The electronic health record (EHR) offers an exciting opportunity for quality improvement efforts. An understanding of the nuances of a site's EHR landscape including the best practices in clinical ...decision support design, basics of data capture, and acknowledgment of the potential unintended consequences of technology change is essential to ensuring effective usage of this powerful tool.
Abstract
Objective
Develop and evaluate an interactive information visualization embedded within the electronic health record (EHR) by following human-centered design (HCD) processes and leveraging ...modern health information exchange standards.
Materials and Methods
We applied an HCD process to develop a Fast Healthcare Interoperability Resources (FHIR) application that displays a patient’s asthma history to clinicians in a pediatric emergency department. We performed a preimplementation comparative system evaluation to measure time on task, number of screens, information retrieval accuracy, cognitive load, user satisfaction, and perceived utility and usefulness. Application usage and system functionality were assessed using application logs and a postimplementation survey of end users.
Results
Usability testing of the Asthma Timeline Application demonstrated a statistically significant reduction in time on task (P < .001), number of screens (P < .001), and cognitive load (P < .001) for clinicians when compared to base EHR functionality. Postimplementation evaluation demonstrated reliable functionality and high user satisfaction.
Discussion
Following HCD processes to develop an application in the context of clinical operations/quality improvement is feasible. Our work also highlights the potential benefits and challenges associated with using internationally recognized data exchange standards as currently implemented.
Conclusion
Compared to standard EHR functionality, our visualization increased clinician efficiency when reviewing the charts of pediatric asthma patients. Application development efforts in an operational context should leverage existing health information exchange standards, such as FHIR, and evidence-based mixed methods approaches.
Introduction
Pulse oximetry monitoring is prescribed to children receiving home oxygen for chronic medical conditions associated with hypoxemia. Although home pediatric pulse oximetry is supported by ...national organizations, there is a lack of guidelines outlining indications and prescribing parameters.
Methods
A mixed‐methods analysis of pediatric home pulse oximetry orders prescribed through the institutional home healthcare provider at a large US children's hospital 6/2018–7/2019 was retrospectively reviewed to determine prescribed alarm parameter limits and recommended interventions. Semi‐structured qualitative interviews with pediatric providers managing patients receiving home oxygen and pulse oximetry were conducted to identify opportunities to improve home pulse oximetry prescribing practices. Interviews were analyzed using a modified content analysis approach to identify recurring themes.
Results
A total of 368 children received home pulse oximetry orders. Orders were most frequently prescribed on noncardiac medical floors (32%). Attending physicians were the most frequent ordering providers (52%). Frequency of use was prescribed in 96% of orders, however, just 70% were provided with specific instructions for interventions when alarms occurred. Provider role and clinical setting were significantly associated with the presence of a care plan. Provider interviews identified opportunities for improvement with the device, management of alarm parameter limits, and access to home monitor data.
Discussion
This study demonstrated significant variability in home pulse oximetry prescribing practices. Provider interviews highlighted the importance of the provider–patient relationship and areas for improvement. There is an opportunity to create standardized guidelines that optimize the use of home monitoring devices for patients, families, and pulmonary providers.
Continuous physiologic monitoring commonly is used in pediatric medical-surgical (med-surg) units and is associated with high alarm burden for clinicians. Characteristics of pediatric patients ...generating high rates of alarms on med-surg units are not known.
To describe the demographic and clinical characteristics of pediatric med-surg patients associated with high rates of clinical alarms.
We conducted a cross-sectional, single-site, retrospective study using existing clinical and alarm data from a children's hospital. Continuously monitored patients from med-surg units who had available alarm data were included. Negative binomial regression models were used to test the association between patient characteristics and the rate of clinical alarms per continuously monitored hour.
Our final sample consisted of 1,569 patients with a total of 38,501 continuously monitored hours generating 265,432 clinical alarms. Peripheral oxygen saturation (SpO
) low alarms accounted for 57.5% of alarms. Patients with medical complexity averaged 11% fewer alarms per hour than those without medical complexity (
< 0.01). Patients older than 5 years had up to 30% fewer alarms per hour than those who were younger than 5 years (
< 0.01). Patients using supplemental oxygen averaged 39% more alarms per hour compared with patients who had no supplemental oxygen use (
< 0.01). Patients at high risk for deterioration averaged 19% more alarms per hour than patients who were not high risk (
= 0.01).
SpO
alarms were the most common type of alarm in this study. The results highlight patient populations in pediatric medical-surgical units that may be high yield for interventions to reduce alarms. Most physiologic monitor alarms in pediatric medical-surgical (med-surg) units are not informative and likely could be safely eliminated to reduce noise and alarm fatigue.
However, identifying and sustaining successful alarm-reduction strategies is a challenge. Research shows that 25% of patients in pediatric med-surg units produce almost three-quarters of all alarms.
These patients are a potential high-yield target for alarm-reduction strategies; however, we are not aware of studies describing characteristics of pediatric patients generating high rates of alarms. The patient populations seen on pediatric med-surg units are diverse. Children of all ages are cared for on these units, with diagnoses ranging from acute respiratory infections, to management of chronic conditions, and to psychiatric conditions. Not all patients on pediatric med-surg units have physiologic parameters continuously monitored,
but among those who do, understanding patient characteristics associated with high rates of alarms may help clinicians, healthcare technology management (HTM) professionals, and others working on alarm management strategies to develop targeted interventions. We conducted an exploratory retrospective study to describe patient characteristics associated with high rates of alarms in pediatric med-surg units.
The COVID-19 pandemic produced unprecedented challenges to healthcare and medical device manufacturing (e.g. personal protective device and replacement part shortages). Additive manufacturing, 3D ...printing, and the maker community were uniquely positioned to respond to these needs by providing in-house design and manufacturing to meet the needs of clinicians and hospitals. This paper reviews the pandemic response of Children's Hospital of Philadelphia CHAMP 3D Lab, a point-ofcare3D printing team that supports clinical and research projects across the hospital network. The CHAMP team responded to a variety of COVID-19 healthcare needs including providing protective eyewear and ventilator components, creating a transport hook, and designing a novel transparent facemask. This case series details our response to these needs, describing challenges experienced and lessons learned in overcoming them so that others may learn from our experiences. Challenges to responding to the pandemic included the need to handle urgent pandemic related requests in addition to our standard fare. This required us to not only expand our capacity without additional resources, but also to develop a system of prioritization. Specific changes made included: streamlining workflows, identifying safety review processes, and developing/enlisting a network of collaborators. Further, we consider how to transition to a future, post-pandemic world without losing the cohesive drive of emergency-induced innovation. This paper aims to share what we have learned and to encourage both teams currently engaged in the printing community and those looking to join it
Background
Like most hospitals, our hospital experienced COVID-19 pandemic-related supply chain shortages. Our additive manufacturing lab’s capacity to offset these shortages was soon overwhelmed, ...leading to a need to improve the efficiency of our existing workflow. We undertook a work system analysis guided by the Systems Engineering Initiative for Patient Safety (SEIPS) construct which is based on human factors and quality improvement principles. Our objective was to understand the inefficiencies in project submission, review, and acceptance decisions, and make systematic improvements to optimize lab operations.
Methods
Contextual inquiry (interviews and workflow analysis) revealed suboptimal characteristics of the system, specifically, reliance on a single person to facilitate work and, at times, fractured communication with project sponsors, with root causes related to the project intake and evaluation process as identified through SEIPS tools. As interventions, the analysis led us to: 1) enhance an existing but underused project submission form, 2) design and implement an internal project scorecard to standardize evaluation of requests, and 3) distribute the responsibility of submission evaluation across lab members. We implemented these interventions in May 2021 for new projects and compare them to our baseline February 1, 2018 through – April 30, 2021 performance (1184 days).
Results
All project requests were submitted using the enhanced project submission form and all received a standardized evaluation with the project scorecard. Prior to interventions, we completed 35/79 (44%) of projects, compared to 12/20 (60%) of projects after interventions were implemented. Time to review new submissions was reduced from an average of 58 days to 4 days. A more distributed team responsibility structure permitted improved workflow with no increase in staffing, allowing the Lab Manager to devote more time to engineering rather than administrative/decision tasks.
Conclusions
By optimizing our workflows utilizing a human factors approach, we improved the work system of our additive manufacturing lab to be responsive to the urgent needs of the pandemic. The current workflow provides insights for labs aiming to meet the growing demand for point-of-care manufacturing.
Abstract
Clinical decision support (CDS) systems delivered through the electronic health record are an important element of quality and safety initiatives within a health care system. However, ...managing a large CDS knowledge base can be an overwhelming task for informatics teams. Additionally, it can be difficult for these informatics teams to communicate their goals with external operational stakeholders and define concrete steps for improvement. We aimed to develop a maturity model that describes a roadmap toward organizational functions and processes that help health care systems use CDS more effectively to drive better outcomes. We developed a maturity model for CDS operations through discussions with health care leaders at 80 organizations, iterative model development by four clinical informaticists, and subsequent review with 19 health care organizations. We ceased iterations when feedback from three organizations did not result in any changes to the model. The proposed CDS maturity model includes three main “pillars”: “Content Creation,” “Analytics and Reporting,” and “Governance and Management.” Each pillar contains five levels—advancing along each pillar provides CDS teams a deeper understanding of the processes CDS systems are intended to improve. A “roof” represents the CDS functions that become attainable after advancing along each of the pillars. Organizations are not required to advance in order and can develop in one pillar separately from another. However, we hypothesize that optimal deployment of preceding levels and advancing in tandem along the pillars increase the value of organizational investment in higher levels of CDS maturity. In addition to describing the maturity model and its development, we also provide three case studies of health care organizations using the model for self-assessment and determine next steps in CDS development.
Home pulse oximeters prescribed for infants with cardiorespiratory conditions generate many false alarms, which create caregiver stress and sleep disturbance and can lead to unsafe practices. ...Additionally, relationships among oximeters, alarms, and everyday living demands are not well understood. Therefore, we aimed to gather parent perspectives on home pulse oximetry monitoring during the problem analysis phase of a quality improvement (QI) initiative.
We purposively sampled and interviewed parents of infants prescribed home pulse oximeters and receiving local home care company services. We based questions on systems engineering frameworks previously used in healthcare. Data were coded iteratively and analyzed deductively (theoretical frameworks) and inductively (emerging themes).
Generally, themes aligned with theoretical frameworks. Parents expressed dissatisfaction with the number of false alarms home pulse oximeters generate, which parents primarily attributed to poor probe adhesiveness and the inability of oximeters to account for infant movement. Interviews highlighted the burden associated with poor device tones and portability. Device-related issues had negative repercussions for the entire family related to sleep quality, mobility, and social interactions. Universally, parents developed workarounds, including cessation of monitoring.
Parents of infants monitored at home using pulse oximetry face many challenges, resulting in compromises in safety. Continuing to instruct parents to comply with prescribed monitoring recommendations may be unrealistic. Instead, we suggest re-engineering the home monitoring system with the needs and goals of children and their families at the center. Our description of adapting qualitative research and systems engineering methods may benefit others developing QI work.
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