Eyal Zimlichman

As one of the most common sources of preventable harm, health care–associated infections (HAIs) represent a major threat to patient safety.^1,2 Recent estimates of the national morbidity and mortality burden of HAIs have made it clear that HAIs represent a major public health problem.³ Furthermore, a robust body of evidence exists describing interventions that can substantially reduce the incidence of HAIs,⁴ and recent analyses indicate that at least 50% are preventable.^5,6 Standard-setting organizations such the National Quality Forum have identified HAIs as a key area of focus for patient safety with the development of a number evidence-based, HAI-specific safe practices.⁷ As a target for those seeking to improve care in the United States, HAIs represent a key opportunity to save lives and reduce costs.^1,2,8,9,

Computerized Provider Order Entry (CPOE) can improve patient safety, quality and efficiency, but hospitals face a host of barriers to adopting CPOE, ranging from resistance among physicians to the cost of the systems. In response to the incentives for meaningful use of health information technology and other market forces, hospitals in the United States are increasingly moving toward the adoption of CPOE. The purpose of this study was to characterize the experiences of hospitals that have successfully implemented CPOE. We used a qualitative approach to observe clinical activities and capture the experiences of physicians, nurses, pharmacists and administrators at five community hospitals in Massachusetts (USA) that adopted CPOE in the past few years. We conducted formal, structured observations of care processes in diverse inpatient settings within each of the hospitals and completed in-depth, semi-structured interviews with clinicians and staff by telephone. After transcribing the audiorecorded interviews, we analyzed the content of the transcripts iteratively, guided by principles of the Immersion and Crystallization analytic approach. Our objective was to identify attitudes, behaviors and experiences that would constitute useful lessons for other hospitals embarking on CPOE implementation. Analysis of observations and interviews resulted in findings about the CPOE implementation process in five domains: governance, preparation, support, perceptions and consequences. Successful institutions implemented clear organizational decision-making mechanisms that involved clinicians (governance). They anticipated the need for education and training of a wide range of users (preparation). These hospitals deployed ample human resources for live, in-person training and support during implementation. Successful implementation hinged on the ability of clinical leaders to address and manage perceptions and the fear of change. Implementation proceeded smoothly when institutions identified and anticipated the consequences of the change. The lessons learned in the five domains identified in this study may be useful for other community hospitals embarking on CPOE adoption.

BACKGROUND: Continuous vital sign monitoring has the potential to detect early clinical deterioration. While commonly employed in the intensive care unit (ICU), accurate and noninvasive monitoring technology suitable for floor patients has yet to be used reliably.OBJECTIVE: To establish the accuracy of the Earlysense continuous monitoring system in predicting clinical deterioration.DESIGN: Noninterventional prospective study with retrospective data analysis.SETTING: Two medical wards in 2 academic medical centers.PATIENTS: Patients admitted to a medical ward with a diagnosis of an acute respiratory condition.INTERVENTION: Enrolled patients were monitored for heart rate (HR) and respiration rate (RR) by the Earlysense monitor with the alerts turned off.MEASUREMENTS: Retrospective analysis of vital sign data was performed on a derivation cohort to identify optimal cutoffs for threshold and 24‐hour trend alerts. This was internally validated through correlation with clinical events recognized through chart review.RESULTS: Of 113 patients included in the study, 9 suffered major clinical deterioration. Alerts were found to be infrequent (2.7 and 0.2 alerts per patient‐day for threshold and trend alert, respectively). For the threshold alerts, sensitivity and specificity in predicting deterioration was found to be 82% and 67%, respectively, for HR and 64% and 81%, respectively, for RR. For trend alerts, sensitivity and specificity were 78% and 90% for HR, and 100% and 64% for RR, respectively.CONCLUSIONS: The Earlysense monitor was able to continuously measure RR and HR, providing low alert frequency. The current study provides data supporting the ability of this system to accurately predict patient deterioration. Journal of Hospital Medicine 2012; © 2012 Society of Hospital Medicine

Ilan and Donchin have compared Israel and Canada's experiences in setting a national patient safety agenda. We broaden this comparison to include the U.S. experience, and suggest that there are three additional key steps which will be important in any national patient safety agenda, and which Israel in particular should consider. These are 1) using health information technology (HIT) to directly improve patient safety, 2) dissemination and broad use of checklists, and 3) measuring patient safety over time at the national level. Especially because of its already substantial commitment to HIT and well-developed HIT sector, Israel has a major opportunity to move forward rapidly in this area and to achieve broad impact on the safety front. This is a commentary on http://www.ijhpr.org/content/1/1/19/

Objective To summarize the Canadian health information technology (HIT) policy experience and impart lessons learned to the US as it determines its policy in this area. Design Qualitative analysis of interviews with identified key stakeholders followed by an electronic survey. Measurements We conducted semi-structured interviews with 29 key Canadian HIT policy and opinion leaders and used a grounded theory approach to analyze the results. The informant sample was chosen to provide views from different stakeholder groups including national representatives and regional representatives from three Canadian provinces. Results Canadian informants believed that much of the current US direction is positive, especially regarding incentives and meaningful use, but that there are key opportunities for the US to emphasize direct engagement with providers, define a clear business case for them, sponsor large scale evaluations to assess HIT impact in a broad array of settings, determine standards but also enable access to resources needed for mid-course corrections of standards when issues are identified, and, finally, leverage implementation of digital imaging systems. Limitations Not all stakeholder groups were included, such as providers or patients. In addition, as in all qualitative research, a selection bias could be present due to the relatively small sample size. Conclusions Based on Canadian experience with HIT policy, stakeholders identified as lessons for the US the need to increase direct engagement with providers and the importance of defining the business case for HIT, which can be achieved through large scale evaluations, and of recognizing and leveraging successes as they emerge.

To perform initial validation of a continuous motion monitoring technology that can potentially be used as a risk assessment tool to determine risk for developing pressure ulcers (PUs). We have used the EverOn system (Earlysense LTD, Ramat Gan, Israel) as a bed movement and activity monitor. The EverOn is a contactless continuous measurement system based on a piezoelectric sensor that is placed under the patient's mattress. The study was a noninterventional study performed in 2 medical departments in 2 medical centers. Recorded movement data from enrolled patients were retrospectively analyzed, and patients were assigned a motion level score. Motion scores for the first night of hospitalization were correlated with the Norton scale as calculated per patient on admission. Overall, 116 patients were included in the study from the 2 sites. Motion score was significantly different between the PU risk groups as determined by the Norton scale (10.7 ± 6.2 for low, 5.4 ± 4.9 for intermediate, and 1.6 ± 3.2 for high risk; P < 0.001). Using the Norton scale as a gold standard to define high risk for developing PU (≤14), the sensitivity of the motion score was 85%, and the specificity was 93%. With regard to individual risk components, we found that activity, mobility, physical condition, and incontinence correlated highly with motion level. The high correlation between the EverOn motion score and the calculated Norton scale indicates the potential of this technology to serve as a risk assessment tool for the development of PUs.