Advance Directives Change Frequently in Nursing Home Residents.

OBJECTIVES: To describe the rate, timing, and pattern of changes in advance directives (ADs) of do not resuscitate (DNR) and do not hospitalize (DNH) orders among new admissions to nursing homes (NHs). DESIGN: A retrospective cohort study. SETTING AND PARTICIPANTS: Admissions to all publicly funded NHs in Ontario, Canada, between January 1, 2013, and December 31, 2017. METHODS: Residents were followed until discharged from incident NH stay, death, or were still present at the end of study (December 31, 2019). They were categorized into 3 mutually exclusive baseline composite AD groups: Full Code, DNR Only, and DNR+DNH. We used Poisson regression models to estimate the incidence rate ratios of AD change between different AD groups and different decision makers for personal care, adjusted for baseline clinical and sociodemographic variables. RESULTS: A total of 102,541 NH residents were eligible for inclusion. Residents with at least 1 AD change accounted for 46% of Full Code, 30% of DNR Only, and 25% of DNR+DNH group. Median time to first AD change ranged between 26 and 55 weeks. For Full Code and DNR Only residents, the most frequent change was to an AD 1 level lower in aggressiveness or intervention, whereas for DNR+DNH residents the most frequent change was to DNR Only. About 16% of residents had 2 or more AD changes during their stay. After controlling for covariates, residents with a DNR-only order or DNR+DNH orders at admission and those with a surrogate decision maker were associated with lower AD change rates. CONCLUSIONS AND IMPLICATIONS: Measuring AD adherence rates that are documented only at a particular time often underestimates the dynamics of AD changes during a resident's stay and results in an inaccurate measure of the effectiveness of AD on resident care. There should be more frequent reviews of ADs as they are quite dynamic. Mandatory review after an acute change in a resident's health would ensure that ADs are current.

Impact of an internal medicine nocturnist service on care of patients with cancer at a large Canadian teaching hospital: a quality-improvement study.

BACKGROUND: Nocturnists (overnight hospitalists) are commonly implemented in US teaching hospitals to adhere to per-resident patient caps and improve care but are rare in Canada, where patient caps and duty hours are comparatively flexible. Our objective was to assess the impact of a newly implemented nocturnist program on perceived quality of care, code status documentation and patient outcomes. METHODS: Nocturnists were phased in between June 2018 and December 2019 at Toronto General Hospital, a large academic teaching hospital in Toronto, Ontario. We performed a quality-improvement study comparing rates of code status entry into the electronic health record at admission, in-hospital mortality, the 30-day readmission rate and hospital length of stay for patients with cancer admitted by nocturnists and by residents. Surveys were administered in June 2019 to general internal medicine faculty and residents to assess their perceptions of the impact of the nocturnist program. RESULTS: From July 2018 to June 2019, 30 nocturnists were on duty for 241/364 nights (66.5%), reducing the mean maximum overnight per-resident patient census from 40 (standard deviation [SD] 4) to 25 (SD 5) (p < 0.001). The rate of admission code status entry was 35.3% among patients admitted by residents (n = 133) and 54.9% among those admitted by nocturnists (n = 339) (p < 0.001). The mortality rate was 10.5% among patients admitted by residents and 5.6% among those admitted by nocturnists (p = 0.06), the 30-day readmission rate was 8.3% and 5.9%, respectively (p = 0.4), and the mean acute length of stay was 7.2 (SD 7.0) days and 6.4 (SD 7.8) days, respectively (p = 0.3). Surveys were completed by 15/24 faculty (response rate 62%), who perceived improvements in patient safety, efficiency and trainee education; however, only 30/102 residents (response rate 29.4%) completed the survey. INTERPRETATION: Although implementation of a nocturnist program did not affect patient outcomes, it reduced residents' overnight patient census, and improved faculty perceptions of quality of care and education, as well as documentation of code status. Our results support nocturnist implementation in Canadian teaching hospitals.

Melatonin Increasingly Used in Hospitalized Patients.

The frequency of melatonin use for insomnia in hospitalized patients is unknown. This study assessed temporal trends of melatonin use in the hospital and compared them with those of use of zopiclone and lorazepam. We performed a retrospective observational study over 6 years from January 2013 to December 2018 at two academic urban hospitals in Toronto, Canada. We abstracted pharmacy dispensing data and standardized rates of medication use by inpatient days. Melatonin use increased from almost none to more than 70 doses per 1,000 inpatient days during 2013-2018, while zopiclone use decreased by 20 doses per 1,000 inpatient days. Melatonin use was twice as high at one hospital and was higher on internal medicine and critical care. Overall use of the three medications increased by 25.7%, which mainly reflects a marked increase in melatonin use. Melatonin is likely being used in a proportion of patients who would not otherwise have received a sleep medication.

Using wearables and self-management apps in patients with COPD: a qualitative study.

BACKGROUND: Technology such as wearable technology and self-management applications could improve the care of patients with chronic obstructive pulmonary disease (COPD) by real-time continuous monitoring, early detection of COPD and improved self-management. However, patients have not been willing to use technology when it is too difficult to use, interferes with their daily lives or threatens their identity, independence and self-care. METHODS: We conducted a qualitative study to determine what patients with COPD would like to see in a wearable device and a mobile application to help manage their condition. Semi-structured interviews were conducted, recorded and transcribed. Thematic analysis was used to identify themes and concepts. RESULTS: We interviewed 14 people with COPD with an average age of 69 years. Participants perceived that the technology could improve their ability to manage their condition both in daily life and during exacerbations by connecting how they feel and by knowing their oxygen saturation, heart rate and activity. The technology may help them address feelings of fear and panic associated with exacerbations and may provide reassurance and connectedness. Some people with COPD wanted their healthcare providers to have access to their data, while others were concerned about inundating them with too much information. Of note, people wanted to maintain control of the information; to make connections with the data, but also in order to be alerted when a possible exacerbation occurs. CONCLUSION: Patients perceived significant potential for wearables and apps to help manage their condition.

Transversus Abdominis Plane Block in Laparoscopic Colorectal Surgery: A Systematic Review.

BACKGROUND: Multimodal analgesia is important for postoperative recovery in laparoscopic colorectal surgery. Multiple randomized controlled trials have investigated the use of transversus abdominis plane local anesthetic infiltration as a method of decreasing postoperative pain and opioid consumption, with variable results. OBJECTIVE: This study aimed to examine the overall effect of transversus abdominis plane block in postoperative pain, opioid use, and speed of recovery in laparoscopic colorectal surgery. DATA SOURCES: A literature search was done with PubMed, EMBASE, Web of Knowledge, and Cochrane Library. Only randomized controlled trials were selected for review. INTERVENTIONS: Transversus abdominis plane local anesthetic infiltration versus no intervention, saline, or other techniques in laparoscopic colorectal surgeries was investigated. MAIN OUTCOME MEASURES: The primary outcome measured was postoperative pain on day 1, at rest or with activity. The secondary outcomes measured were postoperative pain beyond day 1, consumptions of opioid, and length of hospital stay. RESULTS: Eight clinical trials including 649 patients between 2013 and 2018 were included. Resting pain scores within 2 hours (standardized mean difference, -0.53; p = 0.01), 4 hours (standardized mean difference, -0.42; p = 0.004), and 6 hours (standardized mean difference, -0.47; p = 0.03) showed statistically significant reduction. Six studies including 413 patients demonstrated lower cumulative opioid consumption within 24 hours after surgery (standardized mean difference, -0.82; p = 0.01). Five studies including 357 patients did not show a significant difference in length of stay (standardized mean difference, -0.04; p = 0.82). LIMITATIONS: Local anesthetic used in block varied in type and quantity across different studies. There were heterogeneities in pain score measurements and opioid consumption. Patient populations may be different among studies. CONCLUSIONS: Transversus abdominis block can lead to a lower pain score at rest within the first 6 hours and reduce opioid consumption within the first 24 hours. See Video Abstract at http://links.lww.com/DCR/A997.

Hospital-Based Clinicians' Use of Technology for Patient Care-Related Communication: A National Survey.

OBJECTIVE: To characterize current use of communication technologies, including standard text messaging and secure mobile messaging applications, for patient care-related (PCR) communication. METHODS: We used a Society of Hospital Medicine database to conduct a national cross-sectional survey of hospital-based clinicians. RESULTS: We analyzed data from 620 survey respondents (adjusted response rate, 11.0%). Pagers were provided by hospitals to 495 (79.8%) of these clinicians, and 304 (49%) of the 620 reported they received PCR messages most commonly by pager. Use of standard text messaging for PCR communication was common, with 300 (52.9%) of 567 clinicians reporting receipt of standard text messages once or more per day. Overall, 21.5% (122/567) of respondents received standard text messages that included individually identifiable information, 41.3% (234/567) received messages that included some identifiable information (eg, patient initials), and 21.0% (119/567) received messages for urgent clinical issues at least once per day. About one-fourth of respondents (26.6%, 146/549) reported their organization had implemented a secure messaging application that some clinicians were using, whereas few (7.3%, 40/549) reported their organization had implemented an application that most clinicians were using. DISCUSSION: Pagers remain the technology most commonly used by hospital-based clinicians, but a majority also use standard text messaging for PCR communication, and relatively few hospitals have fully implemented secure mobile messaging applications. CONCLUSION: The wide range of technologies used suggests an evolution of methods to support communication among healthcare professionals.

An analysis of messages sent between nurses and physicians in deteriorating internal medicine patients to help identify issues in failures to rescue.

OBJECTIVE: To evaluate in patients who deteriorate and require transfer to the intensive care unit (ICU), how many have a critical text message communicating deterioration and what is the quality of this message? Is message quality, message response or the timeliness of rapid response team (RRT) activation related to death? METHODS: We conducted a retrospective chart review of all ICU transfers from General Internal Medicine (GIM) wards from January 2012 until August 2014. All critical messages (CM) in the 48h prior to ICU transfer were analyzed for RRT calling criteria, time to RRT activation, message quality, presence of vitals, and the quality and timeliness of physician response. RESULTS: Of the 236 patients in the study, 93 (39%) had a CM in the 48h prior to ICU transfer. Within this subset, 76 patients did not have prior RRT activation and the median times from CM to RRT activation and CM to ICU transfer were 8.9 [IQR 2.9, 20.7] and 15.6 [IQR 9.0, 28.7] hours, respectively. Only 45% of messages contained 2 or more vitals and only 3% of messages contained Situation, Background, Assessment, and Recommendations (SBAR). Physician response was timely (3 [IQR 2, 17] min) but response quality was poor; nearly one quarter of responses only acknowledged receipt. Among message characteristics, only the number of SBAR elements was correlated with in-hospital survival (p=0.047). CONCLUSION: Communication between nurses and physicians about critically ill patients could be improved. There appear to be significant gaps in the quality of messages, their responses, and delays in RRT activation.

Analysis of Smartphone Interruptions on Academic General Internal Medicine Wards. Frequent Interruptions may cause a 'Crisis Mode' Work Climate.

INTRODUCTION: Hospital-based medical services are increasingly utilizing team-based pagers and smartphones to streamline communications. However, an unintended consequence may be higher volumes of interruptions potentially leading to medical error. There is likely a level at which interruptions are excessive and cause a 'crisis mode' climate. METHODS: We retrospectively collected phone, text messaging, and email interruptions directed to hospital-assigned smartphones on eight General Internal Medicine (GIM) teams at two tertiary care centres in Toronto, Ontario from April 2013 to September 2014. We also calculated the number of times these interruptions exceeded a pre-specified threshold per hour, termed 'crisis mode', defined as at least five interruptions in 30 minutes. We analyzed the correlation between interruptions and date, site, and patient volumes. RESULTS: A total of 187,049 interruptions were collected over an 18-month period. Daily weekday interruptions rose sharply in the morning, peaking between 11 AM to 12 PM and measuring 4.8 and 3.7 mean interruptions/hour at each site, respectively. Mean daily interruptions per team totaled 46.2 ± 3.6 at Site 1 and 39.2 ± 4.2 at Site 2. The 'crisis mode' threshold was exceeded, on average, 2.3 times/day per GIM team during weekdays. In a multivariable linear regression analysis, site (ß6.43 CI95% 5.44 - 7.42, p<0.001), day of the week (with Friday having the most interruptions) (ß0.481 CI95% 0.236 - 0.730, p<0.05) and patient census (ß1.55 CI95% 1.42 - 1.67, p<0.05) were all predictive of daily interruption volume although there was a significant interaction effect between site and patient census (ß-0.941 CI95% -1.18 - -0.703, p<0.05). CONCLUSION: Interruptions were related to site-specific features, including volume, suggesting that future interventions should target the culture of individual hospitals. Excessive interruptions may have implications for patient safety especially when exceeding a maximal threshold over short periods of time.

Goals of care discussions among hospitalized long-term care residents: Predictors and associated outcomes of care.

INTRODUCTION: There are limited data on the occurrence, predictors, and impact of goals of care (GOC) discussions during hospitalization for seriously ill elderly patients, particularly for long-term care (LTC) residents. METHODS: The study was a retrospective chart review of 200 randomly sampled LTC residents hospitalized via the emergency department and admitted to the general internal medicine service of 2 Canadian academic hospitals, from January 2012 through December 2012. We applied logistic regression models to identify factors associated with, and outcomes of, these discussions. RESULTS: Overall, 9.4% (665 of 7084) of hospitalizations were patients from LTC. In the sample of 200 patients, 37.5% had a documented discussion. No baseline patient characteristic was associated with GOC discussions. Low Glasgow Coma Scale, high respiratory rate, and low oxygen saturation were associated with discussions. Patients with discussions had higher rates of orders for no resuscitation (80% vs 55%) and orders for comfort measures only (7% vs 0%). In adjusted analyses, patients with discussions had higher odds of in-hospital death (52.0, 95% confidence interval [CI]: 6.2-440.4) and 1-year mortality (4.1, 95% CI: 1.7-9.6). Nearly 75% of patients with a change in their GOC did not have this documented in the discharge summary. CONCLUSION: In hospitalized LTC patients, GOC discussions occurred infrequently and appeared to be triggered by illness severity. Orders for advance directives, in-hospital death, and 1-year mortality were associated with discussions. Rates of GOC documentation in the discharge summary were poor. This study provides direction for developing education and practice standards to improve GOC discussion rates and their communication back to LTC. Journal of Hospital Medicine 2015;11:824-831. © 2015 Society of Hospital Medicine.

Frequency and clinical relevance of inconsistent code status documentation.

BACKGROUND: Accurate and complete documentation of hospitalized patients' code status is important to ensure that healthcare providers take appropriate action in the event of a cardiac arrest. OBJECTIVE: Determine the frequency and clinical relevance of incomplete and inconsistent code status documentation. DESIGN: Point-prevalence study. SETTING: Academic medical centers. PATIENTS: Patients admitted to general internal medicine wards. MEASUREMENTS: Frequency and clinical relevance of inconsistent code status documentation across 5 documentation sources. RESULTS: Thirty-eight (20%; 95% confidence interval [CI], 14%-26%) of 187 patients had complete and consistent code status documentation. Another 27 (14%; 95% CI, 9%-19%) patients had no code status documentation. The remaining 122 (65%; 95% CI, 58%-72%) patients had at least 1 code status documentation inconsistency. Of these, 38 (20%; 95% CI, 14%-26%) patients had a clinically relevant code status documentation inconsistency. Multivariate logistic regression analysis demonstrated that increased age (odds ratio [OR] = 1.07 [95% CI, 1.05-1.10] for every 1-year increase in age, P < 0.001) and patients receiving comfort measures (OR = 9.39 [95% CI, 1.35-65.19], P = 0.02) were independently associated with a clinically relevant code status documentation inconsistency. CONCLUSIONS: Incomplete and inconsistent documentation of code status occurred frequently in hospitalized patients, especially elderly patients and patients receiving comfort measures. Having multiple, poorly integrated code status documentation sources leads to a significant number of concerning inconsistencies that create opportunities for healthcare providers to inappropriately deliver or withhold resuscitative measures that conflict with patients' expressed wishes. Institutions need to be aware of this potential documentation hazard and take steps to minimize code status documentation inconsistencies.

Dynamic article: combined endoscopic-laparoscopic surgery for complex colonic polyps: postoperative outcomes and video demonstration of 3 key operative techniques.

BACKGROUND: Combined endoscopic-laparoscopic surgery is a novel technique that can be used to avoid bowel resection for complex colon polyps that are not amenable to colonoscopic resection. OBJECTIVE: The aim of this study was to evaluate the safety and outcomes of combined endoscopic-laparoscopic surgery for complex colonic polyps. DESIGN: This study is a retrospective review of consecutive combined endoscopic-laparoscopic surgeries. SETTING: This study was conducted at a single institution. PATIENTS: All patients that underwent combined endoscopic-laparoscopic surgery for a complex colonic polyp at our center from October 2009 to October 2013 were followed. Each patient's lesion was assessed by a therapeutic endoscopist before referral for combined endoscopic-laparoscopic surgery, and was deemed unresectable based on size, broad base, or location of the polyp. MAIN OUTCOME MEASURES: Intraoperative and postoperative complications, length of hospital stay, and recurrence were the primary outcomes measured. RESULTS: Thirty consecutive patients underwent combined endoscopic-laparoscopic surgery. Twenty (66.7%) patients underwent laparoscopic-assisted colonoscopic polyp excision (10 of these excisions were facilitated by Endoloop placement at the polyp base), 9 (30%) patients underwent colonoscopic-assisted laparoscopic cecectomy, and 1 (3.3%) patient was converted from a colonoscopic-assisted laparoscopic cecectomy to a laparoscopic ileocolic resection. The median length of hospital stay was 2 days (range, 1-16). Twenty-nine (96.7%) of the final pathology results were benign, with 10 (33.3%) showing high-grade dysplasia. One (3.3%) final pathology result was positive for a well-differentiated adenocarcinoma. This patient subsequently underwent a laparoscopic right hemicolectomy and chemotherapy for node-positive disease. One (3.3%) patient experienced a recurrent benign polyp at the previous excision site, which was removed by colonoscopy. The time to detection of recurrence was 274 days. LIMITATIONS: This study looked at a small group of patients, over a short follow-up period. However, all consecutive patients were captured, and there were no losses to follow-up. CONCLUSIONS: Combined endoscopic-laparoscopic surgery for complex benign colonic polyps is a safe procedure, with good clinical outcomes and low recurrence rates.

Put a face to a name: a randomized controlled trial evaluating the impact of providing clinician photographs on inpatients' recall.

BACKGROUND: Inpatients are visited by many health care providers daily; many cannot remember the name of even one member of their clinical care team. We provided inpatients with photographs of their clinicians and evaluated the impact on patient recall and communication with their health care providers. METHODS: A concealed allocation, randomized controlled trial (ClinicalTrials.gov NCT01658644) was conducted between September 2012 and April 2013 in the general internal medicine wards of a large teaching hospital in Toronto, Canada. Consenting patients were randomized into 3 groups: the control group received the current standard of care; the second group received handouts with the names and roles of their clinical care team; and the third group received handouts with the names, roles, and photographs of their clinical care team. Before discharge, patients completed a survey on their ability to recall their clinicians and were asked to rate the quality of communication with their care team. RESULTS: Of the 186 patients (mean age 61 years, female = 44%) who completed surveys (control n = 60; names n = 65; photos n = 61), those receiving photos in the handout correctly identified significantly more clinicians by photograph (P = .001) and recalled more names (P = .002) than patients assigned to the control group. Regarding the perceived quality of communication, the results did not show differences between the control and intervention groups. CONCLUSION: In this era of patient-centered care, providing patients with more information about who is directly involved with their health care appears to be warranted.

Autologous Fat Grafting as a Novel Approach to Parastomal Soft-tissue Volume Deficiencies.

SUMMARY: The aim of this study is to describe a novel approach to revise maladaptive soft-tissue contour around an ileostomy. A patient with permanent ileostomy suffered from significant defects in soft-tissue contour due to scarring and wound contraction. He underwent autologous fat grafting to achieve sealing of his stoma appliance and improve cosmesis. Due to numerous surgeries, the stoma appliance would not seal and required daily appliance changes. The patient received autologous fat grafting to augment the contour around stoma. A complete fitting of stoma was achieved. The patient is satisfied with stoma sealing and is changing his stoma appliance every 5-7 days without skin excoriation. Autologous fat transfer is an effective approach to treat a subset of stoma patients with complex subcutaneous defects.

Medical students and personal smartphones in the clinical environment: the impact on confidentiality of personal health information and professionalism.

BACKGROUND: Smartphones are becoming ubiquitous in health care settings. The increased adoption of mobile technology such as smartphones may be attributed to their use as a point-of-care information source and to perceived improvements in clinical communication and efficiency. However, little is known about medical students' use of personal smartphones for clinical work. OBJECTIVE: The intent of the study was to examine final-year medical students' experience with and attitudes toward using personal mobile technology in the clinical environment, with respect to the perceived impact on patient confidentiality and provider professionalism. METHODS: Cross-sectional surveys were completed by final-year medical students at the University of Toronto. Respondents were asked about the type of personal mobile phone they use, security features on their personal phone, experiences using their personal phone during clinical rotations, and attitudes about using their personal phone for clinical work purposes. RESULTS: The overall response rate was 45.4% (99/218). Smartphone ownership was prevalent (98%, 97/99) with the majority (86%, 85/99) of participants using their personal phones for patient-related communication during clinical rotations. A total of 26% (26/99) of participants reported not having any type of security feature on their personal phone, 94% (90/96) of participants agreed that using their personal phone for clinical work makes them more efficient, and 86% (82/95) agreed that their personal phone allows them to provide better patient care. Although 68% (65/95) of participants believe that the use of personal phones for patient-related communication with colleagues poses a risk to the privacy and confidentiality of patient health information, 22% (21/96) of participants still use their personal phone to text or email identifiable patient data to colleagues. CONCLUSIONS: Our findings suggest that the use of personal smartphones for clinical work by medical students is prevalent. There is a need to more fully address the threat to patient confidentiality posed by the use of unsecured communication devices such as smartphones.

Evaluation of the accuracy of smartphone medical calculation apps.

BACKGROUND: Mobile phones with operating systems and capable of running applications (smartphones) are increasingly being used in clinical settings. Medical calculating applications are popular mhealth apps for smartphones. These include, for example, apps that calculate the severity or likelihood of disease-based clinical scoring systems, such as determining the severity of liver disease, the likelihood of having a pulmonary embolism, and risk stratification in acute coronary syndrome. However, the accuracy of these apps has not been assessed. OBJECTIVE: The objective of this study was to evaluate the accuracy of smartphone-based medical calculation apps. METHODS: A broad search on Google Play, BlackBerry World, and the iTunes App Store was conducted to find medical calculation apps for smartphones. The list of apps was narrowed down based on inclusion and exclusion criteria focusing on functions thought to be relevant by a panel of general internists (number of functions =13). Ten case values were inputted for each function and were compared to manual calculations. For each case, the correct answer was assigned a score of 1. A score for the 10 cases was calculated based on the accuracy of the results for each function on each app. RESULTS: We tested 14 apps and 13 functions for each app if that function was available. We conducted 10 cases for each function for a total of 1240 tests. Most functions tested on the apps were accurate in their results with an overall accuracy of 98.6% (17 errors in 1240 tests). In all, 6 of 14 (43%) apps had 100% accuracy. Although 11 of 13 (85%) functions had perfect accuracy, there were issues with 2 functions: the Child-Pugh scores and Model for End-Stage Liver Disease (MELD) scores on 8 apps. Approximately half of the errors were clinically significant resulting in a significant change in prognosis (8/17, 47%). CONCLUSIONS: The results suggest that most medical calculating apps provide accurate and reliable results. The free apps that were 100% accurate and contained the most functions desired by internists were CliniCalc, Calculate by QxMD, and Medscape. When using medical calculating apps, the answers will likely be accurate; however, it is important to be careful when calculating MELD scores or Child-Pugh scores on some apps. Despite the few errors found, greater scrutiny is warranted to ensure full accuracy of smartphone medical calculator apps.

Educational impact of using smartphones for clinical communication on general medicine: more global, less local.

BACKGROUND: Medical trainees increasingly use smartphones in their clinical work. Similar to other information technology implementations, smartphone use can result in unintended consequences. This study aimed to examine the impact of smartphone use for clinical communication on medical trainees' educational experiences. DESIGN: Qualitative research methodology using interview data, ethnographic data, and analysis of e-mail messages. ANALYSIS: We analyzed the interview transcripts, ethnographic data, and e-mails by applying a conceptual framework consisting of 5 educational domains. RESULTS: Smartphone use increased connectedness and resulted in a high level of interruptions. These 2 factors impacted 3 discrete educational domains: supervision, teaching, and professionalism. Smartphone use increased connectedness to supervisors and may improve supervision, making it easier for supervisors to take over but can limit autonomy by reducing learner decision making. Teaching activities may be easier to coordinate, but smartphone use interrupted learners and reduced teaching effectiveness during these sessions. Finally, there may be professionalism issues in relation to how residents use smartphones during encounters with patients and health professionals and in teaching sessions. CONCLUSIONS: We summarized the impact of a rapidly emerging information technology-smartphones-on the educational experience of medical trainees. Smartphone use increase connectedness and allow trainees to be more globally available for patient care but creates interruptions that cause trainees to be less present in their local interactions with staff during teaching sessions. Educators should be aware of these findings and need to develop curriculum to address the negative impacts of smartphone use in the clinical training environment.

The intended and unintended consequences of communication systems on general internal medicine inpatient care delivery: a prospective observational case study of five teaching hospitals.

BACKGROUND: Effective clinical communication is critical to providing high-quality patient care. Hospitals have used different types of interventions to improve communication between care teams, but there have been few studies of their effectiveness. OBJECTIVES: To describe the effects of different communication interventions and their problems. DESIGN: Prospective observational case study using a mixed methods approach of quantitative and qualitative methods. SETTING: General internal medicine (GIM) inpatient wards at five tertiary care academic teaching hospitals. PARTICIPANTS: Clinicians consisting of residents, attending physicians, nurses, and allied health (AH) staff working on the GIM wards. METHODS: Ethnographic methods and interviews with clinical staff (doctors, nurses, medical students, and AH professionals) were conducted over a 16-month period from 2009 to 2010. RESULTS: We identified four categories that described the intended and unintended consequences of communication interventions: impacts on senders, receivers, interprofessional collaboration, and the use of informal communication processes. The use of alphanumeric pagers, smartphones, and web-based communication systems had positive effects for senders and receivers, but unintended consequences were seen with all interventions in all four categories. CONCLUSIONS: Interventions that aimed to improve clinical communications solved some but not all problems, and unintended effects were seen with all systems.

It's not about pager replacement: an in-depth look at the interprofessional nature of communication in healthcare.

BACKGROUND: Institutions have tried to replace the use of numeric pagers for clinical communication by implementing health information technology (HIT) solutions. However, failing to account for the sociotechnical aspects of HIT or the interplay of technology with existing clinical workflow, culture, and social interactions may create other unintended consequences. OBJECTIVE: To evaluate a Web-based messaging system that allows asynchronous communication between health providers and identify the unintended consequences associated with implementing such technology. DESIGN: Intervention-a Web-based messaging system at the University Health Network to replace numeric paging practices in May 2010. The system facilitated clinical communication on the medical wards for coordinating patient care. Study design-pre-post mixed methods utilizing both quantitative and qualitative measures. PARTICIPANTS: Five residents, 8 nurses, 2 pharmacists, and 2 social workers were interviewed. Pre-post interruption-15 residents from 5 clinical teams in both periods. MEASUREMENTS: The study compared the type of messages sent to physicians before and after implementation of the Web-based messaging system; a constant comparative analysis of semistructured interviews was used to generate key themes related to unintended consequences. RESULTS: Interruptions increased 233%, from 3 pages received per resident per day pre-implementation to 10 messages received per resident per day post-implementation. Key themes relating to unintended consequences that emerged from the interviews included increase in interruptions, accountability, and tactics to improve personal productivity. CONCLUSIONS: Meaningful improvements in clinical communication can occur but require more than just replacing pagers. Introducing HIT without addressing the sociotechnical aspects of HIT that underlie clinical communication can lead to unintended consequences.

Effects of clinical communication interventions in hospitals: a systematic review of information and communication technology adoptions for improved communication between clinicians.

OBJECTIVE: To conduct a systematic review of the literature to identify, describe and assess interventions of information and communication technology on the processes of communication and associated patient outcomes within hospital settings. MATERIALS AND METHODS: Studies published from the years 1996 to 2010 were considered and were selected if they described an evaluation of information and communication technology interventions to improve clinical communication within hospitals. Two authors abstracted data from full text articles, and the quality of individual articles were appraised. Results of interventions were summarized by their effect. RESULTS: There were 18 identified studies that evaluated the use of interventions that included alphanumeric paging, hands-free communication devices, mobile phones, smartphones, task management systems and a display based paging system. Most quantitative studies used a before and after study design and were of lower quality. Of all the studies, there was only one prospective randomized study, but this study used only simulated communication events. Quantitative studies identified improved perceptions of communication and some improvement in communication metrics. Qualitative studies described improvements in efficiency of communication but also issues of loss of control and reliability. CONCLUSIONS: Despite the rapid advancement in information and communications technology over the last decade, there is limited evidence suggesting improvements in the ability of health professionals to communicate effectively. Given the critical nature of communication, we advocate further evaluation of information and communication technology designed to improve communication between clinicians. Outcome measures should include measures of patient-oriented outcomes and efficiency for clinicians.

The use of smartphones in general and internal medicine units: a boon or a bane to the promotion of interprofessional collaboration?

Effective communication and coordination are critical components for improving collaborative care delivery among different healthcare providers who work in mobile and time-pressured environments. Increasingly, healthcare providers are exploring alternative communication technologies to help bridge the temporal and spatial issues that are often inherent in the clinical communication conundrum. Our study examined perceptions of General Internal Medicine (GIM) staff on the usage of Smartphone devices and a Webpaging system, which were implemented on the inpatient GIM units at two teaching hospitals in North America. An exploratory case study approach was employed and in-depth interviews with 31 clinicians were conducted. This data-set serves as a subset and prelude to a larger research study that examined and compared the impacts of different types of communication technologies used in five teaching hospitals. Findings from our study indicate that the use of Smartphone technology was well received among clinicians. Specifically, healthcare professionals valued the use of emails when communicating nonurgent issues and the availability of the phone function that enabled access to clinicians especially in urgent situations. Dissatisfaction, however, was expressed over the suitability of these smartphone features in different communication contexts as well as discrepancies between clinicians over the appropriate use of the communication modes. Future interventions in communication technology should take into considerations how communication mediums and situational contexts (e.g. urgent and nonurgent patient issues) impact interprofessional interactions.