The effects of Computerized Provider Order Entry implementation on communication in Intensive Care Units

The Effect of Clinical Decision Support Systems on Patients, Nurses, and Work Environment in ICUs: A Systematic Review

This study aimed to examine the impact of clinical decision support systems on patient outcomes, working environment outcomes, and decision-making processes in nursing. The authors conducted a systematic literature review to obtain evidence on studies about clinical decision support systems and the practices of ICU nurses. For this purpose, the authors searched 10 electronic databases, including PubMed, CINAHL, Web of Science, Scopus, Cochrane Library, Ovid MEDLINE, Science Direct, Tr-Dizin, Harman, and DergiPark. Search terms included "clinical decision support systems," "decision making," "intensive care," "nurse/nursing," "patient outcome," and "working environment" to identify relevant studies published during the period from the year 2007 to October 2022. Our search yielded 619 articles, of which 39 met the inclusion criteria. A higher percentage of studies compared with others were descriptive (20%), conducted through a qualitative (18%), and carried out in the United States (41%). According to the results of the narrative analysis, the authors identified three main themes: "patient care outcomes," "work environment outcomes," and the "decision-making process in nursing." Clinical decision support systems, which target practices of ICU nurses and patient care outcomes, have positive effects on outcomes and show promise in improving the quality of care; however, available studies are limited.

Dissecting Communication Barriers in Healthcare: A Path to Enhancing Communication Resiliency, Reliability, and Patient Safety

ABSTRACT

Suboptimal exchange of information can have tragic consequences to patient's safety and survival. To this end, the Joint Commission lists communication error among the most common attributable causes of sentinel events. The risk management literature further supports this finding, ascribing communication error as a major factor (70%) in adverse events. Despite numerous strategies to improve patient safety, which are rooted in other high reliability industries (e.g., commercial aviation and naval aviation), communication remains an adaptive challenge that has proven difficult to overcome in the sociotechnical landscape that defines healthcare. Attributing a breakdown in information exchange to simply a generic "communication error" without further specification is ineffective and a gross oversimplification of a complex phenomenon. Further dissection of the communication error using root cause analysis, a failure modes and effects analysis, or through an event reporting system is needed. Generalizing rather than categorizing is an oversimplification that clouds clear pattern recognition and thereby prevents focused interventions to improve process reliability. We propose that being more precise when describing communication error is a valid mechanism to learn from these errors. We assert that by deconstructing communication in healthcare into its elemental parts, a more effective organizational learning strategy emerges to enable more focused patient safety improvement efforts. After defining the barriers to effective communication, we then map evidence-based recovery strategies and tools specific to each barrier as a tactic to enhance the reliability and validity of information exchange within healthcare.

Exploring Research Topics and Trends in Nursing-related Communication in Intensive Care Units Using Social Network Analysis

This study used social network analysis to identify the main research topics and trends in nursing-related communication in intensive care units. Keywords from January 1967 to June 2016 were extracted from PubMed using Medical Subject Headings terms. Social network analysis was performed using Gephi software. Research publications and newly emerging topics in nursing-related communication in intensive care units were classified into five chronological phases. After the weighting was adjusted, the top five keyword searches were "conflict," "length of stay," "nursing continuing education," "family," and "nurses." During the most recent phase, research topics included "critical care nursing," "patient handoff," and "quality improvement." The keywords of the top three groups among the 10 groups identified were related to "neonatal nursing and practice guideline," "infant or pediatric and terminal care," and "family, aged, and nurse-patient relations," respectively. This study can promote a systematic understanding of communication in intensive care units by identifying topic networks. Future studies are needed to conduct large prospective cohort studies and randomized controlled trials to verify the effects of patient-centered communication in intensive care units on patient outcomes, such as length of hospital stay and mortality.

Personalization and Patient Involvement in Decision Support Systems: Current Trends

OBJECTIVES

This survey aims at highlighting the latest trends (2012-2014) on the development, use, and evaluation of Information and Communication Technologies (ICT) based decision support systems (DSSs) in medicine, with a particular focus on patient-centered and personalized care.

METHODS

We considered papers published on scientific journals, by querying PubMed and Web of ScienceTM. Included studies focused on the implementation or evaluation of ICT-based tools used in clinical practice. A separate search was performed on computerized physician order entry systems (CPOEs), since they are increasingly embedding patient-tailored decision support.

RESULTS

We found 73 papers on DSSs (53 on specific ICT tools) and 72 papers on CPOEs. Although decision support through the delivery of recommendations is frequent (28/53 papers), our review highlighted also DSSs only based on efficient information presentation (25/53). Patient participation in making decisions is still limited (9/53), and mostly focused on risk communication. The most represented medical area is cancer (12%). Policy makers are beginning to be included among stakeholders (6/73), but integration with hospital information systems is still low. Concerning knowledge representation/management issues, we identified a trend towards building inference engines on top of standard data models. Most of the tools (57%) underwent a formal assessment study, even if half of them aimed at evaluating usability and not effectiveness.

CONCLUSIONS

Overall, we have noticed interesting evolutions of medical DSSs to improve communication with the patient, consider the economic and organizational impact, and use standard models for knowledge representation. However, systems focusing on patient-centered care still do not seem to be available at large.

Causes of Medication Errors in Intensive Care Units from the Perspective of Healthcare Professionals

Objective:

This study was conducted to explore and to describe the causes of medication errors in Intensive Care Units (ICUs) from the perspective of physicians, nurses, and clinical pharmacists.

Methods:

The study was conducted using a descriptive qualitative method in 2016. We included 16 ICUs of seven educational hospitals affiliated to Isfahan University of Medical Sciences. Participants included 19 members of the healthcare team (physician, nurse, and clinical pharmacist) with at least 1 year of work experience in the ICUs. Participants were selected using purposeful sampling method. Data were collected through semi-structured individual interviews and were used for qualitative content analysis.

Findings:

The four main categories and ten subcategories were extracted from interviews. The four categories were as follows: “low attention of healthcare professionals to medication safety,” “lack of professional communication and collaboration,” “environmental determinants,” and “management determinants.”

Conclusion:

Incorrect prescribing of physicians, unsafe drug administration of nurses, the lack of pharmaceutical knowledge of the healthcare team, and the weak professional collaboration lead to medication errors. To improve patient safety in the ICUs, healthcare center managers need to promote interprofessional collaboration and participation of clinical pharmacists in the ICUs. Furthermore, interprofessional programs to prevent and reduce medication errors should be developed and implemented.

Pharmacist-Physician Communications in a Highly Computerised Hospital: Sign-Off and Action of Electronic Review Messages

BACKGROUND

Some hospital Computerized Physician Order Entry (CPOE) systems support interprofessional communication. The aim of this study was to investigate the effectiveness of pharmacist-physician messages sent via a CPOE system.

METHOD

Data from the year 2012 were captured from a large university teaching hospital CPOE database on: 1) review messages assigned by pharmacists; 2) details of the prescription on which the messages were assigned; and 3) details of any changes made to the prescription following a review message being assigned. Data were coded for temporal, message and prescription factors. Messages were analysed to investigate: 1) whether they were signed-off; and 2) the time taken. Messages that requested a measurable action were further analysed to investigate: 1) whether they were actioned as requested; and 2) the time taken. We conducted a multivariable analysis using Generalised Estimating Equations (GEE) to account for the effects of multiple factors simultaneously, and to adjust for any potential correlation between outcomes for repeated review messages on the same prescription. All analyses were performed using SPSS 22 (IBM SPSS Inc., Chicago, IL, USA), with p<0.05 considered significant.

RESULTS

Pharmacists assigned 36,245 review messages to prescriptions over the 12 months, 34,506 of which were coded for analysis after exclusions. Nearly half of messages (46.6%) were signed-off and 65.5% of these were signed-off in ≤ 48 hours. Of the 9,991 further analysed for action, 35.8% led to an action as requested by the pharmacist and just over half of these (57.0%) were actioned in ≤ 24 hours. Factors predictive of an action were the time since the prescription was generated (p<0.001), pharmacist grade (p<0.001), presence of a high-risk medicine (p<0.001), messages relating to reconciliation (p = 0.004), theme of communication (p<0.001), speciality, (p<0.001), category of medicine (p<0.001), and regularity of the prescription (p<0.001).

CONCLUSION

In this study we observed a lower rate of sign-off and action than we might have expected, suggesting uni-directional communication via the CPOE system may not be optimal. An established pharmacist-physician collaborative working relationship is likely to influence the prioritisation and response to messages, since a more desirable outcome was observed in settings and with grades of pharmacists where this was more likely. Designing systems that can facilitate collaborative communication may be more effective in practice.

Using an inpatient portal to engage families in pediatric hospital care

OBJECTIVE

Assess parent use and perceptions of an inpatient portal application on a tablet computer that provides information about a child's hospital stay.

METHODS

This cross-sectional study was conducted with parents of children hospitalized on a medical/surgical unit at a tertiary children's hospital. From December 2014 to June 2015, parents were provisioned a tablet portal application to use throughout the hospitalization. The portal includes real-time hospital vitals, medications, schedules, lab results, education, health care team pictures/roles, and request and messaging functionalities. Portal use information was gathered from tablet metadata. Parents completed discharge surveys on portal satisfaction, use, and impact on their information needs, engagement, communication, error detection, and care safety and quality. Data were analyzed using descriptive statistics and qualitative content analysis.

RESULTS

Over 6 months, 296 parents used the portal, sending 176 requests and 36 messages. No tablets were lost or damaged. The most used and liked features included vitals, medication list, health care team information, and schedules. Overall, parent survey respondents (90) were satisfied with the portal (90%), reporting that it was easy to use (98%), improved care (94%), and gave them access to information that helped them monitor, understand, make decisions, and care for their child. Many parents reported that portal use improved health care team communication (60%). Most perceived that portal use reduced errors in care (89%), with 8% finding errors in their child's medication list.

CONCLUSIONS

Overall, parents were satisfied with the inpatient portal. Portals may engage parents in hospital care, facilitate parent recognition of medication errors, and improve perceptions of safety and quality.

Residents' numeric inputting error in computerized physician order entry prescription

BACKGROUND

Computerized physician order entry (CPOE) system with embedded clinical decision support (CDS) can significantly reduce certain types of prescription error. However, prescription errors still occur. Various factors such as the numeric inputting methods in human computer interaction (HCI) produce different error rates and types, but has received relatively little attention.

OBJECTIVE

This study aimed to examine the effects of numeric inputting methods and urgency levels on numeric inputting errors of prescription, as well as categorize the types of errors.

METHODS

Thirty residents participated in four prescribing tasks in which two factors were manipulated: numeric inputting methods (numeric row in the main keyboard vs. numeric keypad) and urgency levels (urgent situation vs. non-urgent situation). Multiple aspects of participants' prescribing behavior were measured in sober prescribing situations.

RESULTS

The results revealed that in urgent situations, participants were prone to make mistakes when using the numeric row in the main keyboard. With control of performance in the sober prescribing situation, the effects of the input methods disappeared, and urgency was found to play a significant role in the generalized linear model. Most errors were either omission or substitution types, but the proportion of transposition and intrusion error types were significantly higher than that of the previous research. Among numbers 3, 8, and 9, which were the less common digits used in prescription, the error rate was higher, which was a great risk to patient safety.

CONCLUSIONS

Urgency played a more important role in CPOE numeric typing error-making than typing skills and typing habits. It was recommended that inputting with the numeric keypad had lower error rates in urgent situation. An alternative design could consider increasing the sensitivity of the keys with lower frequency of occurrence and decimals. To improve the usability of CPOE, numeric keyboard design and error detection could benefit from spatial incidence of errors found in this study.

Impact of electronic health record technology on the work and workflow of physicians in the intensive care unit

OBJECTIVE

To assess the impact of EHR technology on the work and workflow of ICU physicians and compare time spent by ICU resident and attending physicians on various tasks before and after EHR implementation.

DESIGN

EHR technology with electronic order management (CPOE, medication administration and pharmacy system) and physician documentation was implemented in October 2007.

MEASUREMENT

We collected a total of 289 h of observation pre- and post-EHR implementation. We directly observed the work of residents in three ICUs (adult medical/surgical ICU, pediatric ICU and neonatal ICU) and attending physicians in one ICU (adult medical/surgical ICU).

RESULTS

EHR implementation had an impact on the time distribution of tasks as well as the temporal patterns of tasks. After EHR implementation, both residents and attending physicians spent more of their time on clinical review and documentation (40% and 55% increases, respectively). EHR implementation also affected the frequency of switching between tasks, which increased for residents (from 117 to 154 tasks per hour) but decreased for attendings (from 138 to 106 tasks per hour), and the temporal flow of tasks, in particular around what tasks occurred before and after clinical review and documentation. No changes in the time spent in conversational tasks or the physical care of the patient were observed.

CONCLUSIONS

The use of EHR technology has a major impact on ICU physician work (e.g., increased time spent on clinical review and documentation) and workflow (e.g., clinical review and documentation becoming the focal point of many other tasks). Further studies should evaluate the impact of changes in physician work on the quality of care provided.

SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients

Healthcare practitioners, patient safety leaders, educators and researchers increasingly recognise the value of human factors/ergonomics and make use of the discipline's person-centred models of sociotechnical systems. This paper first reviews one of the most widely used healthcare human factors systems models, the Systems Engineering Initiative for Patient Safety (SEIPS) model, and then introduces an extended model, 'SEIPS 2.0'. SEIPS 2.0 incorporates three novel concepts into the original model: configuration, engagement and adaptation. The concept of configuration highlights the dynamic, hierarchical and interactive properties of sociotechnical systems, making it possible to depict how health-related performance is shaped at 'a moment in time'. Engagement conveys that various individuals and teams can perform health-related activities separately and collaboratively. Engaged individuals often include patients, family caregivers and other non-professionals. Adaptation is introduced as a feedback mechanism that explains how dynamic systems evolve in planned and unplanned ways. Key implications and future directions for human factors research in healthcare are discussed.