Understanding the impact on intensive care staff workflow due to the introduction of a critical care information system: a mixed methods research methodology.

The Intensive Care Unit (ICU) is a complex and dynamic tertiary care environment that requires health care providers to balance many competing tasks and responsibilities. Inefficient and interruption-driven workflow is believed to increase the likelihood of medical errors and, therefore, present a serious risk to patients in the ICU. The introduction of a Critical Care Information System (CCIS), is purported to result in fewer medical errors and better patient care by streamlining workflow. Little objective research, however, has investigated these assertions. This paper reports on the design of a research methodology to explore the impact of a CCIS on the workflow of Respiratory Therapists, Pediatric Intensivists, Nurses, and Unit Clerks in a Pediatric ICU (PICU) and a General Systems ICU (GSICU) in Northern Canada.

Epidemiology of critically ill children in England and Wales: incidence, mortality, deprivation and ethnicity.

OBJECTIVE: The purpose of this work was to investigate the incidence rate for admission and mortality of children receiving paediatric intensive care in relation to socioeconomic status and ethnicity in England and Wales. DESIGN: National cohort of sequential hospital admissions. SETTING: Twenty nine paediatric intensive care units in England and Wales. PARTICIPANTS: All children aged under 16 years admitted to paediatric intensive care in the 4 years 2004-2007. MAIN OUTCOME MEASURES: Incidence rates for admission and odds ratios (OR) for risk-adjusted mortality by an area based measure of deprivation (Townsend score) and ethnic group (south Asian vs non-south Asian determined using two-name analysis algorithms). RESULTS: The incidence for south Asian children was higher than that of non-south Asian children (138 vs 95/100,000, incidence rate ratio 1.36, 95% CI 1.32 to 1.40). The age-sex standardised incidence for children admitted to paediatric intensive care ranged from 69/100,000 in the least deprived fifth of the population to 124/100,000 in the most deprived fifth. The risk-adjusted OR for mortality for south Asian children was 1.36 (95% CI 1.18 to 1.57) overall, rising to 2.40 (95% CI 1.40 to 4.10) in the least deprived fifth of the population when a statistical interaction term for deprivation was included. CONCLUSIONS: In England and Wales, the admission rate to paediatric intensive care is higher for children from more deprived areas and 36% higher for children from the south Asian population. Risk-adjusted mortality increases in south Asian children as deprivation decreases.

Managers see the problems associated with coding clinical data as a technical issue whilst clinicians also see cultural barriers.

OBJECTIVE: In UK general practice, the coding of clinical data (Read Coding) is far from universal. This study set out to examine the barriers to recording structured information in computerised medical records; and to explore whether managers and clinicians had different perspectives in how these barriers should be overcome. METHOD: A qualitative study, using semi-structured interviews of general practitioners, primary care nurses and practice managers. The interviews were recorded verbatim, and then underwent thematic analysis; additional interviews were conducted until thematic saturation was achieved. RESULTS: For clinicians the recording of structured data within a consultation is not a neutral activity, they are highly aware of diagnostic uncertainty and sensitive to the potential impact of both a correct and incorrect diagnostic label on their relationship with their patient. Clinicians accept that data has to be coded if they are to demonstrate that appropriate evidence based care has been provided to populations; but alongside this they require free-text as a more powerful reminder of the individual human encounter. Managers felt that they could encourage clinicians to code data for re-use as part of population data or as quality target indicators rather than as an enabler of the next consultation. CONCLUSIONS: The primary care consultation is a complex social interaction, and coding of the medical diagnosis in itself imposes the bio-medical model, carries assumptions about certainty, and is perceived by clinicians to potentially jeopardise their relationships with their patient. Further research to elicit patients' views may help clarify the magnitude of this barrier.

A validated logistic regression model to identify coronary heart disease patients within primary care databases in the United kingdom.

We established the optimal search strategy for identifying coronary heart disease (CHD) patients within the Electronic Patient Record (EPR) of 'paperless' family practices in the UK. Multiple logistic regression modelling (MLRM) and Receiver Operating Characteristic (ROC) curves were used to develop the query. The selected search strategy was validated at 2 additional paperless family practices.

Towards a conceptual framework for evaluating primary care research networks.

We describe a conceptual framework that we have developed for evaluating primary care research networks. The framework includes objectives, process indicators, and outcome indicators. We propose the framework as a provisional model that we hope will promote further research and debate.

Measuring blood pressure at the wrist: more comfortable for patients and more convenient for doctors?

OBJECTIVES: To compare the agreement between conventional measurement of blood pressure and measurements obtained using two automated devices; and to compare how comfortable each of the three methods of measurement were for patients. METHODS: Blood pressure measurements and patient comfort scores were recorded using three different devices in 125-surgery and 40-community patients. The devices used were a conventional aneroid sphygmomanometer, an automated device that measured blood pressure on the upper arm and an automated device that measured blood pressure at the wrist. In each patient, the difference between the conventional and automatic measurement was calculated. The limits of agreement of each device were then calculated as the mean difference +/-1.96 standard deviations. RESULTS: In surgery patients, the width of limits of agreement of wrist measurement were 20.0 mm Hg and 12.1 mm Hg for systolic and diastolic blood pressure respectively, compared with 26. 4 mm Hg and 27.7 mm Hg for automatic arm measurement. In community patients, the width of limits of agreement of wrist measurement were 11.6 mm Hg and 11.0 mm Hg for systolic and diastolic blood pressure respectively, compared with 19.5 mm Hg and 12.1 mm Hg for automatic arm measurement. Surgery patients also reported that wrist measurement of blood pressure was significantly more comfortable than either manual or automatic arm measurement (mean comfort scores 4.03 for automatic wrist and 2.13 for automatic arm measurement, Friedman's Test, P<0.001). CONCLUSIONS: Blood pressure measurements taken using the wrist device agreed more closely with those obtained using a conventional aneroid sphygmomanometer than the arm device. The wrist device was also more comfortable for patients than two other methods of blood pressure measurement. Public Health (2000) 114, 165-168

Management of ischaemic heart disease in primary care: towards better practice. STaRNet. South Thames Region Network.

BACKGROUND: Ischaemic heart disease is the commonest cause of mortality in the United Kingdom. The objective of this study was to assess the management of patients with ischaemic heart disease in primary care, focusing particularly on the management of hypercholesterolaemia. METHODS: A cross-sectional survey was carried out of the clinical records of patients aged 25-74 years with confirmed ischaemic heart disease in six general practices (total list size 56 600). RESULTS: Recording of risk factors varied from 97 per cent for blood pressure to 73 per cent for cholesterol measurement. Seventy-two per cent of the patients had adequate blood pressure control, based on their last recorded blood pressure. Sixty-one per cent (267) were known to be taking aspirin daily and 29 per cent (125) had undergone revascularization treatment. Sixty-eight per cent (296) of the patients had pre-treatment cholesterol levels of 5.5 mmol/l or greater and 34 per cent (147) were currently taking lipid lowering drugs. Statins were the most commonly used cholesterol lowering agents and were being taken by 30 per cent (131) of the patients. Patients who had undergone revascularization treatment had levels of recording of risk factors similar to other patients with ischaemic heart disease but were more likely to be taking daily aspirin (71 per cent versus 57 per cent, relative risk 1.24, 95 per cent confidence intervals (CI) 1.07-1.44). The mean pre-treatment cholesterol was 6.49mmol/l and the mean post-treatment cholesterol 5.80 mmol/l (difference 0.69 mmol/l, 95 per cent CI 0.55-0.84 mmol/l). CONCLUSIONS: Systematic searches of computerized and paper medical records can identify subgroups of patients who will benefit from continuing follow-up in primary care. The results of this study suggest that ischaemic heart disease remains an area where there is scope to improve the management of patients in primary care. Considerable effort will be required from the members of the primary health care team to achieve this objective, particularly in the areas of computerized data collection and in the identification and recall of patients.