Communication and the electronic health record training: a comparison of three healthcare systems.

BACKGROUND: The electronic health record (EHR) used in the examination room, is becoming the primary method of medical data storage in primary care practice in the USA. One of the challenges in using EHRs is maintaining effective patient-provider communication. Many studies have focused on communication in the examination room. PURPOSE: Scant research exists on the best methods in educating nurse practitioners and other primary care providers (clinicians). The purpose of this study was to explore various health record training programmes for clinicians. METHODS: One researcher participated in and observed three health systems' EHR training programmes for ambulatory care providers in the Pacific Northwest. A focused ethnographic approach was used, emphasising patient-provider communication. RESULTS: Only one system had formalised communication training in their class, the other two systems emphasised only the software and data aspects of the EHR. CONCLUSIONS: The fact that clinicians are expected to use EHRs in the examination room necessitates the inclusion of communication training in EHR training programmes and/or as a part of primary care nurse practitioner education programmes.

Putting a face on medical errors: a patient perspective.

Knowledge of the patient's perspective on medical error is limited. Research efforts have centered on how best to disclose error and how patients desire to have medical error disclosed. On the basis of a qualitative descriptive component of a mixed method study, a purposive sample of 30 community members told their stories of medical error. Their experiences focused on lack of communication, missed communication, or provider's poor interpersonal style of communication, greatly contrasting with the formal definition of error as failure to follow a set standard of care. For these participants, being a patient was more important than error or how an error is disclosed. The patient's understanding of error must be a key aspect of any quality improvement strategy.

Addressing in-hospital "falls" of newborn infants.

BACKGROUND: During postpartum hospitalization, close physical interactions between mother and newborn facilitate attachment, breastfeeding, and relationship competence. The challenge during this time is to support these important interactions in the hospital while ensuring the safety of the newborn. A literature review indicated that newborn "falls" and drops--collectively referred to as falls-remains largely unaddressed. Experience of a seven-hospital system in Oregon offers a template for understanding how and why infant falls occur in hospitals and how to address the issue. IDENTIFYING THE PROBLEM: For a two-year period (January 2006-December 2007), a query of a live voluntary event database yielded 9 cases of newborn falls (from 22,866 births), for a rate of 3.94 falls per 10,000 births. RESPONDING TO NEWBORN FALLS: A newborn falls committee made preliminary recommendations for interventions to reduce newborn falls, including (1) expanding thel patient safety contract, (2) monitoring mothers more closely, (3) improving equipment safety, and (4) spreading information about newborn falls within the state and throughout the hospital system. For example, staff use the patient safety contract to improve awareness and prevention of falls. The mothers and significant family members are asked to review the safety information and sign the contract. CONCLUSION: Newborns experience in-hospital falls at a rate of approximately 1.6-4.14/10,000 live births, resulting in an estimated 600-1600 falls per year in the United States. Additional reports of rates of newborn falls are urgently needed to determine the true prevalence of this historically underreported event. Standardized evaluation and management guidelines need to be developed to aid the clinician in the appropriate care of newborns experiencing this infrequent event.

Caring for the pregnant woman presenting at periviable gestation: acknowledging the ambiguity and uncertainty.

Counseling the periviable pregnant woman presenting at the edge of viability can often be confusing for the patient and frustrating for the clinician. Although neonatal survival rates have improved dramatically over the last few decades, severe morbidity is still common. This is further complicated by the fact that the information provided to the parents regarding the outcomes may not be up to date or completely accurate. The counseling is also frequently influenced by personal beliefs and biases of the medical staff. An evidence-based approach may improve the experience for both the expectant parents and the health care team.

Counseling pregnant women who may deliver extremely premature infants: medical care guidelines, family choices, and neonatal outcomes.

OBJECTIVES: The justification of neonatal intensive care for extremely premature infants is contentious and of considerable importance. The goal of this report is to describe our experience implementing consensus medical staff guidelines used for counseling pregnant women threatening extremely premature birth between 22 and 26 weeks' postmenstrual age and to give an account of family preferences and the immediate outcome of their infants. METHODS: Retrospective chart review was performed for all women threatening premature birth between 22 and 26 weeks postmenstrual age who presented to our high-risk obstetric service between June 2003 and December 2006. Women participated in comprehensive periviability counseling, which featured our specific obstetric and neonatology care recommendations for them and their infant at each gestational week. A subset of women were approached to obtain consent for a 2-step interview process beginning 3 days after the initial periviability counseling and followed with a 6- to 18-month assessment. RESULTS: Two hundred sixty women were identified as eligible subjects. After periviability counseling, but before any birth, palliative comfort care was requested by a higher percentage of families at each decreasing week. Ninety-five of the 260 women delivered 121 infants at <27 weeks' postmenstrual age. At delivery, at the request of the families and with the agreement of the medical staff, the following proportions of these infants were provided palliative comfort care: 100% at 22 weeks, 61% at 23 weeks, 38% at 24 weeks, 17% at 25 weeks, and 0% at 26 weeks. All nonresuscitations and comfort care measures were supported by the medical and nursing staffs, and all infant deaths occurred within 171 minutes. Fifty women consented to a postcounseling interview, and 25 of them also participated in a follow-up interview 6 to 18 months later. The counseling process and the guidelines were viewed as highly understandable, useful, consistent, and done in a comfortable manner. The tone and content of the parental comments regarding the counseling process were very positive, even more so at the later interview. There were no complaints or negative comments regarding the counseling process or the infant outcomes. CONCLUSIONS: Rational, consensus periviability guidelines are well accepted and can be used by all neonatologists, obstetricians, and nurses who provide care to pregnant women and infants at extremely early gestational ages. Pregnant women see these guidelines as highly understandable, useful, consistent, and respectful. When encouraged to participate with attending staff in discussions involving morbidity and mortality outcomes of premature infants and consensus medical practice recommendations, a substantial proportion of parents will choose palliative comfort care for their extremely premature infant up through 25 weeks' postmenstrual age. We believe the choice of neonatal intensive care versus palliative comfort care in extremely premature infants rightfully belongs to medically informed parents. More research is needed to examine how these decisions are made under diverse conditions of culture, religion, and technology.

Excess cost and length of stay associated with voluntary patient safety event reports in hospitals.

This study estimates excess cost and length of stay associated with voluntary patient safety event reports at 3 hospitals. Voluntary patient safety event reporting has proliferated in hospitals in recent years, yet little is known about the cost of events captured by this type of system. Events captured in an electronic reporting system at 3 urban community hospitals in Portland, Oregon, are evaluated. Cost and length of stay are assessed by linking event reports to risk-adjusted administrative data. Hospital stays with an event report are 17% more costly and 22% longer than stays without events. Medication and treatment errors are the most expensive and most common events, representing 77% of all event types and 77% of added costs. Ninety percent of events result in no measurable harm. Patient safety events captured by voluntary event reporting reflect significant waste and inefficiency in hospital stays.

Use of a prototype acute stroke registry to improve care: profile of receptive stroke programs.

A Wave-II Paul Coverdell Prototype Acute Stroke Registry collected data from 16 hospitals of various sizes and types in Oregon. The goal of this study was to identify whether particular process or structural characteristics of stroke programs in these hospitals were related to the use of reports from the prototype registry to improve care. Researchers surveyed hospitals to ask whether ongoing data completeness reports and monthly comparative quality reports were used to make changes in the acute care process. These self-reports were then confirmed by using the registry data to construct objective run-chart measures over 12 months. Results showed several programmatic characteristics that distinguished programs that used quality reports to make improvements. Hospitals that ignored monthly reports of key performance indicators showed either zero or one positive trend across seven preselected quality indicators. This finding is in contrast to the range of one to four positive changes in quality indicators for report users. Three main characteristics seem to define report users who could translate ongoing findings into potential care improvements: (1) documentation of care processes across departments; (2) access to local or remote stroke teams; and (3) data-collection experiences such as clinical trials, National Institutes of Health Stroke Scale (NIHSS), and outcome feedback. This study could lead to a better understanding as to which characteristics of stroke programs are most important for making rapid improvements for stroke care.

Medical staff guidelines for periviability pregnancy counseling and medical treatment of extremely premature infants.

OBJECTIVES: The goal of this report is to describe the collaborative formation of rational, practical, medical staff guidelines for the counseling and subsequent care of extremely early-gestation pregnancies and premature infants between 22 and 26 weeks. The purposes of the guidelines were to improve knowledge regarding neonatal outcomes, to provide consistency in periviability counseling, and to promote informed, supportive, responsible choices. METHODS: To formulate the guidelines, a 5-step process was conducted; it began with a series of multidisciplinary meetings among maternal-fetal medicine specialists (MFMs), obstetricians, neonatologists, neonatal nurse practitioners, and nurses from both the labor and delivery unit and the NICU at Providence St Vincent Medical Center (Portland, OR). First, our discussions reviewed mortality rates, morbidity rates, and long-term neurodevelopmental outcomes for extremely premature infants. Second, we explored the variations in counseling that pregnant women received, based on providers' individual beliefs and disparate knowledge of neonatal outcomes. Third, we asked participants to complete a survey that focused on the theoretical impending delivery of a premature infant, presenting at each week between 22 and 26 weeks of gestation. Participants indicated their recommendations for NICU care at each gestational age by using a numeric scale. Fourth, the survey results were tabulated and used as a basis for the formation of guidelines related to the recommended obstetric and neonatal care at each week of gestation. MFMs and neonatologists were urged to use these specific guidelines as a framework for counseling pregnant women between 22 and 26 weeks of gestation. Fifth, we surveyed women approximately 3 days after they were counseled by their MFM and neonatologist, to assess comprehension, utility, consistency, and comfort with the periviability counseling. RESULTS: Twenty pregnant women with the possibility of delivery between 22 and 26 weeks of gestation (mean: 24 weeks) received periviability counseling with our consensus medical staff guidelines. The respondents rated the counseling process as highly understandable (80%), useful (95%), consistent (89%), and performed in a comfortable manner (100%). All (100%) of the pregnant women thought they were given enough information to make critical decisions related to the potential level of care of their infant. CONCLUSIONS: Informative, supportive, clear, medical staff guidelines developed to assist in the counseling of women delivering extremely premature infants have been designed and implemented successfully at our hospital. These guidelines form the basis of periviability counseling, which is appreciated by our at-risk pregnant patients. We recommend that all hospitals that provide high-risk obstetric and neonatal intensive care develop similar consensus guidelines based on published outcomes and local provider experience.