Impact of electronic health records on predefined safety outcomes in patients admitted to hospital: a scoping review

Objectives Review available evidence for impact of electronic health records (EHRs) on predefined patient safety outcomes in interventional studies to identify gaps in current knowledge and design interventions for future research.Design Scoping review to map existing evidence and identify gaps for future research.Data sources PubMed, the Cochrane Library, EMBASE, Trial registers.Study selection Eligibility criteria: We conducted a scoping review of bibliographic databases and the grey literature of randomised and non-randomised trials describing interventions targeting a list of fourteen predefined areas of safety. The search was limited to manuscripts published between January 2008 and December 2018 of studies in adult inpatient settings and complemented by a targeted search for studies using a sample of EHR vendors. Studies were categorised according to methodology, intervention characteristics and safety outcome.Results from identified studies were grouped around common themes of safety measures.Results The search yielded 583 articles of which 24 articles were included. The identified studies were largely from US academic medical centres, heterogeneous in study conduct, definitions, treatment protocols and study outcome reporting. Of the 24 included studies effective safety themes included medication reconciliation, decision support for prescribing medications, communication between teams, infection prevention and measures of EHR-specific harm. Heterogeneity of the interventions and study characteristics precluded a systematic meta-analysis. Most studies reported process measures and not patient-level safety outcomes: We found no or limited evidence in 13 of 14 predefined safety areas, with good evidence limited to medication safety.Conclusions Published evidence for EHR impact on safety outcomes from interventional studies is limited and does not permit firm conclusions regarding the full safety impact of EHRs or support recommendations about ideal design features. The review highlights the need for greater transparency in quality assurance of existing EHRs and further research into suitable metrics and study designs

Exercise testing to guide safe discharge from hospital in COVID-19: a scoping review to identify candidate tests

Objectives We aimed to identify exercise tests that have been validated to support a safe discharge to home in patients with or without COVID-19.Study design Scoping review, using PRISMA-ScR reporting standards. Medline, PubMed, AMED, Embase, CINAHL and LitCovid databases were searched between 16 and 22 February 2021, with studies included from any publication date up to and including the search date.Intervention Short exercise tests.Primary outcome measures Safe discharge from hospital, readmission rate, length of hospital stay, mortality. Secondary outcomes measures: safety, feasibility and reliability.Results Of 1612 original records screened, 19 studies were included in the analysis. These used a variety of exercise tests in patients with chronic obstructive pulmonary disease, suspected pulmonary embolism and pneumocystis carinii pneumonia, heart failure or critical illness. Only six studies had examined patients with COVID-19, of these two were still recruiting to evaluate the 1 min sit-to-stand test and the 40-steps test. There was heterogeneity in patient populations, tests used and outcome measures. Few exercise tests have been validated to support discharge decisions. There is currently no support for short exercise tests for triage of care in patients with COVID-19.Conclusions Further research is needed to aid clinical decision-making at discharge from hospital

The Baby Boom and later life: is critical care fit for the future?

Populations around the world are ageing while in many developed countries the proportion of elderly patients admitted to critical care is rising. It is clear that age alone should not be used as a reason for refusing intensive care admission. Critical care in this patient group is challenging in many ways: with advancing age, several physiological changes occur which all lead to a subsequent reduction of physical performance and compensatory capacity, in many cases additionally aggravated by chronic illness. Subsequently, these age-dependent changes (with or without chronic illness) increase the risk for death, treatment costs and a prolonged length of intensive care and hospital stay. This review explores the potential of using co-morbidity and frailty to predict outcome and to help to make better decisions about critical care admission in the elderly. The authors explore the challenges of using different frailty assessment tools and offer a model for holistic approach to answer these questions

Quality metrics for Same Day Emergency Care – Consensus of a multi-professional panel of experts using a modified Delphi process

Same Day Emergency Care (SDEC) services are at the heart of recovery plans for Emergency Care in the National Health Service. There are no validated metrics for the quality of care in SDEC. The Society for Acute Medicine's Quality Improvement Committee invited to a three-stage modified Delphi process to gather metrics used by clinicians. Proposed metrics were ranked and further explored by 33 participating experts from a broad range of backgrounds including clinicians, data scientists and operational managers. Experts ranked five system-based metrics highest. These focus on optimization of the proportion of patients receiving same day care in and out of SDEC units. Patient and staff experience metrics were ranked low, possibly due to present lack of viable examples. The paper adds a glossary with the rationale for ranking of metrics and their use for the improvement of quality and safety of clinical care

Advance care planning in patients referred to hospital for acute medical care: Results of a national day of care survey.

Background:Advance care planning (ACP) is a voluntary process of discussion about future care between an individual and their care provider. ACP is a key focus of national policy as a means to improve patient centered care at the end-of-life. Despite a wide held belief that ACP is beneficial, uptake is sporadic with considerable variation depending on age, ethnicity, location and disease group. Methods:This study looked to establish the prevalence of ACP on initial presentation to hospital with a medical emergency within The Society for Acute Medicine Benchmarking Audit (SAMBA18). 123 acute hospitals from across the UK collected data during a day of care survey. The presence of ACP and the presence of 'Do Not Attempt Cardiopulmonary Resuscitation' orders were recorded separately. Findings:Among 6072 patients presenting with an acute medical emergency, 290 patients (4.8%) had an ACP that was available for the admitting medical team. The prevalence of ACP increased incrementally with age, in patients less than 80 years old the prevalence was 2·9% (95% CI 2·7-3·1) compared with 9·5% (95% CI 9·1-10·0%) in patients aged over 80. In the patients aged over 90 the prevalence of ACP was 12·6% (95% CI 9·8-16·0). ACP was present in 23·3% (95% CI 21.8-24.8%) of patients admitted from institutional care compared with 3·5% (95% CI 3·3-3·7) of patients admitted from home. The prevalence of ACP was 7.1% (95% CI 6·6-7·6) amongst patients re-admitted to the hospital within the previous 30 days. Interpretation:Very few patients have an ACP that is available to admitting medical teams during an unscheduled hospital admission. Even among patients with advanced age, and who have recently been in hospital, the prevalence of available ACP remains low, in spite of national guidance. Further interventions are needed to ensure that patients' wishes for care are known by providers of acute medical care

A Comparison of the Ability of the Physiologic Components of Medical Emergency Team Criteria and the U.K. National Early Warning Score to Discriminate Patients at Risk of a Range of Adverse Clinical Outcomes.

OBJECTIVE: To compare the ability of medical emergency team criteria and the National Early Warning Score to discriminate cardiac arrest, unanticipated ICU admission and death within 24 hours of a vital signs measurement, and to quantify the associated workload. DESIGN: Retrospective cohort study. SETTING: A large U.K. National Health Service District General Hospital. PATIENTS: Adults hospitalized from May 25, 2011, to December 31, 2013. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We applied the National Early Warning Score and 44 sets of medical emergency team criteria to a database of 2,245,778 vital signs sets (103,998 admissions). The National Early Warning Score's performance was assessed using the area under the receiver-operating characteristic curve and compared with sensitivity/specificity for different medical emergency team criteria. Area under the receiver-operating characteristic curve (95% CI) for the National Early Warning Score for the combined outcome (i.e., death, cardiac arrest, or unanticipated ICU admission) was 0.88 (0.88-0.88). A National Early Warning Score value of 7 had sensitivity/specificity values of 44.5% and 97.4%, respectively. For the 44 sets of medical emergency team criteria studied, sensitivity ranged from 19.6% to 71.2% and specificity from 71.5% to 98.5%. For all outcomes, the position of the National Early Warning Score receiver-operating characteristic curve was above and to the left of all medical emergency team criteria points, indicating better discrimination. Similarly, the positions of all medical emergency team criteria points were above and to the left of the National Early Warning Score efficiency curve, indicating higher workloads (trigger rates). CONCLUSIONS: When medical emergency team systems are compared to a National Early Warning Score value of greater than or equal to 7, some medical emergency team systems have a higher sensitivity than National Early Warning Score values of greater than or equal to 7. However, all of these medical emergency team systems have a lower specificity and would generate greater workloads