Adverse Effects of Computers During Bedside Rounds in a Critical Care Unit | Critical Care Medicine | JAMA Surgery | JAMA Network
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Figure.  Study Design
Study Design
Table.  Frequency of Communication Barriers From Preintervention and Postintervention Observations
Frequency of Communication Barriers From Preintervention and Postintervention Observations
1.
Morrison  C, Fitzpatrick  G, Blackwell  A.  Multi-disciplinary collaboration during ward rounds: embodied aspects of electronic medical record usage.  Int J Med Inform. 2011;80(8):e96-e111. doi:10.1016/j.ijmedinf.2011.01.007PubMedGoogle ScholarCrossref
2.
Taylor  SP, Ledford  R, Palmer  V, Abel  E.  We need to talk: an observational study of the impact of electronic medical record implementation on hospital communication.  BMJ Qual Saf. 2014;23(7):584-588. doi:10.1136/bmjqs-2013-002436PubMedGoogle ScholarCrossref
3.
Diller  T, Helmrich  G, Dunning  S, Cox  S, Buchanan  A, Shappell  S.  The Human Factors Analysis Classification System (HFACS) applied to health care.  Am J Med Qual. 2014;29(3):181-190. doi:10.1177/1062860613491623PubMedGoogle ScholarCrossref
4.
Landsberger  HA.  Hawthorne Revisited: Management and the Worker: Its Critics, and Developments in Human Relations in Industry. Ithaca, NY: Cornell University; 1958.
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    Research Letter
    Pacific Coast Surgical Association
    November 2018

    Adverse Effects of Computers During Bedside Rounds in a Critical Care Unit

    Author Affiliations
    • 1Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
    • 2Cedars-Sinai Center for Outcomes Research and Education, Cedars-Sinai Medical Center, Los Angeles, California
    JAMA Surg. 2018;153(11):1052-1053. doi:10.1001/jamasurg.2018.1752

    Multidisciplinary rounds aim to improve communication and have evolved to incorporate the real-time use of the electronic medical record.1 The electronic medical record can be used with varying modalities during multidisciplinary rounds, but is commonly accessed from a computer on wheels. Previous research has demonstrated that adoption of the electronic medical record has led to poor communication owing to reduced face-to-face interactions in which important nonverbal cues convey critical messages.2 The effect that numerous computers on wheels have on communication is unknown. The objective of this study is to determine if reducing the quantity of computers on wheels enhances communication patterns during multidisciplinary rounds in the surgical intensive care unit.

    Methods

    A prospective study was conducted at an academic surgical intensive care unit from March 13 to May 4, 2017, in 3 phases: a preintervention observation, an intervention, and a postintervention observation phase (Figure). This study was approved by the Cedars-Sinai Medical Center Institutional Review Board, who waived the need for consent as deidentified data were collected.

    Observations were conducted by the same individuals, one physician (N.K.D.) and one non–health care personnel (S.E.F.), with expertise in process improvement and human factors analysis.3 Participants were aware of the observers but blinded to the specifics regarding data collection. The frequency of communication barriers was recorded with each patient presentation and included simultaneous conversations occurring within the rounding group, telephone calls, other telephone use such as texting, nursing or physician interruptions, and difficulty hearing the presentation. Difficulty hearing was determined if the observers, who stood with the rounding team, could not hear the presentation content. Telephone use was assessed because telephones are often used to communicate patient information by individuals within the unit or may be used for nonclinical work. Multidisciplinary rounds consisted of 7 to 9 individuals with the same attending physician and fellows, 2 to 3 residents switching during the study period, nursing staff, pharmacists, and respiratory therapists who changed depending on the patient or day.

    The intervention included a reduction in the number of computers on wheels from 6 to 8 in the preintervention phase to 3 to 4 in the postintervention phase, with the exact number at the discretion of the rounding team. Observations in the postintervention phase were conducted to determine how communication barriers changed with the reduction in the number of computers on wheels.

    Data are reported as percentages. A Pearson χ2 test was used to compare frequencies. A 2-sided P value of less than .05 was considered statistically significant.

    Results

    A total of 429 presentations were observed, of which 229 were performed prior to the intervention. The most common barriers present prior to the intervention were from other telephone use (145 [63.3%]), followed by difficulty hearing (117 [51.1%]) and simultaneous conversations (116 [50.7%]) (Table).

    An additional 200 presentations were observed after the intervention, in which the number of computers on wheels was reduced. Significant reductions were noted in how often simultaneous conversations occurred (116 [50.7%] preintervention vs 57 [28.5%] postintervention; P < .001) and difficulty hearing (117 [51.1%] preintervention vs 11 [5.5%] postintervention; P < .001) (Table).

    Discussion

    To better understand the association of computers on wheels with communication behaviors during multidisciplinary rounds in the surgical intensive care unit, we quantified and analyzed communication barriers when the number of computers on wheels changed. Although communication barriers were observed, some were necessary to deliver care and should not be considered disruptive. The lack of change with telephone calls and other telephone use indicates that these communication barriers were likely necessary for patient care.

    With fewer computers on wheels we noted a reduction in simultaneous conversations and difficulty hearing, which may be owing to the increased engagement of the participants as patient information is more likely derived from the presentation when the electronic medical record becomes less accessible. The increased ability to hear patient presentations was likely because of the concurrent reduction in simultaneous conversations, as well as a noticeable change with the arrangement of the rounding group becoming more compact. The association of these changes with efficiency or clinical outcomes was not monitored. Limitations include the potential for a Hawthorne effect4 and a change in the residents during the study period. Alternative technologies should be identified that optimize human-computer interactions and facilitate effective communication.

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    Article Information

    Accepted for Publication: April 9, 2018.

    Corresponding Author: Eric J. Ley, MD, Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Ste 8215NT, Los Angeles, CA 90048 (eric.ley@cshs.org).

    Published Online: July 18, 2018. doi:10.1001/jamasurg.2018.1752

    Author Contributions: Drs Dhillon and Ley had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: All authors.

    Acquisition, analysis, or interpretation of data: Dhillon, Francis, Tatum, Keller, Barmparas, Gewertz.

    Drafting of the manuscript: Dhillon, Francis, Tatum, Gewertz.

    Critical revision of the manuscript for important intellectual content: Francis, Tatum, Keller, Barmparas, Gewertz, Ley.

    Statistical analysis: Dhillon, Tatum.

    Administrative, technical, or material support: Francis, Tatum, Keller, Gewertz, Ley.

    Supervision: Francis, Tatum, Barmparas, Gewertz, Ley.

    Conflict of Interest Disclosures: None reported.

    Previous Presentation: This article was presented at the 89th Annual Meeting of the Pacific Coast Surgical Association; February 17, 2018; Napa, California.

    References
    1.
    Morrison  C, Fitzpatrick  G, Blackwell  A.  Multi-disciplinary collaboration during ward rounds: embodied aspects of electronic medical record usage.  Int J Med Inform. 2011;80(8):e96-e111. doi:10.1016/j.ijmedinf.2011.01.007PubMedGoogle ScholarCrossref
    2.
    Taylor  SP, Ledford  R, Palmer  V, Abel  E.  We need to talk: an observational study of the impact of electronic medical record implementation on hospital communication.  BMJ Qual Saf. 2014;23(7):584-588. doi:10.1136/bmjqs-2013-002436PubMedGoogle ScholarCrossref
    3.
    Diller  T, Helmrich  G, Dunning  S, Cox  S, Buchanan  A, Shappell  S.  The Human Factors Analysis Classification System (HFACS) applied to health care.  Am J Med Qual. 2014;29(3):181-190. doi:10.1177/1062860613491623PubMedGoogle ScholarCrossref
    4.
    Landsberger  HA.  Hawthorne Revisited: Management and the Worker: Its Critics, and Developments in Human Relations in Industry. Ithaca, NY: Cornell University; 1958.
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