Clinical guidelines as plans: An ontological theory

Clinical guidelines are special types of plans realized by collective agents. We provide an ontological theory of such plans that is designed to support the construction of a framework in which guideline-based information systems can be employed in the management of workflow in health care organizations. The framework we propose allows us to represent in formal terms how clinical guidelines are realized through the actions of are realized through the actions of individuals organized into teams. We provide various levels of implementation representing different levels of conformity on the part of health care organizations. Implementations built in conformity with our framework are marked by two dimensions of flexibility that are designed to make them more likely to be accepted by health care professionals than standard guideline-based management systems. They do justice to the fact 1) that responsibilities within a health care organization are widely shared, and 2) that health care professionals may on different occasions be non-compliant with guidelines for a variety of well justified reasons. The advantage of the framework lies in its built-in flexibility, its sensitivity to clinical context, and its ability to use inference tools based on a robust ontology. One disadvantage lies in its complicated implementation

Organizing the U.S. Health Care Delivery System for High Performance

Analyzes the fragmentation of the healthcare delivery system and makes policy recommendations -- including payment reform, regulatory changes, and infrastructure -- for creating mechanisms to coordinate care across providers and settings

Identifying ICU patient safety priorities within a Northern Ontario setting : a delphi study

The purpose of this study was to explore patient safety priorities as perceived by clinical experts working in a northern Ontario adult ICU. A modified Delphi was used to elicit consensus regarding patient safety priorities from the perspective of an expert panel of registered nurses and intensivists. At the onset of the study, the consensus level was set at 70%. Data was collected through serials rounds with researcher-developed questionnaires. Descriptive statistical analysis was completed. No consensus was reached at Round 1. Three points of consensus regarding patient safety priorities were reached at Round 2: improving pain and agitation management; incorporating a checklist into the bullet round reporting tool; and implementing use of visual cues for high-risk lines. These strategies support the need for anticipation, recognition, and management of at risk situations. The results have the potential to guide the advancement of the patient safety mandate within an ICU setting.Master of Science (MSc) in Nursin

Metacognition and Reflection by Interdisciplinary Experts: Insights from Cognitive Science and Philosophy

Interdisciplinary understanding requires integration of insights from different perspectives, yet it appears questionable whether disciplinary experts are well prepared for this. Indeed, psychological and cognitive scientific studies suggest that expertise can be disadvantageous because experts are often more biased than non-experts, for example, or fixed on certain approaches, and less flexible in novel situations or situations outside their domain of expertise. An explanation is that experts’ conscious and unconscious cognition and behavior depend upon their learning and acquisition of a set of mental representations or knowledge structures. Compared to beginners in a field, experts have assembled a much larger set of representations that are also more complex, facilitating fast and adequate perception in responding to relevant situations. This article argues how metacognition should be employed in order to mitigate such disadvantages of expertise: By metacognitively monitoring and regulating their own cognitive processes and representations, experts can prepare themselves for interdisciplinary understanding. Interdisciplinary collaboration is further facilitated by team metacognition about the team, tasks, process, goals, and representations developed in the team. Drawing attention to the need for metacognition, the article explains how philosophical reflection on the assumptions involved in different disciplinary perspectives must also be considered in a process complementary to metacognition and not completely overlapping with it. (Disciplinary assumptions are here understood as determining and constraining how the complex mental representations of experts are chunked and structured.) The article concludes with a brief reflection on how the process of Reflective Equilibrium should be added to the processes of metacognition and philosophical reflection in order for experts involved in interdisciplinary collaboration to reach a justifiable and coherent form of interdisciplinary integration. An Appendix of “Prompts or Questions for Metacognition” that can elicit metacognitive knowledge, monitoring, or regulation in individuals or teams is included at the end of the article

Emergency medical dispatching : protocols, experiences and priorities

Each year, millions of people call the emergency number with a wide variety of symptoms and various levels of illness severity. At its’ core, emergency medical dispatching encompasses the answering of these calls, the assessment of the need for medical assistance, the dispatch of a resource with an appropriate priority level and the provision of instructions assisting the caller. Consequently, emergency medical dispatching is important in ensuring patient safety as well as for ascertaining the best use of limited resources. However, research on different aspects of emergency medical dispatch remains limited. Therefore, this thesis’s overall aim was to provide new knowledge in relation to dispatch protocols and the assessment and prioritization of emergency medical calls. Further, to bring light onto emergency medical dispatchers’ (EMDs) experiences of managing such calls thereby creating an understanding and foundation for further development and strengthening of this first link in the chain of emergency care. The thesis builds upon four studies based on different populations: Study I: a simulation study with the aim to compare the accuracy, in terms of correct dispatch priority, between two dispatch protocols; the Swedish Index and RETTS-A. Expert consensus was used as reference standard. A total of 1,293 calls was included. For priority level, 349 (54%) calls were assessed correctly with Swedish Index and 309 (48%) with RETTS-A (p=0.012). Sensitivity for the highest priority was 82.6% (95% CI: 76.6-87.3) for Swedish Index and 54.0% (95% CI: 44.3-63.4%) for RETTS-A. Overtriage was 37.9% (34.2.-41.7%) in Swedish Index and 28.6% (25.2-32.2) in RETTS-A. The corresponding proportion of undertriage was 6.3% (4.7-8.5) and 23.4% (20,3-26.9) respectively. The results demonstrate that although the Swedish Index had a higher accuracy than RETTS-A, the overall accuracy for both dispatch protocols is low. Study II: a retrospective observational study based on registry data from four Swedish regions in 2015. The aim was to compare calls assessed by an EMD with and without the support of a registered nurse (RN) with respect to priority level, accuracy, and dispatch category. Ambulance personnel’s assessment was used as reference standard. A total of 25,025 calls were included. Dispatch priority was in concordance with the reference standard in 11,319 (50.7%) for EMD and in 481 (41.5%) for EMD+RN, (p<0.01). Overtriage was equal for both groups; 5904 (26,4%) for EMD, and 306 (26.4%) for EMD+RN, (p=0.25). Undertriage was 5122 (22.9%) for EMD and 371 (32.0%) for EMD+RN (p<0.01). Sensitivity for the most urgent priority was 54.6% for EMD, compared to 29.6% for EMD+RN (p<0.01), and specificity was 67.3% and 84.8% (p<0.01) respectively. Dispatch category was in concordance with reference standard in 13,785 (66.4%) EMD and 697 (62.2%) EMD+RN (p=0.01). The results demonstrated that a higher precision was not observed for calls assessed with RN-support. Study III: a qualitative interview study aiming at exploring EMDs experiences of managing emergency medical calls. One main category emerged from the inductive content analysis of 13 interviews: “to attentively manage a multifaceted, interactive task”. The main category was in turn composed of three categories: “to utilize creativity to gather information”, “continuously process and assess complex information” and “engage in the professional role”. Study IV: a retrospective observational registry study on all primary ambulance missions within the Stockholm Region Aug 2019 to Sept 2022. The aim was to identify the proportion of time critical patients, defined as patients receiving time critical interventions in the prehospital setting, having an ambulance dispatched as Priority 1. Further, to describe dispatch categories and emergency department (ED) diagnoses. Of 571 163 included missions, 92 975 (16.3%) were time critical. Of these, 75 504 (81.2%) had an ambulance dispatched as Priority 1, 16 967 (18.2%) as Priority 2, and 504 (0.5%) as Priority 3. When stratified according to dispatch priority, the ranking of the most common dispatch categories differed. ED-diagnosis were mostly symptom-related. The results demonstrate that most patients with time critical conditions receive an ambulance dispatched as Priority 1. Those who are not identified as in need of an ambulance dispatched as Priority 1, differ in regard to their presentation, and often present to the EMCC with unspecific symptoms. In conclusion, this thesis sheds light on different aspects of emergency medical dispatching in regard to emergency calls with a wide range of symptoms. Specifically, it contributes to the evaluation of dispatch protocols and highlights the need for further investigations in relation to the established, yet understudied, practice of emergency medical dispatching performed predominantly by EMDs with and without the support of RNs. Given their key role in managing this multifaceted interactive task, the results can be used to inform future development of protocols and interview techniques. The results further indicate the need for regular feedback, as part of clinical routine. Finally, the thesis enhances the understanding of the population of patients with time critical conditions and contributes to the understanding and future establishment of a definition of time critical conditions in the pre-hospital setting

Improvisation in tightly controlled work environments: The case of medical practice

We present a qualitative analysis of organizational improvisation and provide a preliminary insight into the following question: how is improvisation present in tightly controlled work environments? We conducted in situ observations of, and interviews with, several emergency medical teams and complemented this information with statistical and media data. Using grounded theory, we developed four propositions that were arranged into a model that allowed the identification of two use levels of established routines: (1) the visible side that accommodates contextual requirements, and (2) the improvisational side that provides a response to activity characteristics. This dual process is related to the existence of pressures that operate at the institutional level with practical needs emerging from the operational domain. In contrast with most of the literature, this study reveals that the presence of a broad procedural organizational memory does not restrict improvisation but enables a bureaucratic system to produce flexible improvised performance.Nova Foru

Workflow in Clinical Trial Sites & Its Association with Near Miss Events for Data Quality: Ethnographic, Workflow & Systems Simulation

10.1371/journal.pone.0039671PLoS ONE76

What helps or hinders the transformation from a major tertiary center to a major trauma center? Identifying barriers and enablers using the Theoretical Domains Framework

BACKGROUND: Major Trauma Centers (MTCs), as part of a trauma system, improve survival and functional outcomes from injury. Developing such centers from current teaching hospitals is likely to generate diverse beliefs amongst staff. These may act as barriers or enablers. Prior identification of these may make the service development process more efficient. The importance of applying theory to systematically identify barriers and enablers to changing clinical practice in emergency medicine has been emphasized. This study systematically explored theory-based barriers and enablers towards implementing the transformation of a tertiary hospital into a MTC. Our goal was to demonstrate the use of a replicable method to identify targets that could be addressed to achieve a successful transformation from an organization evolved to provide a particular type of clinical care into a clinical system with different demands, requirements and expectations. METHODS: The Theoretical Domains Framework (TDF) is a tool designed to elicit and analyze beliefs affecting behavior. Semi-structured interviews based around the TDF were conducted in a major tertiary hospital in Scotland due to become a MTC with a purposive sample of major stakeholders including clinicians and nurses from specialties involved in trauma care, clinical managers and administration. Belief statements were identified through qualitative analysis, and assessed for importance according to prevalence, discordance and evidence base. RESULTS AND DISCUSSION: 1728 utterances were recorded and coded into 91 belief statements. 58 were classified as important barriers/enablers. There were major concerns about resource demands, with optimism conditional on these being met. Distracting priorities abound within the Emergency Department. Better communication is needed. Staff motivation is high and they should be engaged in skills development and developing performance improvement processes. CONCLUSIONS: This study presents a systematic and replicable method of identifying theory-based barriers and enablers towards complex service development. It identifies multiple barriers/enablers that may serve as a basis for developing an implementation intervention to enhance the development of MTCs. This method can be used to address similar challenges in developing specialist centers or implementing clinical practice change in emergency care across both developing and developed countries

Technology Target Studies: Technology Solutions to Make Patient Care Safer and More Efficient

Presents findings on technologies that could enhance care delivery, including patient records and medication processes; features and functionality nurses require, including tracking, interoperability, and hand-held capability; and best practices