Sources of inaccuracy in the measurement of adult patients' resting blood pressure in clinical settings: a systematic review.

BACKGROUND: To interpret blood pressure (BP) data appropriately, healthcare providers need to be knowledgeable of the factors that can potentially impact the accuracy of BP measurement and contribute to variability between measurements. METHODS: A systematic review of studies quantifying BP measurement inaccuracy. Medline and CINAHL databases were searched for empirical articles and systematic reviews published up to June 2015. Empirical articles were included if they reported a study that was relevant to the measurement of adult patients' resting BP at the upper arm in a clinical setting (e.g. ward or office); identified a specific source of inaccuracy; and quantified its effect. Reference lists and reviews were searched for additional articles. RESULTS: A total of 328 empirical studies were included. They investigated 29 potential sources of inaccuracy, categorized as relating to the patient, device, procedure or observer. Significant directional effects were found for 27; however, for some, the effects were inconsistent in direction. Compared with true resting BP, significant effects of individual sources ranged from -23.6 to +33 mmHg SBP and -14 to +23 mmHg DBP. CONCLUSION: A single BP value outside the expected range should be interpreted with caution and not taken as a definitive indicator of clinical deterioration. Where a measurement is abnormally high or low, further measurements should be taken and averaged. Wherever possible, BP values should be recorded graphically within ranges. This may reduce the impact of sources of inaccuracy and reduce the scope for misinterpretations based on small, likely erroneous or misleading, changes.

A new instrument to assess physician skill at chest tube insertion: the TUBE-iCOMPT.

Currently no tool exists to assess proceduralist skill at chest tube insertion. As inadequate doctor procedural competence has repeatedly been associated with adverse events, there is a need for a tool to assess procedural competence. This study aims to develop and examine the validity of a tool to assess competency at insertion of a chest tube, using either the Seldinger technique or blunt dissection. A 5-domain 100-point assessment tool was developed inline with British Thoracic Society guidelines and international consensus­the Chest Tube Insertion Competency Test (TUBE-iCOMPT). The instrument was used to assess chest tube insertion in mannequins and live patients. 29 participants (9 novices, 14 intermediate and 6 advanced) were tested by 2 blinded expert examiners on 2 occasions. The tool's validity was examined by demonstrating: (1) stratification of participants according to expected level of expertise (analysis of variance), and (2) test-retest and intertester reliability (intraclass correlation coefficient). The intraclass correlation coefficient of repeated scores for the Seldinger technique and blunt dissection, were 0.92 and 0.91, respectively, for test-retest results, and 0.98 and 0.95, respectively, for intertester results. Clear stratification of scores according to participant experience was seen (p<0.0001). There was no significant difference between scores obtained using mannequins or live patients. This study has validated the TUBE-iCOMPT, which could now be incorporated into chest tube insertion training programmes, providing a way to document acquisition of skill, guide individualised teaching, and assist with the assessment of the adequacy of clinician training.

Improving the efficiency of discharge summary completion by linking to preexisiting patient information databases.

The discharge summary (DS) is a document that contains the diagnosis, comorbidities, procedures, complications, and future treatment plan for a particular patient after an inpatient hospital stay. The DS is completed by junior medical staff and is delivered to the general practitioner (GP). DS completion is time consuming and tedious, and DSs are usually not completed within the recommended time frame after a patient is discharged. Time spent completing DSs correlate to junior doctor overtime, which costs the hospital money in overtime pay. Information that is required in the DS is generally already entered into numerous electronic information systems in the hospital, including the "electronic patient journey board" which lists all the patients in a given ward with their clinical information. This information is constantly updated by all staff in the hospital. A program was developed that transferred this information directly into the patient DS. Ten junior doctors in two departments kept daily records for one week of the time spent compiling DSs, the time at work and the actual overtime claimed, before and after the introduction of the intervention. The mean (± SD) time for DS compilation per week reduced by 2.8 (± 2.4) hours from 10.0 (±3.5) hours (p<0.01) and the mean overtime worked per week reduced by 2.8 (± 3.1) hours from 8.5 (± 4.4) hours (p<0.05). The mean overtime claimed reduced by 1.8 (± 2.8) hours from 5.3 (± 5.4) hours per week (p<0.05), resulting in reduction in mean overtime payment of $114.95 from $290.57 per doctor, per week. Extrapolating to the 60 ward based junior doctors, the potential annual savings for the hospital budget are over $350,000. Additionally, the number of DSs completed within 48 hours increased from 45% to 58%. In summary, the transfer of electronic data from the electronic patient journey board to the discharge summary program has yielded improvements in DS completion rates and overtime worked by medical staff, resulting in significant reduction in overtime costs.

Improving the quality of hospital discharge summaries utilising an electronic prompting system.

The discharge summary (DS) is a summary of an inpatient admission, patient's health state, and future treatment plans which is delivered to the patient's primary care provider. The DS is often incomplete, inaccurate, or unclear. The aim of this project was to improve the quality of the DS through the use of an electronic prompting system. The electronic prompting system was implemented in the acute medical and surgical wards of the hospital as an adjunct to a pre-existing, widely used hospital program that documents all the patients in a ward or belonging to a particular treating team. When using the program, a doctor enters information (with the assistance of the treating consultant) from a drop-down menu and is prompted to include common, departmental specific diagnoses, co-morbidities, complications, and procedures that were commonly missed or documented incorrectly in the DS. Fifteen DSs were randomly selected from a two month period immediately prior to the intervention period and were rated by an external, experienced general practitioner (GP) using a scoring system consistent with the Australian Medical Association Guidelines for quality DSs. Fifteen random DSs from a two month period, four months post-implementation were also rated by the same GP. The quality of the DS improved in all categories evaluated. The overall quality improved from mean (± SD) 2.86 ± 1.64 to 4.13 ± 0.92 out of 5 (p = 0.031). Additionally the implementation of the system was associated with improvements in documentation of the diagnosis, co-morbidities and other relevant clinical information. In summary, electronic prompting systems can improve the quality of DSs to ensure the information contained within the DS is more accurate and complete.