using technology at the bedside stephen lapinsky mount sinai hospital & university of toronto...
TRANSCRIPT
Using Technology at the Bedside
Stephen Lapinsky
Mount Sinai Hospital & University of Toronto
Toronto, Canada
One ICU patient generates up to 236 variable categories
Morris, Crit Care Clin 1999, 15:523
Humans capable of managing 5 to 9 variables adequately
Miller, Psychol Rev 1956, 63:81
Data overload - Data overload - patient informationpatient information
Textbooks
Journal articles
Review articles
Association Guidelines
Hospital protocols
Pharmaceutical company information
Electronic Medical literature
Data overload - Data overload - reference informationreference information
New Technologies
Information Access in HealthcareInformation Access in Healthcare
Electronic patient record
Decision support systems
Handheld computers
Electronic journals
Electronic books
Wireless communication
Electronic imaging
Automated Paging Alert System
Software “agent” scans hospital database
Filters: eg. Location = ICU Hgb < 70 g/L or 20% drop
Generates automated pageOngoing evaluation:
- time to intervention- satisfaction:
physiciannurse
Hospital Wireless Communication
In-hospital wireless telephone using 1.9 GHz
3-line function
Forward to paging or covering nurse
Physicians: call/page on rounds instantly accessible
Nurses: link to call-bell
Digital Wireless Area NetworkIEEE 802.11b Wireless LAN at
11 Mb/s
Wireless cart allowing bedside access to: hospital system (eg. labs) PACS radiology Internet searches Order entry
Potential for: video transmission wireless handhelds wearable computers
Handheld Computers in the ICUHandheld Computers in the ICU
Widespread usenon-medicalmedicine
Why ?
- 10% US physicians
- 40% of residents
Handheld Computers in the ICUHandheld Computers in the ICU
Widespread usenon-medicalmedicine
International compatibility
Why ?
Roles for Handheld computersRoles for Handheld computers
• access to patient information • access to medical reference information
• tracking educational experience
• scheduling, contacts
• non-synchronous communication
Evaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical Care
Study 1: Qualitative evaluation of handheld computers in the ICU
Study 2: Comparison between “paper” and electronic medical reference database
Study 3: Evaluation of Surgical Procedure logging using handheld devices
Study 4: Evaluation of handheld Pharmacopoeias
Study 5: Ontario Critical Care Information Network
Evaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical Care
Study 1:Study 1: Qualitative evaluation of handheld Qualitative evaluation of handheld computers in the ICUcomputers in the ICU
Study 2: Comparison between “paper” and electronic medical reference database
Study 3: Evaluation of Surgical Procedure logging using handheld devices
Study 4: Evaluation of handheld Pharmacopoeias
Study 5: Ontario Critical Care Information Network
Data entry & transfer: on admission update on rounds IR beaming between staff
Reports Daily report Discharge summary IR beam to HP Laserjet 6P
Methods
Results
Evaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical Care
6 month study period: June - November 1999
24 palm handheld users (84 user-months):
3 Focus group meetings at 2 month intervals
2
34
15Attendings
Medical trainees
Resp therapists
Other (pharmacist, nurseeducator, research fellow)
Results
Evaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical Care
Physical attributes of Palm IIIx
Patient Management database
Medical reference database
Suggestions: hardware & software
Suggestions: process
Evaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical Care
Study 1: Qualitative evaluation of handheld computers in the ICU
Study 2:Study 2: Comparison between “paper” and electronicComparison between “paper” and electronic medical reference databasemedical reference database
Study 3: Evaluation of Surgical Procedure logging using handheld devices
Study 4: Evaluation of handheld Pharmacopoeias
Study 5: Ontario Critical Care Information Network
Methods
Paper database:Critical Care Handbook of the
Massachussetts General Hospital
Study 2
Comparison of paper & electronic databasesComparison of paper & electronic databasesComparison of paper & electronic databasesComparison of paper & electronic databases
Methods
Paper database: Critical Care Handbook of the
Massachussetts General Hospital
Palm database:Electronic version of the Mass Gen handbookMount Sinai ICU handbookSearchable databaseTreatment guidelines
Comparison of paper & electronic databasesComparison of paper & electronic databasesComparison of paper & electronic databasesComparison of paper & electronic databases
Methods
Crossover study:3 weeks control (paper), 3 weeks handheld
Subjective assessment:Survey, interview
Objective assessment: Test clinical ICU scenarios, time-constrained
Standardized on a separate group of trainees
Results:No significant difference
Comparison of paper & electronic databasesComparison of paper & electronic databasesComparison of paper & electronic databasesComparison of paper & electronic databases
Evaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical Care
Study 1: Qualitative evaluation of handheld computers in the ICU
Study 2: Comparison between “paper” and electronic medical reference database
Study 3:Study 3: Evaluation of Surgical Procedure logging Evaluation of Surgical Procedure logging using handheld devicesusing handheld devices
Study 4: Evaluation of handheld Pharmacopoeias
Study 5: Ontario Critical Care Information Network
Surgical Procedure Logging SystemSurgical Procedure Logging SystemSurgical Procedure Logging SystemSurgical Procedure Logging System
69 General Surgery residentsData entry on PalmInternet download of procedure data
Procedure data entry
Message broadcasting- from departmental administrators to all Palm users, during routine synchronization
Internet synchronization with a central database
Customized surveys- get feedback from trainees, directly into a central database
Surgical Procedure Logging SystemSurgical Procedure Logging SystemSurgical Procedure Logging SystemSurgical Procedure Logging System
Customized drop down lists
“Surgeon” list specific for the selected hospital
Categories generate sub-categories and procedures based on the American Board of Surgery structure
Surgical Procedure Logging SystemSurgical Procedure Logging SystemSurgical Procedure Logging SystemSurgical Procedure Logging System
Data accessData access
Trainees can access their individual database via a secure web site
Procedures may be reviewed on the Palm
Procedural data is downloaded via the Internet using secure synchronization to a central database.
Surgical Procedure Logging SystemSurgical Procedure Logging SystemSurgical Procedure Logging SystemSurgical Procedure Logging System
ReportsReports
Allow evaluation of
- individual trainees
- teachers
- hospitals
- trainee years
- etc
Surgical Procedure Logging SystemSurgical Procedure Logging SystemSurgical Procedure Logging SystemSurgical Procedure Logging System
Evaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical Care
Study 1: Qualitative evaluation of handheld computers in the ICU
Study 2: Comparison between “paper” and electronic medical reference database
Study 3: Evaluation of Surgical Procedure logging using handheld devices
Study 4:Study 4: Evaluation of handheld Pharmacopoeias Evaluation of handheld Pharmacopoeias
Study 5: Ontario Critical Care Information Network
Comparison of features & content Pharmacopoeias
Mobile Micromedex Epocrates qRx Dr. Drugs A2Z Drugs Lexi-Drugs Moby Drugs & Interactions PDR
Comparison of Handheld PharmacopoeiasComparison of Handheld PharmacopoeiasComparison of Handheld PharmacopoeiasComparison of Handheld Pharmacopoeias
Results:
Essential parameters:
- Physicians identified 9
- Pharmacists identified 14
Content:
A2Z 9/9 13/14
FunctionalityCostUpdates
Evaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical Care
Study 1: Qualitative evaluation of handheld computers in the ICU
Study 2: Comparison between “paper” and electronic medical reference database
Study 3: Evaluation of Surgical Procedure logging using handheld devices
Study 4: Evaluation of handheld Pharmacopoeias
Study 5:Study 5: Ontario Critical Care Information Network Ontario Critical Care Information Network
Dr. B. KashinDr. H. Clasky
Dr. T. RogoveinDr. D. McRitchie
Dr. S. LapinskyDr. T. StewartDr. R. WaxDr. S. Fischer
INFORMATION DATABASE
• content determined by user’s needs
• evidence-based management guidelines
• regularly updated according to feedback
InternetSynchronisation
from office, home, ICU
Palm Handheld Reference Resource
• mobile, point-of-care access to medical information
• optimal formatting to facilitate rapid data retrieval
• hyperlinked text, tables, images, calculators
online feedback re: online feedback re: content, formatcontent, format
Does the handheld resource work?
- videotaped "think aloud" analysis of the technology in action
Do community intensivists find the content and technology helpful?
- Surveys downloaded to users’ handhelds- Moderated focus group meetings
Does the network improve resource use?
- Clinician performance pre/post with a computer-controlled human simulator
- Comparison of ICU mortality, duration of mechanical ventilation and length of stay, patient transfers
Evaluation
Centre of ExcellenceCentre of Excellence
ICU Information
Database
Peripheral Peripheral HospitalHospital
Peripheral Peripheral HospitalHospital
Peripheral Peripheral HospitalHospital
Peripheral Peripheral HospitalHospital
Peripheral Peripheral HospitalHospital
Peripheral Peripheral HospitalHospital
Peripheral Peripheral HospitalHospital
Peripheral Peripheral HospitalHospital
Centre of ExcellenceCentre of Excellence
Feedback, surveyssuggestions
Reference Information