Performance Measures Using Electronic Health Records: Five Case Studies

Presents the experiences of five provider organizations in developing, testing, and implementing four types of electronic quality-of-care indicators based on EHR data. Discusses challenges, and compares results with those from traditional indicators

Effectiveness of Order Sets in the Management of Diabetic Ketoacidosis and Hyperosmolar Hyperglycemia

Diabetes mellitus (DM) is an endocrine disorder that affects the metabolism of glucose, for which there were an estimated 415 million cases world-wide. There are two common types of DM, Type 1 and Type 2. A significant difference between the two types of DM is the underlying cause of the disease but the two disease processes have similar characteristics. Both Type 1 and Type 2 DM can be associated with severe complications. Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are two of the most common medical emergencies. DKA is commonly found in those with Type 1 DM and can be characterized by elevated serum glucose levels, decreased serum pH, and the presence of ketones the serum and urine. HHS is more commonly found in those with Type 2 DM and can be characterized by serum glucose levels \u3e 600 mg/dl and serum osmolality \u3e 320 mOsm/kg. Ketones and severe metabolic acidosis are not typically present with HHS. While there are some differences among the two types of complications, the management of DKA and HHS are similar. Major components of management of both conditions includes intravenous fluid resuscitation, electrolyte replacement, and insulin therapy to manage serum glucose levels. Order sets are often used in medicine and in other industries to guide treatment or processes. A comprehensive literature review was conducted to examine the effectiveness of order sets in the treatment of DKA and HHS. Despite a lack of high-level evidence, outcomes showed consistent improvements in patient outcomes status post the implementation of a treatment guided order set. Common outcomes measured included hospital length of stay, intensive care unit length of stay, time to anion gap closure, hypoglycemic events, time to ketone clearance, and compliance with treatment guidelines. The outcomes of focus of this literature review were the hospital and intensive care unit length of stay and time to closure of the anion gap. Since the use of order sets for the treatment of DKA and HHS has been shown to improve patient outcomes, hospitals and hospital groups should work to implement order sets for the treatment of hyperglycemic emergencies

Bar-Code Technology and Nursing Adaptations

Background: Medication administration errors (MAEs) have long been a prevalent problem and endanger patient safety. Bar-code medication administration (BCMA) systems were developed for the purpose of preventing the occurrence of MAEs. However, it has been demonstrated that the implementation of BCMA has brought about unanticipated consequences on nursing work and new, potential predictable paths to MAEs. More recently, investigators have introduced a new approach to describe the impact of BCMA on nursing work, which reflects nurses’ adaptations to the operational problems of BCMA under difficult circumstances. A more complete understanding of the process of nurses’ adaptations to technology will better inform intervention program for performance and safety improvement. Specific Aims: The specific aims of this study were to: 1) conduct an integrative literature review about operational problems of BCMA, 2) validate a typology of operational problems of BCMA yielded in the literature review, and 3) assess nurses’ adaptations to BCMA operational problems and describe their perceptions about the adaptations. Conceptual Framework: The conceptual framework guided this study was an integration of the work system from the Systems Engineering Initiative for Patient Safety (SEIPS) model and the frames perspective. When there is a collision between the frames (system frame and practice frame), the operational problems occur, and then nurses make adaptations to the operational problems. In this study, it is considered that the “system frame” is functionalized as the “work system”, which is the core of the SEIPS model. Methods: A prospective, exploratory design was conducted to meet the study aims. This descriptive study included two convenience samples of registered nurses working on identified medical and surgical adult acute care units. An observation of BCMA use and a semi-structured interview was conducted with each participant of one group of sample (N=22) to collect data about the operational problems of BCMA. Another group of sample (N=21) conducted scenario interviews and follow-up interviews to describe their adaptations to the operational problems of BCMA. Results: This study found that 1) the triggers of operational problems of BCMA can be categorized according to the elements of the work system of the SEIPS model, which are technology and tools, tasks, person, environment, and organization; 2) the five elements of the SEIPS work system were validated for use as a typology of the triggers of operational problems of BCMA; 3) nurses conducted different adaptations with various strategies to accommodate to the operational problems of medication administration using BCMA; and 4) the perceptions of nurses about the adaptations to the operational problems of BCMA can be addressed by the sequential steps, implying nurses think in a logic and objective way during adaptations. Conclusions: This study provides a new way to approach the impact of BCMA on nursing work – adaptations. This is one of the first studies that attempts to understand nurses’ adaptations to the operational problems of BCMA, and also one of the first studies that investigates nurses’ perceptions about adaptations. Future research should more rigorously study nurses’ adaptive behaviors to operational problems.PHDNursingUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttps://deepblue.lib.umich.edu/bitstream/2027.42/146043/1/liujia_1.pd

Early Detection and Treatment of Acute Clinical Decline in Hospitalized Patients: An Observational Study of ICU Transfers and an Assessment of the Effectiveness of a Rapid Response Program: A Dissertation

The Institute for Healthcare Improvement (IHI) has promoted implementing a RRS to provide safer care for hospitalized patients. Additionally, the Joint Commission made implementing a RRS a 2008 National Patient Safety Goal. Although mandated, the evidence to support the effectiveness of a RRS to reduce cardiac arrests on hospital medical or surgical floors and un-anticipated ICU transfers remains inconclusive, partly because of weak study designs and partly due to a failure of published studies to report all critical aspects of their intervention. This study attempted to evaluate the effectiveness and the implementation of a RRS on the two campuses of the UMass Memorial Medical Center (UMMMC). The first study presented was an attempt to identify the preventability and timeliness of floor to ICU transfers. This was done using 3 chief residents who reviewed 100 randomly selected medical records. Using Cohen’s kappa to assess the inter-rater reliability it was determined that 13% of the cases could have possibly been preventable with earlier intervention. The second study was an evaluation of the effectiveness of the Rapid Response System. Outcomes were cardiac arrests, code calls and floor to ICU admissions. There were two study periods 24 months before the intervention and 24 months after. A Spline regression model was used to compare the two time periods. Though there was a consistent downward trend over all 4 years there were no statistically significant changes in the cardiac arrests and ICU transfers when comparing the before and after periods. There was a significant reduction in code calls to the floors on the University campus. The third study was a modified process evaluation of the Rapid Response intervention that will assess fidelity of RRS implementation, the proportion of the intended patient population that is reached by the RRS, the overall number of RRS calls implemented (dose delivered) and the perceptions of the hospital staff affected by the RRS with respect to acceptability and satisfaction with the RRS and barriers to utilization. The process evaluation showed that that the Rapid Response System was for the most part being used as it was designed, though the nurses were not using the specific triggers as a deciding factor in making the call. Staff satisfaction with the intervention was very high. Overall these studies demonstrated the difficulty in clearly defining outcomes and data collection in a large hospital system. Additionally the importance of different study designs and analysis methods are discussed

Intricacies of Professional Learning in Health Care: The Case of Supporting Self-Management in Paediatric Diabetes

This thesis offers a rethinking of the role for education as critical workplace pedagogy in complex problems of health care. Taking the case of paediatric diabetes, the study explored how health-care professionals learn the work of supporting children, and their parents, to self-manage the condition. By reconceptualising work problems as sociomaterial learning struggles, this research contributes new understandings of informal professional learning in everyday health-care provision. Data were generated through fieldwork in an outpatient clinic. Particular challenges of supporting self-management in this case were the difficulties of balancing policy aspirations for empowerment with biomedical knowledge about risks to immediate and long-term health. Tracing the materialisation of learning as it unfolded in moments of health-care practice showed professionals handling multiple and contradictory flows of information. Particular challenges were posed by insulin-pump technologies, which have specific implications for professional roles and responsibilities, and introduce new risks. A key insight is that professionals were concerned primarily with the highly complicated perpetual discernment of safe parameters within which children and their parents might reasonably be allowed to contribute to self-management. Such discernment does not readily correspond to the notion of empowerment circulating in the policies and guidelines intended to enable professionals to accomplish this work. As a result, this thesis argues that the work of discernment is obscured. Learning strategies evolve, but could be supported and extended by explicit recognition of the important work of learning as it unfolds in everyday practices of supporting self-management in paediatric diabetes. Most importantly, workplace pedagogies could be developed in ways that attune to the profound challenges and uncertainties that are at stake in these practices

A grounded theory study of the role of disclosure in the management of long-term conditions: who needs to know?

A high and increasing proportion of people in the United Kingdom are living with a long-term condition (DH, 2005a). The National Health Service is facing the challenge of increased pressure on its service provision. Government Policy has placed emphasis on supporting individuals to self-care (Department of Health, 2005a, c). However, there are specific challenges associated with living with a long-term condition, and in particular the psychosocial aspects of illness when set alongside a clinical approach to care (Gabe et al, 2004, Bury et al, 2005) It has been argued that disclosure of illness may in itself be a self-care strategy (Munir et al, 2005). However, to date individuals‟ experiences of disclosure of long-term conditions are neither clearly defined nor its role in managing a long-term condition fully understood. The aims of the study were to explore the role of disclosure in the management of a long-term health condition. The study drew on constructivist grounded theory (Charmaz, 2006) undertaking thirty-five in-depth qualitative interviews (fifteen people living with epilepsy, and twenty people living with type 1 diabetes) recruited from patient support groups and clinical nurse specialist‟s clinics. This study identified that strategies of disclosure are not necessarily fixed but may be subject to change over time. “Learning about disclosure” is an integral part of living with a long-term condition. Three key disclosure roles were identified: (1) access to self-care and social support, (2) non-disclosure (concealment) of the condition to protect one‟s identity from stigma. (3) redressing myths about the condition in advance: to avoid perceived stigma. The findings provide important insights that could enable health care professionals to develop more of an emphasis on including disclosure as an issue when talking to patients about managing type 1 diabetes and epilepsy and this is also relevant to a broad spectrum of long-term conditions

Security and privacy issues in implantable medical devices: A comprehensive survey

Bioengineering is a field in expansion. New technologies are appearing to provide a more efficient treatment of diseases or human deficiencies. Implantable Medical Devices (IMDs) constitute one example, these being devices with more computing, decision making and communication capabilities. Several research works in the computer security field have identified serious security and privacy risks in IMDs that could compromise the implant and even the health of the patient who carries it. This article surveys the main security goals for the next generation of IMDs and analyzes the most relevant protection mechanisms proposed so far. On the one hand, the security proposals must have into consideration the inherent constraints of these small and implanted devices: energy, storage and computing power. On the other hand, proposed solutions must achieve an adequate balance between the safety of the patient and the security level offered, with the battery lifetime being another critical parameter in the design phase. (C) 2015 Elsevier Inc. All rights reserved.This work was partially supported by the MINECO Grant TIN2013-46469-R (SPINY: Security and Privacy in the Internet of You)

Integrating Failure Mode Effect Analysis into the Medical Device Approval Process

Medical devices that utilize computer software are becoming common place in today’s health care environment. Device failures can have life threatening consequences. The medical device approval process issued by the FDA should enhance the software testing requirements. In this paper we suggest that Failure Mode Effect Analysis (FEMA) should be a standard component in the testing of software in medical devices that can have life threatening consequences

Can-Do-Tude: an Online Intervention Using Principles of Motivational Interviewing and Tailored Diabetes Self-Management Education for Adolescents with Type 1 Diabetes

abstract: Type 1 diabetes (T1D) is one of the most common chronic diseases in youth and it has been shown that adolescents have the worst glycemic control of any age group. The objective of this study was to develop, test and evaluate the feasibility of an online intervention (Can-Do-Tude) that uses the principles of motivational interviewing (MI) to deliver tailored diabetes self-management education to adolescents with T1D. Bandura’s efficacy belief system was used to guide the design of this study. The study used a multi-phase, multi-method approach. The first phase (alpha) of this study was a qualitative descriptive design to examine the intervention’s fidelity. Evaluation of performance was conducted by experts in the fields of MI, T1D, adolescence and/or online education. The second phase (beta) was a quantitative descriptive design conducted in order to evaluate feasibility by examining the acceptability (recruitment, retention and satisfaction) and implementation (diabetes self-management self-efficacy) to determine whether the intervention was appropriate for further testing. First phase findings showed that the intervention passed all measures with the content experts (n = 6): it was functional, accurate, usable and secure. Improvements to the intervention were made based on reviewer recommendations. For the second phase 5 adolescents between 14 and 17 were enrolled. Three adolescents completed all 4 weeks of the intervention while 2 completed only 3 weeks. Participants (n = 3) rated satisfaction on a 5-point Likert-type scale ranging from “not at all” satisfied (1) to “very much” satisfied (5). There was a positive response to the intervention (M = 4.28, SD = 0.55). Implementation was measured by a pre- and post-test for diabetes self-management self-efficacy. Participants (n = 3) demonstrated overall improvements in diabetes self-management self-efficacy (Z = -2.952, p = .007). Implications for further Can-Do-Tude research are planned at a metropolitan diabetes center using updated technology including an application platform. Although the sample was small, findings indicate that the intervention can be conducted using a web-based format and there is initial evidence of improvement in self-efficacy for diabetes self-management.Dissertation/ThesisDoctoral Dissertation Nursing and Healthcare Innovation 201