This paper describes the development and evaluation of an innovative application designed to engage children and their parents in weekly asthma self-monitoring and self-management to prompt an early response to deteriorations in chronic asthma control, and to provide their physicians with longitudinal data to assess the effectiveness of asthma therapy and prompt adjustments. The evaluation included 2 iterative usability testing cycles with 6 children with asthma and 2 parents of children with asthma to assess user performance and satisfaction with the application. Several usability problems were identified and changes were made to ensure acceptability of the application and relevance of the content. This novel application is unique compared to existing asthma tools and may shift asthma care from the current reactive, acute care model to a preventive, proactive patient-centered approach where treatment decisions are tailored to patients’ individual patterns of chronic asthma control to prevent acute exacerbations.

Background

In 2003 the Accreditation Council for Graduate Medical Education mandated work hour restrictions. Violations can results in a residency program being cited or placed on probation. Recurrent violations could results in loss of accreditation. We wanted to determine specific intern and workload factors associated with violation of a specific mandate, the 30-hour duty period requirement.

Methods

Retrospective review of interns’ performance against the 30-hour duty period requirement during inpatient ward rotations at a pediatric residency program between June 24, 2008 and June 23, 2009. The analytical plan included both univariate and multivariable logistic regression analyses.

Results

Twenty of the 26 (77%) interns had 80 self-reported episodes of continuous work hours greater than 30 hours. In multivariable analysis, noncompliance was inversely associated with the number of prior inpatient rotations (odds ratio: 0.49, 95% confidence interval (0.38, 0.64) per rotation) but directly associated with the total number of patients (odds ratio: 1.30 (1.10, 1.53) per additional patient). The number of admissions on-call, number of admissions after midnight and number of discharges post-call were not significantly associated with noncompliance. The level of noncompliance also varied significantly between interns after accounting for intern experience and workload factors. Subject to limitations in statistical power, we were unable to identify specific intern characteristics, such as demographic variables or examination scores, which account for the variation in noncompliance between interns.

Conclusions

Both intern and workload factors were associated with pediatric intern noncompliance with the 30-hour duty period requirement during inpatient ward rotations. Residency programs must develop information systems to understand the individual and experience factors associated with noncompliance and implement appropriate interventions to ensure compliance with the duty hour regulations.

To reduce readmission risk in children hospitalized with asthma, The Joint Commission (JC) mandated hospitals to initiate preventive measures and provide patients/caregivers with a home management plan of care (HMPC) at discharge. Standard methods for recording HMPC compliance require hospitals to commit considerable resources. We developed an asthma-specific “reminder and decision support” (RADS) system to facilitate patient discharge while supporting many clinical and administrative needs, including: 1) providers’ compliance with asthma preventive measures, 2) creation of patient’s discharge instructions, 3) recording HMPC components for JC accreditation, and 4) creation of discharge summaries with auto-faxing mechanism to primary care providers for follow-up. RADS resulted in significant increased and sustained HMPC compliance (73% vs. 89%, p<0.01) and reduced labor time (53 vs. 15 hours/week, p=0.02) compared to standard methods. Most quality improvement interventions achieve short-term goals, but long-term improvements require decision support tools that support multiple needs while minimizing resource use.

Information technology can improve healthcare efficiency. We developed and implemented a simple and inexpensive tool, the “Automated Case Finding and Alerting System” (ACAS), using data from an existing clinical information system to facilitate identification of potentially eligible patients for clinical trials and patient encounters for billing purposes. We validated the ACAS by calculating the level of agreement in patient identification with data generated from manual identification methods. There was substantial agreement between the two methods both for clinical trial (kappa:0.84) and billing (kappa:0.97). Automated identification occurred instantaneously vs. about 2 hours/day for clinical trial and 1 hour 10 minutes/day for billing, and was inexpensive ($98.95, one time fee) compared to manual identification ($1,200/month for clinical trial and $670/month for billing). Automated identification was more efficient and cost-effective than manual identification methods. Repurposing clinical information beyond their traditional use has the potential to improve efficiency and decrease healthcare cost.

The Liaison Committee for Medical Education requires monitoring of the students’ clinical experiences. Student logs, typically used for this purpose, have a number of limitations. We used an electronic system called Patient Tracker to passively generate student encounter data. The data contained in Patient Tracker was compared to the information reported on student logs and data abstracted from the patients’ charts. Patient Tracker identified 30% more encounters than the student logs. Compared to the student logs, Patient Tracker contained a higher average number of diagnoses per encounter (2.28 vs. 1.03, p<0.01). The diagnostic data contained in Patient Tracker was also more accurate under 4 different definitions of accuracy. Only 1.3% (9/677) of diagnoses in Patient Tracker vs. 16.9% (102/601) diagnoses in the logs could not be validated in patients’ charts (p<0.01). Patient Tracker is a more effective and accurate tool for documenting student clinical encounters than the conventional student logs.

Hospital bed demands sometimes exceed capacity, leading to delays in patient admissions, transfers and cancellations of surgical procedures. Effective strategies must be in place for an efficient use of existing beds. Establishing such strategies at academic hospitals poses serious challenges. We developed and implemented a web-based software application called “Patient Tracker” to manage the discharge process, minimize delays in admission and reduce surgical procedure cancellations. We also tested the effectiveness of the software on the work flow by comparing outcomes between the pre-implementation control group (2002–2003) and the post-implementation experimental group (2003–2006). Following the implementation of the software, the number of cancelled surgical procedures decreased (120 vs. 12, p<0.01). During the same period, the average number of inpatient admissions increased (5725 vs. 6120), and the median emergency department LOS decreased (247 vs. 232, p<0.01).