Maysam Ali Abdulwahid

Background: Interoperable networks connect information technology systems of different organisations, allowing professionals in one organisation to access patient data held in another one. Health policy-makers in many countries believe that they will improve the co-ordination of services and, hence, the quality of services and patient safety. To the best of our knowledge, there have not been any previous systematic reviews of the effects of these networks on patient safety. Objectives: The aim of the study was to establish how, why and in what circumstances interoperable information technology networks improved patient safety, failed to do so or increased safety risks. The objectives of the study were to (1) identify programme theories and prioritise theories to review; (2) search systematically for evidence to test the theories; (3) undertake quality appraisal, and use included texts to support, refine or reject programme theories; (4) synthesise the findings; and (5) disseminate the findings to a range of audiences. Design: Realist synthesis, including consultation with stakeholders in nominal groups and semistructured interviews. Settings and participants: Following a stakeholder prioritisation process, several domains were reviewed: older people living at home requiring co-ordinated care, at-risk children living at home and medicines reconciliation services for any patients living at home. The effects of networks on services in health economies were also investigated. Intervention: An interoperable network that linked at least two organisations, including a maximum of one hospital, in a city or region. Outcomes: Increase, reduction or no change in patients’ risks, such as a change in the risk of taking an inappropriate medication. Results: We did not find any detailed accounts of the ways in which interoperable networks are intended to work and improve patient safety. Theory fragments were identified and used to develop programme and mid-range theories. There is good evidence that there are problems with the co-ordination of services in each of the domains studied. The implicit hypothesis about interoperable networks is that they help to solve co-ordination problems, but evidence across the domains showed that professionals found interoperable networks difficult to use. There is insufficient evidence about the effectiveness of interoperable networks to allow us to establish how and why they affect patient safety. Limitations: The lack of evidence about patient-specific measures of effectiveness meant that we were not able to determine ‘what works’, nor any variations in what works, when interoperable networks are deployed and used by health and social care professionals. Conclusions: There is a dearth of evidence about the effects of interoperable networks on patient safety. It is not clear if the networks are associated with safer treatment and care, have no effects or increase clinical risks. Future work: Possible future research includes primary studies of the effectiveness of interoperable networks, of economies of scope and scale and, more generally, on the value of information infrastructures. Study registration: This study is registered as PROSPERO CRD42017073004. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 40. See the NIHR Journals Library website for further project information.

Background: There is a widespread belief that information technologies will improve diagnosis, treatment and care. Evidence about their effectiveness in health care is, however, mixed. It is not clear why this is the case, given the remarkable advances in hardware and software over the last 20 years. This review focuses on interoperable information technologies, which governments are currently advocating and funding. These link organisations across a health economy, with a view to enabling health and care professionals to coordinate their work with one another and to access patient data wherever it is stored. Given the mixed evidence about information technologies in general, and current policies and funding, there is a need to establish the value of investments in this class of system. The aim of this review is to establish how, why and in what circumstances interoperable systems affect patient safety. Methods: A realist synthesis will be undertaken, to understand how and why inter-organisational systems reduce patients’ clinical risks, or fail to do so. The review will follow the steps in most published realist syntheses, including (1) clarifying the scope of the review and identifying candidate programme and mid-range theories to evaluate, (2) searching for evidence, (3) appraising primary studies in terms of their rigour and relevance and extracting evidence, (4) synthesising evidence, (5) identifying recommendations, based on assessment of the extent to which findings can be generalised to other settings. Discussion: The findings of this realist synthesis will shed light on how and why an important class of systems, that span organisations in a health economy, will contribute to changes in patients’ clinical risks. We anticipate that the findings will be generalizable, in two ways. First, a refined mid-range theory will contribute to our understanding of the underlying mechanisms that, for a range of information technologies, lead to changes in clinical practices and hence patients’ risks (or not). Second, many governments are funding and implementing cross-organisational IT networks. The findings can inform policies on their design and implementation. Systematic review registration: PROSPERO CRD42017073004

Background Optimising the efficiency and productivity of senior doctors is critical to ED function and delivery of safe patient care. Time and motion studies (TMS) can allow quantification of how these doctors spend their working time, identify inefficiencies in the current work processes and provide insights into improving working conditions, and enhancing productivity. Three questions were addressed: (1) How do senior emergency doctors spend their time in the ED? (2) How much of their time is spent on multitasking? (3) What is the number of tasks completed per hour? Methods The literature was systematically searched for TMS of senior emergency doctors. We searched for articles published in peer-reviewed journals in English language from 1998 to 2018 in the following databases: MEDLINE, EMBASE, Scopus, Web of Science and Cochrane. Studies were assessed for methodological quality using evidence-based quality criteria relevant for TMS including duration of observation, observer bias, Hawthorne effect and whether the task classification acknowledged any previous existing schemes. A narrative synthesis approach was followed. Results Fourteen TMS were included. The studies were liable to several biases including observer and Hawthorne bias. Overall, the time spent on direct face-to-face contact with the patient accounted for at least around 25%–40% of the senior doctors’ time. The remaining time was mostly spent on indirect clinical care such as communication (8%–44%), documentation (10%–28%) and administrative tasks (2%–20%). The proportion of time spent on multitasking ranged from 10% to 23%. When reported, the number of tasks performed per hour was generally high. Conclusion The review revealed that senior doctors spent a large percentage of their time on direct face-to-face contact with patients. The review findings provided a grounded understanding of how senior doctors spent their time in the ED and could be useful in implementing improvements to the emergency care system.

Introduction Despite the focus during the last decade on introducing interventions such as senior doctor initial assessment or senior doctor triage (SDT) to reduce emergency department (ED) crowding, there has been little attempt to identify the views of emergency healthcare professionals on such interventions. The aim of this study was to gain an understanding of SDT from the perspective of emergency hospital staff. A secondary aim of this study was to develop a definition of SDT based on the interview findings and the available literature on this process. Methods Qualitative semi-structured telephone interviews were conducted with participants of different backgrounds including senior doctors, nurses, paramedics and ED managers. Textual data were analysed using a template analysis approach. Results 27 participants from 13 EDs across England were interviewed. SDT was viewed as a safety mechanism and a measure to control patient flow. The most prominent positive aspect was the ability to initiate early investigations and treatment. Various shortcomings of SDT were described such as the lack of standardisation of the process and its cost implications. Participants identified a number of barriers to this process including insufficient resources and exit block, and called for solutions focused on these issues. A proposed definition of an ‘ideal’ SDT was developed where it is described as a systematic brief assessment of patients arriving at the ED by a senior doctor-led team, which takes place in a dedicated unit. The aim of this assessment is to facilitate early investigation and management of patients, early patient disposition and guide junior staff to deliver safe and high-quality clinical care. Conclusion This is the first national study to explore the opinions of various emergency and managerial staff on the SDT model. It revealed variable interpretations of this model and what it can and cannot offer. This has led to a standard definition of the SDT process, which can be useful for clinicians and researchers in emergency care.