The use of computerised clinical decision support systems in emergency care : a substantive review of the literature

Objectives: This paper provides a substantive review of international literature evaluating the impact of computerised clinical decision support systems (CCDSS) on the care of emergency department (ED) patients. Material and Methods: A literature search was conducted using Medline, CINAHL, EMBASE electronic resources and grey literature. Studies were selected if they compared the use of a CCDSS with usual care in a face-to-face clinical interaction in an ED. Results: Of the 23 studies included approximately half demonstrated a statistically significant positive impact on aspects of clinical care with the use of CCDSSs. The remaining studies showed small improvements, mainly around documentation. However, the methodological quality of the studies was poor with few or no controls to mitigate against confounding variables. The risk of bias was high in all but six studies. Discussion: The ED environment is complex and does not lend itself to robust quantitative designs such as Randomised Controlled Trials. The quality of the research in approximately 75% of the studies was poor and therefore conclusions cannot be drawn from these results. However the studies with a more robust design show evidence of the positive impact of CCDSSs on ED patient care. Conclusion This is the first review to consider the role of CCDSSs in emergency care and expose the research in this area. The role of CCDSSs in Emergency Care may provide some solutions to the current challenges in EDs but further high quality research is needed to better understand what technological solutions can offer clinicians and patients. OBJECTIVES This paper provides a description of a substantive review of published international literature evaluating the impact of computerised clinical decision support systems (CCDSS) on the care of emergency department (ED) patients. The principal aims of this review are: to identify the body of CCDSS research undertaken in EDs, the research methods used, their quality and the impact of CCDSSs on clinical care in EDs. The discussion synthesises what is known and not known about the effectiveness of CCDSSs in Emergency Care and the quality of the current evidence base

Impact of a Localized Lean Six Sigma Implementation on Overall Patient Safety and Process Efficiency

Continuous quality improvement tools have been widely used in the Healthcare Industry to increase efficiency and patient safety as well as to reduce cost. This research explores the impact of a Lean Six Sigma (LSS) process improvement initiative on the overall process efficiency and patient safety in the Labor and Delivery (L+D) units of a large hospital provider. This study focuses on the application of a modeling and simulation methodology to investigate the influence of a localized process improvement intervention on the overall L+D unit output by considering patient flow, system capacity, and unit performance. The simulation models capacity profiles and patient flow through the system to determine patient throughput and waiting times. Baseline data was obtained from information systems logs from two Sentara Healthcare. Finally, the simulation analysis provides evidence to support decision making regarding process improvement implementation across the evaluated scenarios; the results evidence a significant time reduction, not only in the registration process but also in the “Time to Arrive to the Physician.

Unanticipated influence of coordination mechanisms on physician workstyles and ED operational efficiency

The coordination of activities in a work context has been examined by many disciplines and in recent years the role of information systems and other artifacts has become increasingly prominent. The emergency department (ED) of a hospital in a large US city is used to study how information systems and other coordinating mechanisms affect how physicians choose to perform their work and how such choices can impact the ED’s overall operational performance. The study used direct observation of the work performed in the ED, interviews of physicians, nurses and other ED staff members, and the analysis of historical performance data. The key findings were that the existing coordination mechanisms are a mix of fixed and mobile, computer and paper-based information systems, and other artifacts. The workstyles adopted by physicians were shaped by incidental characteristics of these coordination mechanisms. Some workstyles appear to have adverse, albeit unintended, effects on aspects of the department’s operational performance

Implementing SBIRT in a Critical Access Emergency Department

Purpose: Universal screening and brief intervention with referral to treatment (SBIRT) has become best practice for emergency departments (EDs) over the last two decades. Given the prevalence of alcohol use and the subsequent health impacts of drinking, EDs are well positioned to be on the front line of screening for risky drinking. The available literature is clear in its consensus that universal screening for alcohol use in the ED is critical to identifying people at high risk for drinking and improving health outcomes. Aims: This project aimed to implement an SBIRT process in a critical access ED. To achieve this global aim, the project team developed an SBIRT process and educated nurses and providers on its use in the department. Methods: The project team performed a two-month retrospective chart review determining the baseline rate of alcohol screening in the department. An SBIRT process was implemented in the unit. After implementation of the SBIRT process, a two-month chart review measured staff usage of the new procedure. Results: Over the two-month implementation period, the percentage of patients in the ED screened for alcohol use increased from an average of sixty-five percent before the intervention to seventy-nine percent after. Conclusions: Increased alcohol screening for patients in a critical access ED is possible with education and buy in from clinical staff. The existing electronic screener tool was widely preferred to the newer, paper AUDIT_C tool. Embedding the new screener tool in the electronic chart may be a way to increase convenience and therefore its adoption. Keywords: SBIRT, alcohol use disorder, emergency department alcohol screening

Application of Queuing Analytic Theory to Decrease Waiting Times in Emergency Department: Does it Make Sense?

Background: Patients who receive care in an emergency department (ED), are usually unattended while waiting in queues. Objectives: This study was done to determine, whether the application of queuing theory analysis might shorten the waiting times of patients admitted to emergency wards. Patients and Methods: This was an operational study to use queuing theory analysis in the ED. In the first phase, a field study was conducted to delineate the performance of the ED and enter the data obtained into simulator software. In the second phase, "ARENA" software was used for modeling, analysis, creating a simulation and improving the movement of patients in the ED. Validity of the model was confirmed through comparison of the results with the real data using the same instrument. The third phase of the study concerned modeling in order to assess the effect of various operational strategies, on the queue waiting time of patients who were receiving care in the ED. Results: In the first phase, it was shown that 47.7% of the 3000 patient records were cases referred for trauma treatment, and the remaining 52.3% were referred for non-trauma services. A total of 56% of the cases were male and 44% female. Maximum input was 4.5 patients per hour and the minimum input was 0.5 per hour. The average length of stay for patients in the trauma section was three hours, while for the non-trauma section it was four hours. In the second phase, modeling was tested with common scenarios. In the third phase, the scenario with the addition of one or more senior emergency resident(s) on each shift resulted in a decreased length of stay from 4 to 3.75 hours. Moreover, the addition of one bed to the Intensive Care Unit (ICU) and/or Critical Care Unit (CCU) in the study hospital, reduced the occupancy rate of the nursing service from 76% to 67%. By adding another clerk to take electrocardiograms (ECG) in the ED, the average time from a request to performing the procedure is reduced from 26 to 18 minutes. Furthermore, the addition of 50% more staff to the laboratory and specialist consultations led to a 90 minute reduction in the length of stay. It was also shown that earlier consultations had no effect on the length of stay. Conclusions: Application of queuing theory analysis can improve movement and reduce the waiting times of patients in bottlenecks within the ED throughput

Development of an Advanced Practice Registered Nurse Primary Care Telephone Clinic

Abstract Development of an Advanced Practice Registered Nurse Primary Care Telephone Clinic This pilot project developed and implemented a telephone clinic based on established Veterans Affairs telephone policy and procedures and determined patient acceptability of this new visit type as an alternative to face to face visits. The review of the literature produced research that indicates telephone clinics are a viable visit option for patients. Telephone visits provide access to the primary care provider while being convenient and economical for patients. Research studies demonstrate that patients are satisfied with this visit option. The pilot project was successfully implemented in a Veterans Administration Community Based Outpatient Clinic. To evaluate the effectiveness of the project, cycle time measurements and patient satisfaction surveys for telephone visits and face to face visits were obtained. The telephone visits were found to have shorter provider visit wait times than patients having an in-clinic provider evaluation and also were found to have shorter provider visit durations than face to face visits. These findings did not affect patient satisfaction as patients who received telephone visits responded positively regarding their satisfaction with care. Overall, there was no statistical difference in patient satisfaction with patients who received telephone visits as compared to those who received a face to face provider visit. The telephone clinic improved clinic efficiency and provided more available appointment slots to care for more complex patients

The Experience of Decision-Making among Telephone Advice/Triage Nurses

The role of the telephone advice/triage nurse is both complex and demanding. All decisions are made while assessing patients without seeing or touching patients. In addition, the role is often developed to decrease health care costs which can be perceived by nurses as being in conflict with their nursing beliefs. The ambiguous nature of the role makes these nurses\u27 daily experiences with decision-making a challenge. Using a phenomenological method, the lived experience of decision-making among telephone advice/triage nurses was explored by conducting multiple interviews with ten nurses. The internal structure of the lived experience was identified through the philosophical perspective of Merleau-Ponty\u27s phenomenology of perception and the process of Van Manen\u27s researching lived experience. Eight essential themes emerged to explain the lived experience. Connecting relationships between nurses and patients were critical to the process of decision-making as well as to what it meant for the nurses to be decision-makers. Nurses involved patients in decision-making, utilized decision-making support protocols, considered deviating from protocols, and sought validation for certain decisions. The nurses\u27 perceptions of what it was like to assume responsibility for decision-making reflected feelings of self-accountability to job responsibility. All nurses realized that they needed to know clinical information about their patients, but some shared that they needed to maintain an awareness of their personal knowing to support their decision-making. Different ways of coming to decisions included making justifiable decisions based upon what was best for the patient, validating the right call based upon nurse comfort, and striking a balance based upon maintaining system equilibrium between patient satisfaction and the health care organization\u27s resources. All nurses spoke of themselves as decision-makers and sensed feelings of confidence, certainty, and uncertainty in being decision-makers. All study themes were conjoined, occurring simultaneously among the descriptions of the decision-making experience. The study\u27s findings support theoretical work in decision-making as well as cognitive development. Focusing upon the experience and meaning of decision-making, bringing to light the everyday experience of nurse decision-making has important implications for the science of nursing and clinical practice