A Pilot of Digital Whiteboards for Improving Patient Satisfaction in the Emergency Department: Nonrandomized Controlled Trial

BACKGROUND

Electronic paper (E-paper) screens use electrophoretic ink to provide paper-like low-power displays with advanced networking capabilities that may potentially serve as an alternative to traditional whiteboards and television display screens in hospital settings. E-paper may be leveraged in the emergency department (ED) to facilitate communication. Providing ED patient status updates on E-paper screens could improve patient satisfaction and overall experience and provide more equitable access to their health information.

OBJECTIVE

We aimed to pilot a patient-facing digital whiteboard using E-paper to display relevant orienting and clinical information in real time to ED patients. We also sought to assess patients' satisfaction after our intervention and understand our patients' overall perception of the impact of the digital whiteboards on their stay.

METHODS

We deployed a 41-inch E-paper digital whiteboard in 4 rooms in an urban, tertiary care, and academic ED and enrolled 110 patients to understand and evaluate their experience. Participants completed a modified Hospital Consumer Assessment of Health Care Provider and Systems satisfaction questionnaire about their ED stay. We compared responses to a matched control group of patients triaged to ED rooms without digital whiteboards. We designed the digital whiteboard based on iterative feedback from various departmental stakeholders. After establishing IT infrastructure to support the project, we enrolled patients on a convenience basis into a control and an intervention (digital whiteboard) group. Enrollees were given a baseline survey to evaluate their comfort with technology and an exit survey to evaluate their opinions of the digital whiteboard and overall ED satisfaction. Statistical analysis was performed to compare baseline characteristics as well as satisfaction.

RESULTS

After the successful prototyping and implementation of 4 digital whiteboards, we screened 471 patients for inclusion. We enrolled 110 patients, and 50 patients in each group (control and intervention) completed the study protocol. Age, gender, and racial and ethnic composition were similar between groups. We saw significant increases in satisfaction on postvisit surveys when patients were asked about communication regarding delays (P=.03) and what to do after discharge (P=.02). We found that patients in the intervention group were more likely to recommend the facility to family and friends (P=.04). Additionally, 96% (48/50) stated that they preferred a room with a digital whiteboard, and 70% (35/50) found the intervention "quite a bit" or "extremely" helpful in understanding their ED stay.

CONCLUSIONS

Digital whiteboards are a feasible and acceptable method of displaying patient-facing data in the ED. Our pilot suggested that E-paper screens coupled with relevant, real-time clinical data and packaged together as a digital whiteboard may positively impact patient satisfaction and the perception of the facility during ED visits. Further study is needed to fully understand the impact on patient satisfaction and experience.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04497922; https://clinicaltrials.gov/ct2/show/NCT04497922.

3.0 vs 1.5 T MRI in the detection of focal cartilage pathology--ROC analysis in an experimental model

OBJECTIVE

To use receiver operator characteristics (ROC) analysis for assessing the diagnostic performance of three cartilage-specific MR sequences at 1.5 and 3 T in detecting cartilage lesions created in porcine knees.

DESIGN

Eighty-four cartilage lesions were created in 27 porcine knee specimens at the patella, the medial and lateral femoral and the medial and lateral tibial cartilage. MR imaging was performed using a fat saturated spoiled gradient echo (SPGR) sequence (in plane spatial resolution/slice thickness: 0.20 x 0.39 mm2/1.5 mm) and two fat saturated proton density weighted (PDw) sequences (low spatial resolution: 0.31 x 0.47 mm2/3 mm and high spatial resolution: 0.20 x 0.26 mm2/2 mm). The images were independently analyzed by three radiologists concerning the absence or presence of lesions using a five-level confidence scale. Significances of the differences for the individual sequences were calculated based on comparisons of areas under ROC curves (A(Z)).

RESULTS

The highest A(Z)-values for all three radiologists were consistently obtained for the SPGR (A(Z) = 0.84) and the high-resolution (hr) PDw (A(Z) = 0.79) sequences at 3T. The corresponding A(Z)-values at 1.5 T were 0.77 and 0.69; the differences between 1.5 and 3 T were statistically significant (P < 0.05). A(Z)-values for the low-resolution PDw sequence were lower: 0.59 at 3 T and 0.55 at 1.5 T and the differences between 1.5 and 3T were not significant.

CONCLUSION

With optimized hr MR sequences diagnostic performance in detecting cartilage lesions was improved at 3 T. For a standard, lower spatial resolution PDw sequence no significant differences, however, were found.

Stewart-Treves syndrome: MR imaging of a postmastectomy upper-limb chronic lymphedema with angiosarcoma

The rare occurrence of angiosarcoma in postmastectomy upper-limb lymphedema with magnetic resonance (MR) imaging is discussed. Unfamiliarity with this aggressive vascular tumor and its harmless appearance often leads to delayed diagnosis. Angiosarcoma complicating chronic lymphedema may be low in signal intensity on T2-weighting and short tau inversion recovery (STIR) imaging reflecting the densely cellular, fibrous stroma, and sparsely vascularized tumor histology. Additional administration of intravenous contrast medium revealed significant enhancement of the tumorous lesions. Awareness of angiosarcoma and its MR imaging appearance in patients with chronic lymphedema may be a key to early diagnosis or allow at least inclusion in the differential diagnosis.

Superficial inflammatory and primary neoplastic lymphadenopathy: diagnostic accuracy of power-doppler sonography

OBJECTIVE

To evaluate the sensitivity, specificity and diagnostic accuracy of a cut-off of the resistive index of 0.5 for the differentiation between inflammatory and neoplastic primary lymphadenopathies.

SUBJECTS AND METHODS

We measured the resistive index of superficial enlarged lymph nodes in a total of 50 patients (29 males and 21 females; age range 12-72 years, mean age 41.6 year) using an ATL 5000 HDI. A resistive index greater than or equal to 0.5 indicated an inflammatory lymph node and a resistive index <0.5 was consistent with neoplastic primary lymphadenopathies. The gold standard was either surgical biopsy or lymph-node reduction seen with ultrasound examination after antibiotic therapy.

RESULTS

The sensitivity of the resistive index for distinguishing inflammatory from neoplastic lymphadenopathy was 84.6%, the specificity 100% and the diagnostic accuracy 95.7% (P < 0.001, statistically significant).

CONCLUSION

The results of this study indicate that power-Doppler using a resistive index cut-off of 0.5 was a valid technique for distinguishing between inflammatory and primary neoplastic lymph nodes in patients with superficial lymphadenopathies.

High resolution MRI of small joints: impact of spatial resolution on diagnostic performance and SNR

This study focuses on the spatial resolution required for cartilage imaging. The purposes of this study were (I) to analyze the diagnostic performance in diagnosing artificially produced cartilage lesions in a small joint model using an optimized fat saturated three-dimensional gradient-echo sequence, (II) to relate the lesion size and depth as diagnosed in the magnetic resonance images with the corresponding pathologic findings and (III) to assess signal-to-noise (SNR) ratios for each of the protocols. Twenty-five artificial cartilage lesions were created in the knee joints of 10 rabbits. These specimens and seven specimens without lesions were imaged at 1.5 T using a three-dimensional gradient-echo sequence with varying slice thickness, field of view and matrix. A total of 404 corresponding images were selected, 50% with and 50% without cartilage lesions. Six radiologists scored all images according to five levels of confidence and receiver operating characteristic (ROC) analysis was performed. Lesion size and depth were compared to the corresponding pathological specimen sections. Additionally SNR ratios were calculated. ROC analysis of pooled data from all readers showed the highest area under the ROC curve for the sequence with the highest spatial resolution, while the diagnostic performance was significantly lower in the other sequences (p <0.01). Assessment of the lesion size and depth was correct in 45% and 40% respectively with the highest resolution and in 29% and 23% with the lowest resolution. SNR ratios decreased with increasing spatial resolution. In conclusion this study shows that increasing spatial resolution improves diagnostic performance in cartilage lesions, though SNR decreases substantially. Assessment of correct lesion size and depth still is limited.

[CT and MRI in elastofibroma. A rare, benign soft tissue tumor]

Elastofibroma is a rare, benign soft-tissue tumor that occurs along the chest wall in the periscapular region. We identified five patients with a surgical diagnosis of elastofibroma who had had CT and/or MR scans. CT and MR imaging were compared to histologic findings in two patients. CT was available in three patients and demonstrated periscapular soft-tissue tumor with an attenuation similar to that of adjacent muscle. In one patient, the tumors appeared homogeneous. In two patients, the tumor showed strands of low density similar to that of adjacent subcutaneous fat on CT. On MR imaging, all five tumors showed predominantly low-signal intensity on both T1 and T2-weighted images. The tumors contained focal areas with high-signal intensity on T1-weighted scans that showed intermediate to high-signal intensity with T2-weighting. The areas of low-signal intensity on both T1 and T2-weighted images corresponded histologically to fibroelastic tissue. The areas of high signal intensity on T1-weighting and intermediate to high-signal intensity on T2-weighting reflected focal areas of fat within the tumor. Although CT and MR imaging findings are not specific, the presence of a soft-tissue tumor along the chest wall in a periscapular location that shows predominantly low intensity on all sequences reflecting fibrous tissue with interspersed focal areas of fatty tissue is highly suggestive of elastofibroma.

Alcohol-induced bone disease: relationship to age and parathyroid hormone levels

Alcohol abuse leads to osteopenia and fractures. Epidemiological evidence suggests that older alcoholics are at substantially greater risk of fractures than younger alcoholics. To examine the interaction of age and alcohol abuse on bone mineral homeostasis, we studied 27 subjects with a history of 10 more years of alcohol abuse ranging in age from 26-68 years. They were evaluated for disordered bone mineral homeostasis by assessing bone density (by quantitative computed tomography of the lumbar spine), histomorphometry of a transcortical biopsy from the iliac crest, serum levels of vitamin D metabolites and parathyroid hormone, and serum and urine levels of bone minerals. Seventeen of the subjects were found to have spinal compression fractures by routine radiologic procedures. The older the subject the more likely the subject was to have such a fracture. Bone densitometry indicated a marked reduction in spinal bone density with 15 subjects below 2 SD of normal aged-matched controls. Bone density fell sharply with the age of the subject. Histomorphometry of iliac crest bone biopsies revealed no evidence of osteomalacia, but total resorption surfaces were increased. Consistent with the lack of osteomalacia were the normal levels of the vitamin D metabolites. The increased total resorption surfaces were correlated with high normal or elevated levels of parathyroid hormone as indicated both by radioimmunoassay and by urinary cAMP levels. Bone formation and active bone resorption (resorption surfaces containing osteoclasts) did not correlate with parathyroid hormone levels, however, but correlated negatively with age.(ABSTRACT TRUNCATED AT 250 WORDS)

Elevated 1,25-dihydroxyvitamin D levels in patients with chronic obstructive pulmonary disease treated with prednisone

Glucocorticoid administration is a well established cause of osteopenia. Mechanisms underlying the deleterious effect of glucocorticoids on bone may include direct inhibition of bone formation as well as indirect effects through changes in intestinal calcium absorption, renal calcium excretion, and/or levels of the calciotropic hormones. To further examine the potential role of the calciotropic hormones we measured serum levels of PTH and 1,25 dihydroxyvitamin D [1,25(OH)2D], as well as serum and urine levels of calcium and vertebral bone density in patients with chronic obstructive pulmonary disease being managed with or without prednisone. Patients treated with prednisone had lower spinal bone density (53 vs. 106 mg/cm3) and higher serum calcium (2.40 vs. 2.33 mmol/l), urine calcium (6.9 vs. 2.7 mmol/24h), and 1,25(OH)2D levels (147 vs. 95 pmol/L). Compared to the patients not treated with glucocorticoids. PTH levels also tended to be higher (33 vs. 26 microliters-eq/ml), but the difference was not significant. Serum and urine calcium levels correlated positively with 1,25(OH)2D levels, but none of these measurements correlated with PTH levels. Our results suggest that prednisone treatment alters the regulation of 1,25(OH)2D production, and this may contribute to the loss of bone mineral induced by prednisone.

A prospective comparison of computerized arthrotomography and magnetic resonance imaging of the glenohumeral joint

Twenty-five patients with shoulder instability or shoulder pain of undetermined etiology were prospectively evaluated with magnetic resonance imaging and computerized arthrotomography. Actual lesions were determined by arthroscopy or at the time of open surgical repair. The images obtained were interpreted independently by three radiologists blinded to both surgical results and the results of previous diagnostic tests. Sensitivity, specificity, and accuracy were determined for each imaging technique for a variety of pathologic entities, including anterior and posterior labral abnormalities, capsular redundancy, biceps-labral complex abnormalities, humeral head (Hill-Sachs) impression lesions, and glenohumeral loose bodies. Analysis of imaging techniques also included construction of receiver operator curves for labral abnormalities. Magnetic resonance imaging showed better diagnostic results in the evaluation of glenoid labral and humeral head impression lesions (P < 0.05). Both imaging techniques were equally successful in identifying biceps-labral lesions and intraarticular loose bodies within the glenohumeral joint. Neither imaging technique was consistent in the evaluation of capsular redundancy. Receiver operator curve analysis confirmed that magnetic resonance imaging was the more accurate imaging study in evaluating anterior and posterior glenoid labral abnormalities.

Magnetic resonance imaging of the shoulder: rationale and current applications

Because it can demonstrate a wide range of tissue contrast with excellent resolution, magnetic resonance (MR) imaging has revolutionized imaging in many areas of the musculoskeletal system and has generated excitement among those interested in the painful shoulder. Shoulder impingement syndrome and glenohumeral instability constitute the two major categories of shoulder derangements. Correct diagnosis requires the use of appropriate pulse sequences and imaging planes, proper patient positioning, and a satisfactory surface coil. In addition the imager must have a thorough understanding of shoulder anatomy and pathology. We present a summary of the current status of MR imaging of the shoulder including technical, anatomic, and pathologic considerations and a review of the pertinent literature.

[Possibilities of MR tomography of diseases of the hand and wrist]

MRI studies of 63 patients with various abnormalities of the hand and wrist were analyzed. Studies were performed on scanners with a field strength of 0.35, 0.5, or 1.5 T. Imaging parameters included T1- and T2-weighted sequences in the coronal and transverse planes and contiguous slices 3-5 mm thick. In 37 patients with post-traumatic disorders, MRI revealed carpal avascular necrosis, tendon abnormalities and, in some cases, abnormalities of interosseous ligaments and the triangular fibrocartilage. In 15 patients with such inflammatory diseases as arthritis, tenosynovitis and carpal tunnel syndrome and in 11 patients with tumors, MRI provided clear delineation of osseous and soft tissue abnormalities. The current role of MRI in the diagnosis of hand and wrist abnormalities is discussed on the basis of these results.

A posterior ascending popliteal cyst mimicking thrombophlebitis following total knee arthroplasty (TKA)

Pain and swelling of the lower extremity following total knee arthroplasty are not infrequent. The most frequent conditions responsible for these symptoms include thrombophlebitis, prosthetic loosening, infection, and fracture of either the prosthesis or the bones. In addition to these conditions, a dissecting or ruptured popliteal cyst should be considered in the differential diagnosis of acute calf pain and swelling following total knee arthroplasty. Two patients with symptoms of phlebothrombosis were evaluated retrospectively two to three years following total knee arthroplasty. In both patients the popliteal cysts dissected proximally into the thigh. A dissecting popliteal cyst is diagnosed by arthrography. The usual arthrographic films evaluated for a Baker's or popliteal cyst are anteroposterior and lateral views of the calf. These films are inadequate in patients who have undergone total knee arthroplasty; the dissecting cysts observed in the patients of the present report dissected proximally above the knee and were diagnosed on anteroposterior and lateral views of the distal femur. The more common symptoms noted after total knee arthroplasty should not be excluded due to the presence of a dissecting or ruptured cyst, as one of the patients of the present report also had a superimposed infection. Clinical considerations of a dissecting popliteal cyst are emphasized so that arthrography can be performed early in the course of the symptoms and proper treatment initiated.

1(7),8-p-MENTHADIENE EX PYROLYSIS OF β-PINENE

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