transition support for clinical staff. RESULTS: An iterative, well-governed approach, led by a combination of information technology (IT) and clinical staff with a responsive vendor, enabled a complex new EPMA system in a large acute NHS trust to be deployed with limited resources despite the ongoing COVID-19 pandemic. DISCUSSION: The development and deployment of EMPA and EPR systems across NHS trusts is a key enabler for better healthcare delivery. This case study shows it is possible to deploy a new clinical IT system at scale without interruption of clinical services and with a relatively modest deployment team. Sustainability of the project was also ensured through a clear clinically led governance structure to manage risk quickly and carry lessons learnt onto new developments.

A scoping review of real-time automated clinical deterioration alerts and evidence of impacts on hospitalised patient outcomes.

BACKGROUND: Hospital patients experiencing clinical deterioration are at greater risk of adverse events. Monitoring patients through early warning systems is widespread, despite limited published evidence that they improve patient outcomes. Current limitations including infrequent or incorrect risk calculations may be mitigated by integration into electronic medical records. Our objective was to examine the impact on patient outcomes of systems for detecting and responding to real-time, automated alerts for clinical deterioration. METHODS: This review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews checklist. We searched Medline, CINAHL and Embase for articles implementing real-time, automated deterioration alerts in hospitalised adults evaluating one or more patient outcomes including intensive care unit admission, length of stay, in-hospital cardiopulmonary arrest and in-hospital death. RESULTS: Of 639 studies identified, 18 were included in this review. Most studies did not report statistically significant associations between alert implementation and better patient outcomes. Four studies reported statistically significant improvements in two or more patient outcomes, and were the only studies to directly involve the patient's clinician. However, only one of these four studies was robust to existing trends in patient outcomes. Of the six studies using robust study designs, one reported a statistically significant improvement in patient outcomes; the rest did not detect differences. CONCLUSIONS: Most studies in this review did not detect improvements in patient outcomes following the implementation of real-time deterioration alerts. Future implementation studies should consider: directly involving the patient's physician or a dedicated surveillance nurse in structured response protocols for deteriorating patients; the workflow of alert recipients; and incorporating model features into the decision process to improve clinical utility.

Early detection and treatment of acute illness in medical patients with novel software: a prospective quality improvement initiative.

OBJECTIVE: An ageing population and rising healthcare costs place healthcare systems at risk of failure. Our goal was to develop a technology that would identify illness early, initiate action and therein improve patient care, outcomes and save healthcare resources. DESIGN: This was a prospective interventional quality improvement study. SETTING: A 40 bed medical floor in a 300 bed Canadian tertiary care regional referral hospital. PARTICIPANTS: General ward patients randomly assigned to control or treatment groups. There was no cross-over or loss to follow-up. INTERVENTION: We designed an algorithm and software programme capable of detecting the sentinel change in a deteriorating patient's clinical condition and once detected direct early investigation and care. Study duration was 1 year. MAIN OUTCOME MEASURES: Primary outcome was patient transfer from the general medical ward to the intensive care unit (ICU). The secondary outcome was the time needed to (1) order investigations (2) contact senior medical staff and (3) senior medical staff intervention. RESULTS: We identified a decrease in the transfer of patients from the medical ward to the ICU. Over the course of the study including 273 patients (110 in the control group and 163 in the treatment group), transfers dropped from 14 to 3 with a relative risk reduction of 85.54% (95% CI 84.96 to 86.1), a number needed to treat of 9.19 (95% CI 9.01 to 9.36) and a absolute risk reduction of 10.89% (95% CI 10.7 to 11.1). We also found a statistically significant reduction in the time required to order investigations (p=0.049), contact senior medical staff (p=0.040) and senior medical staff intervention (p=0.045). CONCLUSION: A novel algorithm and software in the hands of nursing staff identified acute illness with adequate sensitivity and specificity to dramatically reduce ICU transfers and time to clinical intervention on a medical ward.

Implementation of clinical decision support to manage acute kidney injury in secondary care: an ethnographic study.

BACKGROUND: Over the past decade, acute kidney injury (AKI) has become a global priority for improving patient safety and health outcomes. In the UK, a confidential inquiry into AKI led to the publication of clinical guidance and a range of policy initiatives. National patient safety directives have focused on the mandatory establishment of clinical decision support systems (CDSSs) within all acute National Health Service (NHS) trusts to improve the detection, alerting and response to AKI. We studied the organisational work of implementing AKI CDSSs within routine hospital care. METHODS: An ethnographic study comprising non-participant observation and interviews was conducted in two NHS hospitals, delivering AKI quality improvement programmes, located in one region of England. Three researchers conducted a total of 49 interviews and 150 hours of observation over an 18-month period. Analysis was conducted collaboratively and iteratively around emergent themes, relating to the organisational work of technology adoption. RESULTS: The two hospitals developed and implemented AKI CDSSs using very different approaches. Nevertheless, both resulted in adaptive work and trade-offs relating to the technology, the users, the organisation and the wider system of care. A common tension was associated with attempts to maximise benefit while minimise additional burden. In both hospitals, resource pressures exacerbated the tensions of translating AKI recommendations into routine practice. CONCLUSIONS: Our analysis highlights a conflicted relationship between external context (policy and resources), and organisational structure and culture (eg, digital capability, attitudes to quality improvement). Greater consideration is required to the long-term effectiveness of the approaches taken, particularly in light of the ongoing need for adaptation to incorporate new practices into routine work.

Application of human factors to improve usability of clinical decision support for diagnostic decision-making: a scenario-based simulation study.

OBJECTIVE: In this study, we used human factors (HF) methods and principles to design a clinical decision support (CDS) that provides cognitive support to the pulmonary embolism (PE) diagnostic decision-making process in the emergency department. We hypothesised that the application of HF methods and principles will produce a more usable CDS that improves PE diagnostic decision-making, in particular decision about appropriate clinical pathway. MATERIALS AND METHODS: We conducted a scenario-based simulation study to compare a HF-based CDS (the so-called CDS for PE diagnosis (PE-Dx CDS)) with a web-based CDS (MDCalc); 32 emergency physicians performed various tasks using both CDS. PE-Dx integrated HF design principles such as automating information acquisition and analysis, and minimising workload. We assessed all three dimensions of usability using both objective and subjective measures: effectiveness (eg, appropriate decision regarding the PE diagnostic pathway), efficiency (eg, time spent, perceived workload) and satisfaction (perceived usability of CDS). RESULTS: Emergency physicians made more appropriate diagnostic decisions (94% with PE-Dx; 84% with web-based CDS; p<0.01) and performed experimental tasks faster with the PE-Dx CDS (on average 96 s per scenario with PE-Dx; 117 s with web-based CDS; p<0.001). They also reported lower workload (p<0.001) and higher satisfaction (p<0.001) with PE-Dx. CONCLUSIONS: This simulation study shows that HF methods and principles can improve usability of CDS and diagnostic decision-making. Aspects of the HF-based CDS that provided cognitive support to emergency physicians and improved diagnostic performance included automation of information acquisition (eg, auto-populating risk scoring algorithms), minimisation of workload and support of decision selection (eg, recommending a clinical pathway). These HF design principles can be applied to the design of other CDS technologies to improve diagnostic safety.