Impact of electronic health records on predefined safety outcomes in patients admitted to hospital: a scoping review

Objectives Review available evidence for impact of electronic health records (EHRs) on predefined patient safety outcomes in interventional studies to identify gaps in current knowledge and design interventions for future research.Design Scoping review to map existing evidence and identify gaps for future research.Data sources PubMed, the Cochrane Library, EMBASE, Trial registers.Study selection Eligibility criteria: We conducted a scoping review of bibliographic databases and the grey literature of randomised and non-randomised trials describing interventions targeting a list of fourteen predefined areas of safety. The search was limited to manuscripts published between January 2008 and December 2018 of studies in adult inpatient settings and complemented by a targeted search for studies using a sample of EHR vendors. Studies were categorised according to methodology, intervention characteristics and safety outcome.Results from identified studies were grouped around common themes of safety measures.Results The search yielded 583 articles of which 24 articles were included. The identified studies were largely from US academic medical centres, heterogeneous in study conduct, definitions, treatment protocols and study outcome reporting. Of the 24 included studies effective safety themes included medication reconciliation, decision support for prescribing medications, communication between teams, infection prevention and measures of EHR-specific harm. Heterogeneity of the interventions and study characteristics precluded a systematic meta-analysis. Most studies reported process measures and not patient-level safety outcomes: We found no or limited evidence in 13 of 14 predefined safety areas, with good evidence limited to medication safety.Conclusions Published evidence for EHR impact on safety outcomes from interventional studies is limited and does not permit firm conclusions regarding the full safety impact of EHRs or support recommendations about ideal design features. The review highlights the need for greater transparency in quality assurance of existing EHRs and further research into suitable metrics and study designs

Quality metrics for Same Day Emergency Care – Consensus of a multi-professional panel of experts using a modified Delphi process

Same Day Emergency Care (SDEC) services are at the heart of recovery plans for Emergency Care in the National Health Service. There are no validated metrics for the quality of care in SDEC. The Society for Acute Medicine's Quality Improvement Committee invited to a three-stage modified Delphi process to gather metrics used by clinicians. Proposed metrics were ranked and further explored by 33 participating experts from a broad range of backgrounds including clinicians, data scientists and operational managers. Experts ranked five system-based metrics highest. These focus on optimization of the proportion of patients receiving same day care in and out of SDEC units. Patient and staff experience metrics were ranked low, possibly due to present lack of viable examples. The paper adds a glossary with the rationale for ranking of metrics and their use for the improvement of quality and safety of clinical care

How To Hospital: barriers to developing a patient \u27Hospital Survival Guide\u27 to support information transfer during ward-rounds on the patient journey from admission to hospital to discharge

Clinicians can enable patients to actively participate in their care but communication with patients is often poor and highly variable. The aim of this study was to explore patients\u27 understanding of their current illness while in hospital and using a codesign process to create prototype tools to facilitate better communication during ward rounds. A mixed-methods, multistep design with step 1: Application of a questionnaire addressing domains of care in the acute medical unit; step 2: Development of communication aids that were codesigned with active help of patients, students and a specialist in user centric design to address patient needs and step 3: Evaluation of tools with patients in four Plan-Do-Study-Act cycles. In the initial survey of 30 patients 12 (40%) patients did not know what their diagnosis was and 5 (17%) did not know the results of recent key tests. 20 (67%) patients felt that staff communication and coordination could be improved. An intervention was prototyped with four variations: (1) An A6 ward-round summary sheet completed by doctors during ward rounds. The system worked well but was highly person dependent. (2) An A4 patient-owned diary (\u27How to Hospital\u27) that contained information about key processes in hospital and space to document conversations from rounds and prompts for questions. 10 patients read the diary and commented favourably but did not complete any pages. (3) \u27Diary-cards\u27: a basic set of information cards was given to patients on admission to hospital. (4) Patient specific \u27diary-cards\u27 were completed by clinicians - 10 forms were piloted during rounds and improved subsequent day information retention of diagnosis to 80%. Our study identified interventions that were feasible but remained person-dependent. The patients\u27 ownership of information in relation to their care might facilitate retention and satisfaction but the optimal format for these interventions for enhancing communication remains unclear

The use of different sepsis risk stratification tools on the wards and in emergency departments uncovers different mortality risks: results of the three Welsh national multicenter point-prevalence studies

OBJECTIVES: To compare the performance of Sequential Organ Failure Assessment, systemic inflammatory response syndrome, Red Flag Sepsis, and National Institute of Clinical Excellence sepsis risk stratification tools in the identification of patients at greatest risk of mortality from sepsis in nonintensive care environments. DESIGN: Secondary analysis of three annual 24-hour point-prevalence study periods. SETTING: The general wards and emergency departments of 14 acute hospitals across Wales. Studies were conducted on the third Wednesday of October in 2017, 2018, and 2019. PATIENTS: We screened all patients presenting to the emergency department and on the general wards. MEASUREMENTS AND MAIN RESULTS: We recruited 1,271 patients, of which 724 (56.9%) had systemic inflammatory response syndrome greater than or equal to 2, 679 (53.4%) had Sequential Organ Failure Assessment greater than or equal to 2, and 977 (76.9%) had Red Flag Sepsis. When stratified according to National Institute of Clinical Excellence guidelines, 450 patients (35.4%) were in the “High risk” category in comparison with 665 (52.3%) in “Moderate to High risk” and 156 (12.3%) in “Low risk” category. In a planned sensitivity analysis, we found that none of the tools accurately predicted mortality at 90 days, and Sequential Organ Failure Assessment and National Institute of Clinical Excellence tools showed only moderate discriminatory power for mortality at 7 and 14 days. Furthermore, we could not find any significant correlation with any of the tools at any of the mortality time points. CONCLUSIONS: Our data suggest that the sepsis risk stratification tools currently utilized in emergency departments and on the general wards do not predict mortality adequately. This is illustrated by the disparity in mortality risk of the populations captured by each instrument, as well as the weak concordance between them. We propose that future studies on the development of sepsis identification tools should focus on identifying predicator values of both the short- and long-term outcomes of sepsis

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

Introduction: The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures. Methods: In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025. Findings: Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2–6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5–5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4–10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32–4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23–11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation. Interpretation: After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification

Continuous Monitoring of Respiratory Rate in Emergency Admissions: Evaluation of the RespiraSense™ Sensor in Acute Care Compared to the Industry Standard and Gold Standard

Respiratory Rate (RR) is the best marker to indicate deterioration but measurement are often inaccurate. The RespiraSense™ is a non-invasive, wireless, body worn, motion-tolerant and continuous respiratory rate monitor. We aimed to determine whether the performance of RespiraSense™ was equivalent to that of a gold standard measurement technique of capnography and the industry standard of manual counts. RespiraSense™ measures respiratory rate and transmit signals wirelessly to a tablet device. We measured respiratory rate in 24 emergency admissions to an Acute Medical Unit in the UK. Patients were observed for two hours. Manual counts were undertaken every 15 min and compared to measurements with capnography and RespiraSense™. Data from 17 patients admitted as medical emergencies was evaluated. For measurements obtained at rest a mean RR of 19.3 (SD 4.89) for manual measurements compared to mean RR of 20.2 (SD 4.54) for measurements obtained with capnography and mean RR of 19.8 (SD 4.52) with RespiraSense™. At rest, RespiraSense™ has a bias of 0.38 and limits of agreement of 1.0 to 1.8 bpm, when compared to the capnography derived RR. Measurements were within pre-defined limits of error at rest. Continuous measurement of RR with RespiraSense™ in patients admitted as acute emergencies is both feasible and reliable

Impact of electronic health records on predefined safety outcomes in patients admitted to hospital: a scoping review

ObjectivesReview available evidence for impact of electronic health records (EHRs) on predefined patient safety outcomes in interventional studies to identify gaps in current knowledge and design interventions for future research.DesignScoping review to map existing evidence and identify gaps for future research.Data sourcesPubMed, the Cochrane Library, EMBASE, Trial registers.Study selectionEligibility criteria: We conducted a scoping review of bibliographic databases and the grey literature of randomised and non-randomised trials describing interventions targeting a list of fourteen predefined areas of safety. The search was limited to manuscripts published between January 2008 and December 2018 of studies in adult inpatient settings and complemented by a targeted search for studies using a sample of EHR vendors. Studies were categorised according to methodology, intervention characteristics and safety outcome.Results from identified studies were grouped around common themes of safety measures.ResultsThe search yielded 583 articles of which 24 articles were included. The identified studies were largely from US academic medical centres, heterogeneous in study conduct, definitions, treatment protocols and study outcome reporting. Of the 24 included studies effective safety themes included medication reconciliation, decision support for prescribing medications, communication between teams, infection prevention and measures of EHR-specific harm. Heterogeneity of the interventions and study characteristics precluded a systematic meta-analysis. Most studies reported process measures and not patient-level safety outcomes: We found no or limited evidence in 13 of 14 predefined safety areas, with good evidence limited to medication safety.ConclusionsPublished evidence for EHR impact on safety outcomes from interventional studies is limited and does not permit firm conclusions regarding the full safety impact of EHRs or support recommendations about ideal design features. The review highlights the need for greater transparency in quality assurance of existing EHRs and further research into suitable metrics and study designs.</jats:sec

Availability of Pharmacy services within Acute Medicine:Analysis from the Society for Acute Medicine Benchmarking Audit 2022

Objectives: Patients seen in acute medicine services are at high risk of medication errors and subsequent harm. Pharmacy services within acute medicine or emergency departments have been shown to reduce medication errors and improve patient outcomes. However, there is limited understanding of national provision of pharmacy services within acute medicine. We aimed to evaluate the current availability of pharmacy services for acute medicine patients in the UK.Methods: Data was collected through an organisational survey of acute medicine departments nationally in June 2022. Questions aimed to evaluate the organisation and availability of pharmacy services necessary to meet national guidance regarding medication reconciliation for acute admissions. Key findings: Across 129 acute hospitals in the UK, 98% utilised pharmacy services for medicines reconciliation on the acute medical unit, however only 36% of hospitals had access to these services from 9 am-5 pm on the weekend, and only 16% had access throughout the out of hours period (Monday-Sunday, 5 pm-9 am). Availability of out-of-hours services did not appear to be related to hospital size (Chi-square p=0.94). Pharmacy services were provided in the emergency department in 29% of hospitals, with only 12% providing 24/7 coverage. Conclusions: There is considerable variation in pharmacy services accessible within acute medicine services nationally. Further research is required to understand this variability, its impact on clinical outcomes, and how this could best be addressed within acute medicine. <br/

Availability of Pharmacy services within Acute Medicine:Analysis from the Society for Acute Medicine Benchmarking Audit 2022

Objectives: Patients seen in acute medicine services are at high risk of medication errors and subsequent harm. Pharmacy services within acute medicine or emergency departments have been shown to reduce medication errors and improve patient outcomes. However, there is limited understanding of national provision of pharmacy services within acute medicine. We aimed to evaluate the current availability of pharmacy services for acute medicine patients in the UK.Methods: Data was collected through an organisational survey of acute medicine departments nationally in June 2022. Questions aimed to evaluate the organisation and availability of pharmacy services necessary to meet national guidance regarding medication reconciliation for acute admissions. Key findings: Across 129 acute hospitals in the UK, 98% utilised pharmacy services for medicines reconciliation on the acute medical unit, however only 36% of hospitals had access to these services from 9 am-5 pm on the weekend, and only 16% had access throughout the out of hours period (Monday-Sunday, 5 pm-9 am). Availability of out-of-hours services did not appear to be related to hospital size (Chi-square p=0.94). Pharmacy services were provided in the emergency department in 29% of hospitals, with only 12% providing 24/7 coverage. Conclusions: There is considerable variation in pharmacy services accessible within acute medicine services nationally. Further research is required to understand this variability, its impact on clinical outcomes, and how this could best be addressed within acute medicine. <br/