Isla M. Hains

Objective To assess evidence of the impact of Picture Archiving and Communication Systems (PACS) on clinicians' work practices in the intensive care u

The Intensive Care Unit (ICU) is an information intense environment where Clinical Information Systems (CISs) can greatly impact patient care and the workload of clinicians. With the introduction of an ICU CIS imminent across New South Wales hospitals, we aimed to understand how ICU clinicians perceived a new system would impact on work practices in Australian ICUs, as much of the current evidence is generated from overseas. We conducted interviews with 66 doctors and nurses in 3 ICUs without a CIS. Many had positive perceptions regarding the impact of its introduction, though others were more guarded and unsure. Clinicians believed information access to patient would improve, communication processes could potentially change and there was potential for work processes to be more efficient. It was expected that ward rounds and handover would be less disrupted with all information available at the bedside or at the handover setting. There were mixed responses about whether a CIS would save time and how it would influence patient care, though the majority believed a CIS would improve safety by providing a means for increasing accountability and reducing medication errors. Concerns were raised about the transition from paper to a CIS and the training required. This information provides valuable evidence in the Australian setting regarding clinicians' expectations of a new ICU CIS to assist with future implementations. It also provides baseline data as a foundation for future research once the CIS is implemented. It is clear that robust quantitative studies are required to gain a detailed understanding of how a new CIS will impact clinicians' work processes and that appropriate training is crucial for full benefits to be achieved.

Medication monitoring of ambulatory rheumatology patients on Disease Modifying Anti-Rheumatic Drugs (DMARDS) is time consuming and complex, with possibilities for error. Electronic systems have the potential to improve the process. The aim of this study was to evaluate the impact of an electronic Drug Monitoring System (eDMS) on the time nurses' spent on clinical documentation associated with monitoring. The study was conducted with all nurses (n=4) in the Rheumatology Department of a large metropolitan Australian teaching hospital. The eDMS was designed as a module of the Hospital Clinical Information System (HCIS) to assist clinicians in monitoring rheumatology patients on DMARDS. Timing data were collected using a modified time and motion work measurement technique using software on a handheld computer. Data included the time nurses spent on documentation regarding medication monitoring before and after the implementation of the eDMS. Results showed that following implementation of the eDMS nurses spent significantly less time documenting medication monitoring information (13.6% to 7.2%, P<.0001). The cumbersome paper-based Drug Monitoring Patient List was replaced entirely by the eDMS. Consequently, there was a significant decrease in the time nurses spent using the HCIS (13.01% to 2.8%, p<.0001) for monitoring and the use of loose-leaf paper also decreased (7.6% to 5.0%, p = 0.002). The eDMS made the process of drug monitoring quicker and simpler for nurses and thus permitted them to increase their time spent in direct patient care.

Picture Archiving and Communication Systems (PACS) allow the fast delivery of imaging studies to clinicians at the point-of-care, supporting quicker decision-making. PACS has the potential to have a significant impact in the Intensive Care Unit (ICU) where critical decisions are made on a daily basis, particularly during ward rounds. We aimed to examine how accessing image information is integrated into ward rounds and if the presence of PACS produced innovations in ward round practices. We observed ward rounds and conducted interviews with ICU doctors at three hospitals with differing levels of PACS availability and computerization. Imaging results were infrequently viewed by clinicians during ward rounds in two ICUs: one without PACS and one which had both PACS and bedside computers. In the third ICU, where PACS was only available at a central workstation, images were frequently viewed throughout the daily round and integrated into decisions about patient care. The presence of bedside computers does not automatically result in innovations to work practice. Despite the ability to utilize PACS at the bedside to support decision-making, use was varied. Research to understand how the complexities and context of the ICU contribute to work practice innovation and why practice changes differ is required.

Doctors are the main users of x-rays and other medical images in hospitals and as such picture archive and communication systems (PACS) have been designed to improve their work processes and clinical care by providing them with faster access to images. Nurses working in intensive care units (ICUs) also access images as an integral part of their work, yet no studies have examined the impact of PACS on the work of intensive care nurses. Our study aimed to examine whether and how ICU nurses view and use images and whether access to PACS promotes innovation in work practices. We interviewed (n=49) and observed (n=23) nurses in three Australian metropolitan teaching hospital ICUs with varying degrees of PACS implementation. Our study found that nurses with access to PACS were able to independently and easily access images, did so more frequently when required, and perceived that this had the potential to positively impact upon patient safety. Those without PACS usually viewed images more traditionally as part of a ward round. The introduction of PACS to ICU settings promotes changes in nursing work practices by providing nurses with the ability to act more autonomously, with the potential to enhance patient care.

Patient transportation is an important component of health-care delivery; however, the quality and safety issues relating to non-emergency patient transport services have rarely been discussed compared with the transport of emergency patients. This systematic review examines the factors associated with the quality and safety of non-emergency transport services. Medline, Pre-Medline, CINAHL and Embase databases were searched for publications between 1990 and September 2009. Articles investigating non-emergency hospital transport services. Study characteristic and outcome data were abstracted by one author and reviewed by a second and third author. Twelve articles from seven countries were included. Five studies examined issues relating to the structure of transport services, which focused on the use of policies and protocols to assist the transfer process. All studies addressed factors associated with the transfer process such as communication, appropriateness of personnel, time to arrange transfers, and the safety and efficiency of the process. Outcomes were measured in one study. Communication, efficiency and appropriateness are key factors that are advanced as impacting on the quality and safety of non-emergency transport services. Standardization of the non-emergency transport process shows promise in reducing risk and increasing efficiency. Applying information and communication technology to improve the quality of transport services has received little attention despite its potential benefits. Patient outcomes in relation to quality and safety of transport services are rarely measured. Available evidence suggests that safety of non-emergency patient transfers is sometimes compromised due to poor standardization and failures in communication processes.

Computerised clinical decision support systems (CDSSs) are used widely to improve quality of care and patient outcomes. This systematic review evaluated the impact of CDSSs in targeting specific aspects of prescribing, namely initiating, monitoring and stopping therapy. We also examined the influence of clinical setting (institutional vs ambulatory care), system- or user-initiation of CDSS, multi-faceted vs stand alone CDSS interventions and clinical target on practice changes in line with the intent of the CDSS.