Characterizing Workflow to Inform Clinical Decision Support Systems in Nursing Homes

Effects of a QI intervention on pediatric asthma treatment using patient outcomes and workflow in an emergency department

OBJECTIVE

Evaluate a nurse-initiated quality improvement (QI) intervention aimed at enhancing asthma treatment in a pediatric emergency department (ED), utilizing outcomes and workflow.

METHODS

We evaluated the impact of QI interventions for pediatric patients presenting to the ED with asthma with pre-post analysis. A pediatric asthma score (PAS) of >8 indicated moderate to severe asthma. This secondary analysis of the electronic health record (EHR), evaluated on 1) patient outcomes (time to clinical treatment, ED length of stay [EDLOS], admissions and discharges home), 2) clinical workflow.

RESULTS

We compared 886 visits occurring between 01/01/2015 and 09/27/2015 (pre-implementation period) with 752 visits between 01/01/2016 and 09/27/2016 (post-implementation). Time to first documentation of PAS was decreased post-intervention (p<.001) by >30 min (75 ± 57 to 39 ± 54 min). There were significant decreases in time to treatment with both steroid and bronchodilator administration (both p<.001). EDLOS did not significantly change. Based on acuity level, those discharged home from the ED with high acuity (PAS score ≥8), had a significant decrease in time to initial PAS, steroid and bronchodilator use and EDLOS. Of those with high acuity who were admitted to the hospital, there was a difference pre- to post-implementation, in time to first PAS (p<.05), but not to treatment. Workflow visualization provided additional insights and detailed (task level) comparisons of the timing of ED activities.

CONCLUSIONS

Nurse-initiated ED interventions, can significantly improve the timeliness of pediatric asthma evaluation and treatment. Examining workflow along with the outcomes, can better inform QI evaluations and clinical management.

Defining the concepts of a smart nursing home and its potential technology utilities that integrate medical services and are acceptable to stakeholders: a scoping review

BACKGROUND AND OBJECTIVES

Smart technology in nursing home settings has the potential to elevate an operation that manages more significant number of older residents. However, the concepts, definitions, and types of smart technology, integrated medical services, and stakeholders' acceptability of smart nursing homes are less clear. This scoping review aims to define a smart nursing home and examine the qualitative evidence on technological feasibility, integration of medical services, and acceptability of the stakeholders.

METHODS

Comprehensive searches were conducted on stakeholders' websites (Phase 1) and 11 electronic databases (Phase 2), for existing concepts of smart nursing home, on what and how technologies and medical services were implemented in nursing home settings, and acceptability assessment by the stakeholders. The publication year was inclusive from January 1999 to September 2021. The language was limited to English and Chinese. Included articles must report nursing home settings related to older adults ≥ 60 years old with or without medical demands but not bed-bound. Technology Readiness Levels were used to measure the readiness of new technologies and system designs. The analysis was guided by the Framework Method and the smart technology adoption behaviours of elder consumers theoretical model. The results were reported according to the PRISMA-ScR.

RESULTS

A total of 177 literature (13 website documents and 164 journal articles) were selected. Smart nursing homes are technology-assisted nursing homes that allow the life enjoyment of their residents. They used IoT, computing technologies, cloud computing, big data and AI, information management systems, and digital health to integrate medical services in monitoring abnormal events, assisting daily living, conducting teleconsultation, managing health information, and improving the interaction between providers and residents. Fifty-five percent of the new technologies were ready for use in nursing homes (levels 6-7), and the remaining were proven the technical feasibility (levels 1-5). Healthcare professionals with higher education, better tech-savviness, fewer years at work, and older adults with more severe illnesses were more acceptable to smart technologies.

CONCLUSIONS

Smart nursing homes with integrated medical services have great potential to improve the quality of care and ensure older residents' quality of life.

Uncovering Discrepancies in IV Vancomycin Infusion Records between Pump Logs and EHR Documentation

BACKGROUND

Infusion start time, completion time, and interruptions are the key data points needed in both area under the concentration-time curve (AUC)- and trough-based vancomycin therapeutic drug monitoring (TDM). However, little is known about the accuracy of documented times of drug infusions compared with automated recorded events in the infusion pump system. A traditional approach of direct observations of infusion practice is resource intensive and impractical to scale. We need a new methodology to leverage the infusion pump event logs to understand the prevalence of timestamp discrepancies as documented in the electronic health records (EHRs).

OBJECTIVES

We aimed to analyze timestamp discrepancies between EHR documentation (the information used for clinical decision making) and pump event logs (actual administration process) for vancomycin treatment as it may lead to suboptimal data used for therapeutic decisions.

METHODS

We used process mining to study the conformance between pump event logs and EHR data for a single hospital in the United States from July to December 2016. An algorithm was developed to link records belonging to the same infusions. We analyzed discrepancies in infusion start time, completion time, and interruptions.

RESULTS

Of the 1,858 infusions, 19.1% had infusion start time discrepancy more than ± 10 minutes. Of the 487 infusion interruptions, 2.5% lasted for more than 20 minutes before the infusion resumed. 24.2% (312 of 1,287) of 1-hour infusions and 32% (114 of 359) of 2-hour infusions had over 10-minute completion time discrepancy. We believe those discrepancies are inherent part of the current EHR documentation process commonly found in hospitals, not unique to the care facility under study.

CONCLUSION

We demonstrated pump event logs and EHR data can be utilized to study time discrepancies in infusion administration at scale. Such discrepancy should be further investigated at different hospitals to address the prevalence of the problem and improvement effort.

Considerations for Designing EHR-Embedded Clinical Decision Support Systems for Antimicrobial Stewardship in Pediatric Emergency Departments

OBJECTIVE

This study was aimed to explore the intersection between organizational environment, workflow, and technology in pediatric emergency departments (EDs) and how these factors impact antibiotic prescribing decisions.

METHODS

Semistructured interviews with 17 providers (1 fellow and 16 attending faculty), and observations of 21 providers (1 physician assistant, 5 residents, 3 fellows, and 12 attendings) were conducted at three EDs in the United States. We analyzed interview transcripts and observation notes using thematic analysis.

RESULTS

Seven themes relating to antibiotic prescribing decisions emerged as follows: (1) professional judgement, (2) cognition as a critical individual resource, (3) decision support as a critical organizational resource, (4) patient management with imperfect information, (5) information-seeking as a primary task, (6) time management, and (7) broad process boundaries of antibiotic prescribing.

DISCUSSION

The emerging interrelated themes identified in this study can be used as a blueprint to design, implement, and evaluate clinical decision support (CDS) systems that support antibiotic prescribing in EDs. The process boundaries of antibiotic prescribing are broader than the current boundaries covered by existing CDS systems. Incongruities between process boundaries and CDS can under-support clinicians and lead to suboptimal decisions. We identified two incongruities: (1) the lack of acknowledgment that the process boundaries go beyond the physical boundaries of the ED and (2) the lack of integration of information sources (e.g., accessibility to prior cultures on an individual patient outside of the organization).

CONCLUSION

Significant opportunities exist to improve appropriateness of antibiotic prescribing by considering process boundaries in the design, implementation, and evaluation of CDS systems.

Research Priorities in Post-acute and Long-term Care: Results of a Stakeholder Needs Assessment

OBJECTIVES

Conduct a needs assessment among post-acute and long-term care (PA-LTC) stakeholder groups to identify (1) research topics of highest priority and (2) perspectives on research, including concerns/barriers to conducting research in the PA-LTC setting.

DESIGN

Mixed methods multistakeholder engagement process. Needs assessment conducted with tailored strategies per stakeholder group: interview, survey, and focus group.

SETTING AND PARTICIPANTS

Four stakeholder groups-medical directors/providers (n = 89), administrative leadership (n = 5), frontline staff (n = 17), and family members of residents and residents themselves (n = 11)-were recruited from the Colorado PA-LTC community through an academic-community partnership between the University of Colorado and Colorado Medical Directors Association.

MAIN OUTCOME(S)

Stakeholder perspectives on research and high priority PA-LTC research topics.

RESULTS

Research priorities common across stakeholder groups included polypharmacy (overuse of medication generally and overuse of antibiotics specifically), care transitions, mental health (including dementia, Alzheimer's disease, behaviors), chronic pain, urinary tract infection, and quality of life issues. Providers specifically prioritized heart failure, Parkinson's, and other chronic illnesses. Administrators and directors of nurses emphasized hospitalizations. Staff prioritized medication/therapy compliance. Families/residents prioritized neurologic disease. Concerns included staff burden, consenting process, privacy, and family involvement.

CONCLUSIONS/IMPLICATIONS

PA-LTC patients have a lot to offer as participants and decision makers in research, frontline staff are enthusiastic about participation, family members want to be involved, and providers value research findings in their practice but need a more supportive environment to produce and participate in research.

Usability Testing of a Mobile Clinical Decision Support App for Urinary Tract Infection Diagnosis in Nursing Homes

The aim of the current study was to conduct usability testing of a mobile clinical decision support (CDS) prototype designed for urinary tract infection (UTI) assessment by nurses in nursing homes (NHs). Usability of the UTIDecide smartphone application (app) was evaluated using cognitive walk-through and think-aloud protocol sessions with nurses (n = 6) at two NH sites. This evaluation was followed by unsupervised field tests lasting ≥1 week with nurses at one site (n = 4) and posttest interviews and administration of the System Usability Scale (SUS). Cognitive walk-through/think-aloud sessions yielded interface design recommendations that were implemented prior to field tests. All test sessions resulted in highly positive perceived usability and usefulness from participants. Average SUS score was 92.5 (n = 3), which equates to an "A" grade for usability. Design recommendations identified for future app versions are: (a) integration of the mobile CDS app with organizational information systems; and (b) expanded features to support assessment of other conditions. [Journal of Gerontological Nursing, 45(7), 11-17.].