Factors influencing the successful implementation of a novel digital health application to streamline multidisciplinary communication across multiple organisations for emergency care

RATIONALE

Delivering optimal patient health care requires interdisciplinary clinician communication. A single communication tool across multiple pre-hospital and hospital settings, and between hospital departments is a novel solution to current systems. Fit-for-purpose, secure smartphone applications allow clinical information to be shared quickly between health providers. Little is known as to what underpins their successful implementation in an emergency care context.

AIMS

To identify (a) whether implementing a single, digital health communication application across multiple health care organisations and hospital departments is feasible; (b) the barriers and facilitators to implementation; and (c) which factors are associated with clinicians' intentions to use the technology.

METHODS

We used a multimethod design, evaluating the implementation of a secure, digital communication application (Pulsara™). The technology was trialled in two Australian regional hospitals and 25 Ambulance Victoria branches (AV). Post-training, clinicians involved in treating patients with suspected stroke or cardiac events were administered surveys measuring perceived organisational readiness (Organisational Readiness for Implementing Change), clinicians' intentions (Unified Theory of Acceptance and Use of Technology) and internal motivations (Self-Determination Theory) to use Pulsara™, and the perceived benefits and barriers of use. Quantitative data were descriptively summarised with multivariable associations between factors and intentions to use Pulsara™ examined with linear regression. Qualitative data responses were subjected to directed content analysis (two coders).

RESULTS

Participants were paramedics (n = 82, median 44 years) or hospital-based clinicians (n = 90, median 37 years), with organisations perceived to be similarly ready. Regression results (F(11, 136) = 21.28, p = <0.001, Adj R2  = 0.60) indicated Habit, Effort Expectancy, Perceived Organisational Readiness, Performance Expectancy and Organisation membership (AV) as predictors of intending to use Pulsara™. Themes relating to benefits (95% coder agreement) included improved communication, procedural efficiencies and faster patient care. Barriers (92% coder agreement) included network accessibility and remembering passwords. PulsaraTM was initiated 562 times.

CONCLUSION

Implementing multiorganisational, digital health communication applications is feasible, and facilitated when organisations are change-ready for an easy-to-use, effective solution. Developing habitual use is key, supported through implementation strategies (e.g., hands-on training). Benefits should be emphasised (e.g., during education sessions), including streamlining communication and patient flow, and barriers addressed (e.g., identify champions and local technical support) at project commencement.

Real-world, feasibility study to investigate the use of a multidisciplinary app (Pulsara) to improve prehospital communication and timelines for acute stroke/STEMI care

OBJECTIVES

To determine if a digital communication app improves care timelines for patients with suspected acute stroke/ST-elevation myocardial infarction (STEMI).

DESIGN

Real-world feasibility study, quasi-experimental design.

SETTING

Prehospital (25 Ambulance Victoria branches) and within-hospital (2 hospitals) in regional Victoria, Australia.

PARTICIPANTS

Paramedics or emergency department (ED) clinicians identified patients with suspected acute stroke (onset <4.5 hours; n=604) or STEMI (n=247).

INTERVENTION

The Pulsara communication app provides secure, two-way, real-time communication. Assessment and treatment times were recorded for 12 months (May 2017-April 2018), with timelines compared between 'Pulsara initiated' (Pulsara) and 'not initiated' (no Pulsara).

PRIMARY OUTCOME MEASURE

Door-to-treatment (needle for stroke, balloon for STEMI) Secondary outcome measures: ambulance and hospital processes.

RESULTS

Stroke (no Pulsara n=215, Pulsara n=389) and STEMI (no Pulsara n=76, Pulsara n=171) groups were of similar age and sex (stroke: 76 vs 75 years; both groups 50% male; STEMI: 66 vs 63 years; 68% and 72% male). When Pulsara was used, patients were off ambulance stretcher faster for stroke (11(7, 17) vs 19(11, 29); p=0.0001) and STEMI (14(7, 23) vs 19(10, 32); p=0.0014). ED door-to-first medical review was faster (6(2, 14) vs 23(8, 67); p=0.0001) for stroke but only by 1 min for STEMI (3 (0, 7) vs 4 (0, 14); p=0.25). Door-to-CT times were 44 min faster (27(18, 44) vs 71(43, 147); p=0.0001) for stroke, and percutaneous intervention door-to-balloon times improved by 17 min, but non-significant (56 (34, 88) vs 73 (49, 110); p=0.41) for STEMI. There were improvements in the proportions of patients treated within 60 min for stroke (12%-26%, p=0.15) and 90 min for STEMI (50%-78%, p=0.20).

CONCLUSIONS

In this Australian-first study, uptake of the digital communication app was strong, patient-centred care timelines improved, although door-to-treatment times remained similar.

Abstract WP303: Improving Treatment Within the Golden Hour in and Out of Hours With a Multi-Disciplinary Pre-Hospital, Within-Hospital Communication System

Delivery of time-critical stroke care requires rapid assessment, diagnosis and treatment, involving multiple clinicians. However, disparate communication systems exist between in-field paramedics and hospital clinicians, with variation for in and out of hours presentations. Repetition of patient information and fragmented systems may contribute to delayed processes.

Aim: To determine if smartphone communication technology can improve clinical care timelines for patients with suspected acute stroke in and out of hours.

Methods: A 12 month pre-post historical-control design was used. The Pulsara TM Stop Stroke/STEMI smartphone and tablet app (Pulsara) was implemented in 25 Ambulance Victoria branches and 2 hospitals in rural Victoria, Australia, during 2016/2017. Pulsara provides secure, simultaneous, two-way, real-time communication. Eligible patients had suspected acute stroke as assessed by paramedics or hospital clinicians. Analyses compare timelines (median minutes) for when Pulsara is (Pulsara+), or is not (Pulsara-), used by clinicians in hours (08:00-17:00; IH) and out of hours (17:01-07:59; OH).

Results: Pulsara was used in 80% (210/265) of cases. Using Pulsara, patients are off-ambulance stretcher 5 minutes faster (10 minutes Pulsara+ vs 15 minutes Pulsara- ; p=0.23), and depart hospital 4 minutes faster (11 minutes Pulsara+ vs 15 minutes Pulsara- ; p=0.02). The time to first medical review is similar IH (7 minutes), but 7 minutes faster OH (7 minutes Pulsara+ vs 14 minutes Pulsara-; p=.03). Time to CT scan is 40 minutes faster IH (27 minutes Pulsara+ vs 67 minutes Pulsara- ; p=.02), and 29 minutes faster OH (29 minutes Pulsara+ vs 58 minutes Pulsara- ; p=.0001). Pulsara was used on all cases receiving thrombolysis. Compared to the pre-Pulsara period, when Pulsara was used the proportion treated within 60 minutes increased from 9% (1/11) to 23% (3/13) during in hours, and from 13% (2/15) to 26% (7/27) out of hours.

Conclusion: The use of Pulsara improved hospital metrics and care timelines for treatment of patients with suspected stroke. There is a two-fold increase of patients treated within 60 minutes in hours, and also out of hours (when staffing levels are less). Pulsara has significantly improved stroke care in these two rural hospitals.

The prediction of saleable meat yield in lamb carcasses

A total of 281 lamb carcasses covering three weight groups (18–22.9, 23–25.9 and 26–30 kg) and fatness (< 3 mm, 3–5 mm and > 5 mm) were used to determine the usefulness of several carcass measurements for predicting saleable meat yield. Carcasses were measured for fat and muscle depth, 3–4 cm from the mid-line between the 10th and 11th ribs, 12th and 13th ribs and immediately adjacent to the 13th rib using a Hennessey Grading Probe. This technique also determined total tissue depth at 11 cm from the mid-line between the 10th and 11th and 12th and 13th ribs. The depth of tissues over the 12th rib 11 cm from the mid-line was measured with a ruler. Carcasses were also visually assessed for muscle development (conformation score) on a 5-point scale (1 = thinly fleshed; 5 = thickly fleshed). All carcasses were fabricated into primal cuts which were trimmed to 5 mm of fat and deboned to provide an estimate of saleable meat yield. Ewe lamb carcasses had a higher proportion of kidney fat than wethers in all weight and fat groups (which ranged from 2.6 to 17.9 g kg−1 carcass weight). Saleable meat yield decreased as carcasses became fatter, whereas weight group had little influence on saleable meat yield within a fat group. Ewe lamb carcasses had lower saleable meat yields than wether lamb carcasses, mainly because of their higher amounts of kidney fat. A ruler measurement of tissue depth over the 12th rib combined with carcass conformation score provided the most precise prediction (R2 = 0 61; RSD 17.1) of saleable meat yield. It was concluded that a simple manual system based on these two measurements provided an adequate prediction of saleable meat yield. The accuracy of the procedure would be increased by excluding kidney fat from carcass weight for the prediction of saleable meat yield. Key words: Lamb, carcass, composition, probe, fat, grade