This short-term project identified how to better support disposition decision making in emergency departments using electronic whiteboards (e-boards).
There are 3 main objectives:
1.Assess variation in disposition decisions by emergency department physicians
2.Compare disposition strategies with vs. without the use of ED Tracking Board software
3.Identify barriers and facilitators to the use of automated detection of high mortality risk indicators
Data collection: Direct (in situ) ethnographic observations will be conducted in emergency departments at two sites for 5 days each by 3 trained observers. Data collection will sequentially capture both 1) observable activities and verbalizations, and 2) self-report data about how artifacts (tools) support or hinder performance.
Data analysis: A qualitative case-based analysis will be employed. For each case, decisions will be coded for: site, educational level of physician, disposition strategy, information included in the disposition decision, and barriers and facilitators to use of automated enhancements.
All 23 physicians used the manual whiteboard, including adding and viewing data. Most physicians were non-users of the e-board (6/9 Site 1; 14/14 Site 2). Manual whiteboard data were more accurate than e-board data (27 vs. 169 inaccurate items). For the manual whiteboard, categories included inaccurate admit times (9), missing admit times (7), missing physician assignments (5), and missing chief complaints (3). For the e-board, categories included names/locations of overflow patients (40), missing patients (34), outdated patients (28), patients assigned to the wrong bed (27), and inaccurate physician assignments (12). For the manual whiteboard, the primary functions at Site 1 were to track real-time changes to patient identifiers, locations, nursing assignments, and pending activities as well as support physician handoffs. At Site 1, secondary functions of the manual whiteboard included coordinating and tracking physician assignments, noting contact information to support admitting patients, and personal reminders of tasks to be done. For the manual whiteboard, the primary functions at Site 2 were to inform physicians and nurses about newly arrived patients assigned to them, inform nurses of physician orders, inform physicians of the status of ordered items, and track real-time changes to patient identifiers, locations, and pending activities, as well as support physician handoffs. Flexibility in the number and content of whiteboard columns, ease of data entry and updates, ease of viewing whiteboard data at a distance and from a central location, ability for others to view whiteboard data such as police officers and families, and ease of using symbols as shorthand information supported these functions. At both sites, the primary function of the e-board was to support electronic data collection of patient admitting and departure times, which was primarily input by clerks at both sites. At Site 1, a secondary function was to highlight when patients were going to cross the mandated 6-hour limit for time spent in the emergency department prior to admission, for which violations at that site were discussed during weekly meetings with hospital administrators.
Improving the ED Tracking Board software, a national informatics application, might reduce lengths of stay in the emergency department and potentially reduce patient mortality by better supporting accurate and timely disposition decisions for high-risk patients.
External Links for this Project
- Patterson ES, Rogers ML, Tomolo AM, Wears RL, Tsevat J. Comparison of extent of use, information accuracy, and functions for manual and electronic patient status boards. International journal of medical informatics. 2010 Dec 1; 79(12):817-23. [view]