Digital whiteboards

Touchscreens on the wards that allow access to the 'patient administration system' PAS have been installed in Truro. in fact they've been there for a few weeks but we had a presentation of the system (Swift+ - I can't work out who the actual supplier is) at the lunchtime meeting.

The patients' names are shown - as they would have been on the traditional whiteboard - and the bed they occupy. Other administrative information is displayed such as specialty, consultant, expected date of discharge, and icons representng safety issues like falls, dementia and so on. Any member of staff can update the screens and final responsibility for access and accuracy lies with the nursing shift leader. All changes are made on the PAS and this enables a 'live bed state'. This allows more accurate information for hospital management and also the opportunity to access and update the data from PCs during a handover or a multidisciplinary meeting.

Perhaps it would be better to refer to the bed state as a 'real time bed state' to avoid questions about what the dead bed state might refer to.

We discussed representing shared care on the whiteboards especially in the orthopaedic wards where geriatricians actively manage the hip fracture patients especially. The old whiteboards could be adorned with coloured stickers developing a visual summary unique to the culture of a particular ward. This type of 'user' creativity is something that can be overlooked by IT design if they don't involve the people who will use the tool. Also, I think more attention needs to be given to the utility of the data to the staff that are entering it.

Anyhow, the system looks good and can't wait to try it out. Do you wash your hands before or after using the touchscreens (or both)?

Progress testing and educational data mining

I read George Siemens's interview on O'Reilly Radar, How data and analytics can improve education, and was struck by an example he gave on how education could be changed with the use of analytics.

"In terms of evaluation of learners, assessment should be in-process, not at the conclusion of a course in the form of an exam or a test. Let's say we develop semantically-defined learning materials and ways to automatically compare learner-produced artifacts (in discussions, texts, papers) to the knowledge structure of a field. Our knowledge profile could then reflect how we compare to the knowledge architecture of a domain — i.e. "you are 64% on your way to being a psychologist" or "you are 38% on your way to being a statistician." Basically, evaluation should be done based on a complete profile of an individual, not only the individual in relation to a narrowly defined subject area."

An example of this in medicine is the formative assessment work, progress testing, developed in the Netherlands called Progress Test Feedback System PRoF. It is used at the Peninsula Medical School in the UK. Progress Test (Word Doc). OK it doesn't go as far as saying you are 45% doctor but it does allow students and their tutors to understand where they are on their learning trajectory.

PICME - 3 methods compared for improving prescribing in Spain

Interesting study from Spain of 3 different interventions, compared to control, to improve prescribing safety in primary care. [1]

• control
• report (received feedback reports)
• session (group sessions)
• face-to-face (personal interviews)

No improvement was seen in the report group compared to the control. Face to face was more expensive. The best seemed to be the session group which was the most cost-effective at reducing drug interactions.

An older study on prescribing quality in Spain showed that one-to-one was better than group learning. [2]

It is likely that local context and the exact mode of delivery of interventions explains a lot of the variation in outcomes. What is hard in this type of research is to learn what can be generalised to other circumstances.

1.

Lopez-Picazo JJ, Ruiz JC, Sanchez JF, Ariza A, Aguilera B. A randomized trial of the effectiveness and efficiency of interventions to reduce potential drug interactions in primary care. Am J Med Qual 2011 Apr;26(2):145-153.[cited 2011 Jul 25] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21403177

2.

Figueiras A, Sastre I, Tato F, Rodríguez C, Lado E, Caamaño F, Gestal-Otero JJ. One-to-one versus group sessions to improve prescription in primary care: a pragmatic randomized controlled trial. Med Care 2001 Feb;39(2):158-167. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11176553

Asthma QI in North Carolina

This quality improvement project in asthma that included health professional education, patient education and free medication did not appear to lessen the rate of return visits for asthma-related symptoms at 30 and 60 days. However, it did describe the rural population of people with asthma and their informal relationship with asthma care.

"In North Carolina, nearly one-fourth of persons with asthma visit an emergency department (ED) or urgent care center at least once a year because of an exacerbation of asthma symptoms. ... Many patients who use the ED for care appear to have mild, intermittent asthma and do not identify a regular source of primary care. Efforts to improve asthma care on a communitywide basis and to reduce preventable exacerbations should include care provided in EDs, as this may be the only source of asthma care for many asthma patients. The project demonstrated that regional, collaborative performance improvement efforts in EDs are possible but that many barriers exist to this approach." [1]

1.

Crane S, Sailer D, Patch SC. Improving asthma care in emergency departments: results of a multihospital collaborative quality initiative in rural western North Carolina. N C Med J 2011 Apr;72(2):111-117.[cited 2011 Jul 25] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21721495

Patients vs. cardiologists #twitjc week 7

Thanks again to @fidouglas and @silv24 for organising this week's Twitter Journal Club on a paper about the "beliefs" of cardiologists and their patients on the use of percutaneous coronary intervention (PCI) - stents / angioplasty.

The paper by researchers from Baystate Medical Center, Springfield, Massachusetts [1] found that patients were far more optimistic that PCI would reduce their chances of myocardial infarction or death.

My thoughts (5 minutes before the Twitter Journal Club discussion starts) are that it is an interesting paper but it is from one institution with a particularly opaque consent form and the surveys of patients and cardiologists are unvalidated survey tools. It suggests that patients in this facility are not fully informed of the use of PCI before they undergo cardiac catheterisation. To get them fully informed would be a challenge.

1. Rothberg MB, Sivalingam SK, Ashraf J, Visintainer P, Joelson J, Kleppel R, Vallurupalli N, Schweiger MJ. Patients' and Cardiologists' Perceptions of the Benefits of Percutaneous Coronary Intervention for Stable Coronary Disease. Annals of Internal Medicine 2010;153(5):307 -313.[cited 2011 Jul 24 ] Available from: http://www.annals.org/content/153/5/307.abstract

Non-invasive ventilation in the elderly

Review of a recent paper in Age & Ageing by one of the consultants at Truro for the eldercare lunchtime meeting.

The older person did better than anticipated on non-invasive ventilation (NIV) during acute exacerbations of COPD. [1] The authors concluded "NIV should be offered as an alternative to patients considered poor candidates for intubation and those with a [Do Not Intubate] order."

This has been shown in younger patients over 10 years ago [2] and we are aware that physician predictions of prognosis on ventilation can be unreliable. [3]

The challenge is how and where to manage such elderly NIV patients in the hospital. It needs specialist expertise and sophisticated equipment but clearly has a survival benefit for older patients with acute respiratory failure.

1.

Nava S, Grassi M, Fanfulla F, Domenighetti G, Carlucci A, Perren A, Dell’Orso D, Vitacca M, Ceriana P, Karakurt Z, Clini E. Non-invasive ventilation in elderly patients with acute hypercapnic respiratory failure: a randomised controlled trial. Age and Ageing 2011 Jul;40(4):444 -450. Available from: http://ageing.oxfordjournals.org/content/40/4/444.abstract

2.

Plant PK, Owen JL, Elliott MW. Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial. Lancet 2000 Jun;355(9219):1931-1935. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10859037

3.

Wildman MJ, Sanderson C, Groves J, Reeves BC, Ayres J, Harrison D, Young D, Rowan K. Implications of prognostic pessimism in patients with chronic obstructive pulmonary disease (COPD) or asthma admitted to intensive care in the UK within the COPD and asthma outcome study (CAOS): multicentre observational cohort study. BMJ 2007 Dec;335(7630):1132. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17975254

Velluvial Matrix

The "velluvial matrix" is a useful phrase that can be hidden in your original writing to catch those who may try to plagiarize your work at a later date.

http://doc2doc.bmj.com/forums/bmj_student-bmj_dean-of-medical-school-admits-plagiarism-think-of-medical-educators

Philip Baker, Dean of the University of Alberta’s faculty of medicine, gave an inspirational speech at the graduation banquet but ... it was not his speech. It was Atul Gawande's speech from the year before published in The New Yorker.

Lessons for those wanting to plagiarize for important speeches to students:

1. don't
2. technology will catch you out especially if those darned students have internet access when they are listening to your stolen speech
3. try and avoid really obvious Google terms like 'velluvial matrix' which will find the original source even if someone clicks the 'I'm feeling lucky' button on Google
4. preface any stolen part of your speech with "so and so said ... and I quote ..."

Action Learning

Reading an interesting article using action learning analysis for needs assessment in multidisciplinary teams in the NHS.[1]

Action learning has quite a pedigree in the UK with the work of Professor Reg Revans.

"Revans was convinced - and the proposition became known as Revans' Law - that for an organisation to survive, its rate of learning must be at least equal to the rate of change in its external environment. But learning is hard. Thinking about this at the coal board, and in the NHS, Revans was struck by the potential released by the ability to own up to ignorance without fear of ridicule or reprisal, and the inability of traditional "chalk and talk" teaching methods to solve practical problems, or provide a framework for real human growth. " Guardian, Orbituary, 2003.

1. Staniland K, Rosen L, Wild J. Staff support in continuing professional development. Nurs Manag (Harrow). 2011;18(1):33-37. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21667815. Accessed July 18, 2011.

Whole System Demonstrator

Good overview of the DoH's Whole System Demonstrator research project by Sharon Eustace, Nurse Consultant at Cornwall Primary Care Trust.

The system uses simple-to-use monitoring and daily questionnaire equipment in patients' homes that communicate with a central system. A nurse checks the patients results and the survey questions each day. The results of this study will be out soon and it would be intriguing to see what aspects are effective. Is it the remote monitoring? Is it the prompting of the patient each day to address the symptoms of their chronic disease? Is it the direct access to health staff?

She explained how she had extended the telehealth project to include incontinence patients in Cornwall.