Barwise, Amelia K

OBJECTIVES: To investigate whether a novel acute care multipatient viewer (AMP), created with an understanding of clinician information and process requirements, could reduce time to clinical decision-making among clinicians caring for populations of acutely ill patients compared with a widely used commercial electronic medical record (EMR). DESIGN: Single center randomized crossover study. SETTING: Quaternary care academic hospital. SUBJECTS: Attending and in-training critical care physicians, and advanced practice providers. INTERVENTIONS: AMP. MEASUREMENTS AND MAIN RESULTS: We compared ICU clinician performance in structured clinical task completion using two electronic environments—the standard commercial EMR (Epic) versus the novel AMP in addition to Epic. Twenty subjects (10 pairs of clinicians) participated in the study. During the study session, each participant completed the tasks on two ICUs (7–10 beds each) and eight individual patients. The adjusted time for assessment of the entire ICU and the adjusted total time to task completion were significantly lower using AMP versus standard commercial EMR (–6.11; 95% CI, –7.91 to –4.30 min and –5.38; 95% CI, –7.56 to –3.20 min, respectively; p < 0.001). The adjusted time for assessment of individual patients was similar using both the EMR and AMP (0.73; 95% CI, –0.09 to 1.54 min; p = 0.078). AMP was associated with a significantly lower adjusted task load (National Aeronautics and Space Administration-Task Load Index) among clinicians performing the task versus the standard EMR (22.6; 95% CI, –32.7 to –12.4 points; p < 0.001). There was no statistically significant difference in adjusted total errors when comparing the two environments (0.68; 95% CI, 0.36–1.30; p = 0.078). CONCLUSIONS: When compared with the standard EMR, AMP significantly reduced time to assessment of an entire ICU, total time to clinical task completion, and clinician task load. Additional research is needed to assess the clinicians’ performance while using AMP in the live ICU setting.

Background Diagnostic error (DE) is a common problem in clinical practice, particularly in the emergency department (ED) setting. Among ED patients presenting with cardiovascular or cerebrovascular/neurological symptoms, a delay in diagnosis or failure to hospitalise may be most impactful in terms of adverse outcomes. Minorities and other vulnerable populations may be at higher risk of DE. We aimed to systematically review studies reporting the frequency and causes of DE in under-resourced patients presenting to the ED with cardiovascular or cerebrovascular/neurological symptoms. Methods We searched EBM Reviews, Embase, Medline, Scopus and Web of Science from 2000 through 14 August 2022. Data were abstracted by two independent reviewers using a standardised form. The risk of bias (ROB) was assessed using the Newcastle-Ottawa Scale, and the certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation approach. Results Of the 7342 studies screened, we included 20 studies evaluating 7436,737 patients. Most studies were conducted in the USA, and one study was multicountry. 11 studies evaluated DE in patients with cerebrovascular/neurological symptoms, 8 studies with cardiovascular symptoms and 1 study examined both types of symptoms. 13 studies investigated missed diagnoses and 7 studies explored delayed diagnoses. There was significant clinical and methodological variability, including heterogeneity of DE definitions and predictor variable definitions as well as methods of DE assessment, study design and reporting. Among the studies evaluating cardiovascular symptoms, black race was significantly associated with higher odds of DE in 4/6 studies evaluating missed acute myocardial infarction (AMI)/acute coronary syndrome (ACS) diagnosis compared with white race (OR from 1.18 (1.12–1.24) to 4.5 (1.8–11.8)). The association between other analysed factors (ethnicity, insurance and limited English proficiency) and DE in this domain varied from study to study and was inconclusive. Among the studies evaluating DE in patients with cerebrovascular/neurological symptoms, no consistent association was found indicating higher or lower odds of DE. Although some studies showed significant differences, these were not consistently in the same direction. The overall ROB was low for most included studies; however, the certainty of evidence was very low, mostly due to serious inconsistency in definitions and measurement approaches across studies. Conclusions This systematic review demonstrated consistent increased odds of missed AMI/ACS diagnosis among black patients presenting to the ED compared with white patients in most studies. No consistent associations between demographic groups and DE related to cerebrovascular/neurological diagnoses were identified. More standardised approaches to study design, measurement of DE and outcomes assessment are needed to understand this problem among vulnerable populations. Trial registration number The study protocol was registered in the International Prospective Register of Systematic Reviews PROSPERO 2020 CRD42020178885 and is available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020178885.

Abstract Objectives Intensive care unit (ICU) direct care nurses spend 22% of their shift completing tasks within the electronic health record (EHR). Miscommunications and inefficiencies occur, particularly during patient hand-off, placing patient safety at risk. Redesigning how direct care nurses visualize and interact with patient information during hand-off is one opportunity to improve EHR use. A web-based survey was deployed to better understand the information and visualization needs at patient hand-off to inform redesign. Methods A multicenter anonymous web-based survey of direct care ICU nurses was conducted (9–12/2021). Semi-structured interviews with stakeholders informed survey development. The primary outcome was identifying primary EHR data needs at patient hand-off for inclusion in future EHR visualization and interface development. Secondary outcomes included current use of the EHR at patient hand-off, EHR satisfaction, and visualization preferences. Frequencies, means, and medians were calculated for each data item then ranked in descending order to generate proportional quarters using SAS v9.4. Results In total, 107 direct care ICU nurses completed the survey. The majority (46%, n = 49/107) use the EHR at patient hand-off to verify exchanged verbal information. Sixty-four percent (n = 68/107) indicated that current EHR visualization was insufficient. At the start of an ICU shift, primary EHR data needs included hemodynamics (mean 4.89 ± 0.37, 98%, n = 105), continuous IV medications (4.55 ± 0.73, 93%, n = 99), laboratory results (4.60 ± 0.56, 96%, n = 103), mechanical circulatory support devices (4.62 ± 0.72, 90%, n = 97), code status (4.40 ± 0.85, 59%, n = 108), and ventilation status (4.35 + 0.79, 51%, n = 108). Secondary outcomes included mean EHR satisfaction of 65 (0–100 scale, standard deviation = ± 21) and preferred future EHR user-interfaces to be organized by organ system (53%, n = 57/107) and visualized by tasks/schedule (61%, n = 65/107). Conclusion We identified information and visualization needs of direct care ICU nurses. The study findings could serve as a baseline toward redesigning an EHR interface.

Introduction: The COVID-19 pandemic has disproportionally affected historically marginalized populations and their access to resources and healthcare. In times of crisis, authentic community engagement is more important than ever. This study was Phase 1 of a larger 3-phase study to conduct timely community-engaged research with community members to understand the disproportionate impact of COVID-19 on historically underserved communities. The objective of this work was to conduct key informant (KI) interviews (1) to understand community organizations perspectives about the role that large academic health centers play as they interface with community organizations to support their work, (2) to leverage KI’s expertise to identify needs and assets within the community, and (3) to inform both Phase 2 (focus group qualitative research) and Phase 3 (survey) of the broader study. Methods: A total of 24 key informants were identified through purposeful sampling and one-on-one semi-structured interviews were conducted across 4 states using video conferencing. Results: Barriers to access and lack of transparency were highlighted as major issues requiring reform—in particular, aggressive billing practices and insurance barriers exacerbated local distrust of medical institutions. KIs recognized the health institution’s support for testing and vaccination during the COVID-19 pandemic, but noted other significant gaps in care, especially regarding mental health support. Although communication with the health institution was consistent for some KIs, others experienced unsustained communication efforts that hindered cooperation and relationship building. Conclusions: Leaders in the community as key stakeholders can provide unique insights into the challenges and potential solutions required to promote health equity, and foster understanding between local communities and healthcare institutions.

Diagnostic error or delay (DEOD) is common in the acute care setting and results in poor patient outcomes. Many factors contribute to DEOD, but little is known about how contributors may differ across acute care areas and professional roles. As part of a sequential exploratory mixed methods research study, we surveyed acute care clinical stakeholders about the frequency with which different factors contribute to DEOD. Survey respondents could also propose solutions in open text fields. N = 220 clinical stakeholders completed the survey. Care Team Interactions, Systems and Process, Patient, Provider, and Cognitive factors were perceived to contribute to DEOD with similar frequency. Organization and Infrastructure factors were perceived to contribute to DEOD significantly less often. Responses did not vary across acute care setting. Physicians perceived Cognitive factors to contribute to DEOD more frequently compared to those in other roles. Commonly proposed solutions included: technological solutions, organization level fixes, ensuring staff know and are encouraged to work to the full scope of their role, and cultivating a culture of collaboration and respect. Multiple factors contribute to DEOD with similar frequency across acute care areas, suggesting the need for a multi-pronged approach that can be applied across acute care areas.