Aims and objectives
To explore the impact of implementing an electronic health record system on staff at a Scottish hospice.
Background
Electronic health records are broadly considered preferable to paper‐based systems. However, changing from one system to the other is difficult. This study analysed the impact of this change in a Scottish hospice.
Design
Naturalistic prospective repeated‐measures mixed‐methods approach.
Methods
Data on the usability of the system, staff engagement and staff experience were obtained at four time points spanning 30 months from inception. Quantitative data were obtained from surveys, and qualitative from concurrent analysis of free‐text comments and focus group. Participants were all 150 employees of a single hospice in Scotland.
Results
Both system usability and staff engagement scores decreased for the first two years before recovering at 30 months. Staff experience data pointed to two main challenges: (1) Technical issues, with subthemes of accessibility and usability. (2) Cultural issues, with subthemes of time, teamwork, care provision and perception of change.
Conclusions
It took 30 months for system usability and staff engagement scores to rise, after falling significantly for the first two years. The unintended outcomes of implementation included challenges to the way the patient story was both recorded and communicated. Nevertheless, this process of change was found to be consistent with the ‘J‐curve’ theory of organisational change, and as such, it is both predictable and manageable for other organisations.
Relevance to clinical practice
It is known that implementing an electronic health record system is complex. This paper puts parameters on this complexity by defining both the nature of the complexity (‘J’ curve) and the time taken for the organisation to begin recovery from the challenges (two years). Understanding these parameters will help health organisations across the world plan more strategically.
Clinicians have no clear evidence to follow in either treating death rattle or preventing it occurring. However, several risk factors look promising candidates for prospective analysis, so this review concludes with clear recommendations for further research.
Introduction Long-term abdominal drains (LTADs) prevent ascites build-up, improve quality of life (QOL) and reduce hospital admissions for patients with refractory ascites. In NHS Grampian patients with decompensated end-stage liver disease (ESLD) not suitable for transplant or TIPSS are offered an informed choice between repeated large-volume paracentesis (LVP) and LTAD. In NHSG, LTADs are inserted by Palliative Medicine physicians. Methods • Retrospective data collection/analysis for ESLD patients who underwent LTAD insertion in NHSG between 2020-2022. Results 23 ESLD patients underwent LTAD insertion. 8 further patients were referred for LTAD but died before insertion. In the 3 months prior to LTAD, patients had an average of 3 admissions for LVP (range 1-6). The mean number of days between LTAD insertion and death was 59 (range 7-320). LTAD insertion prevented a mean of 2 further admissions for LVP per patient (range 0-10). 74% had no complications and either had LTAD in until death, or are still alive. 2 patients (9%) had infections; 1 resolved with antibiotics, 1 required drain removal. 4 patients (15%) accidentally had their LTADs pulled out or damaged. Prior to LTAD, 65% of patients had no evidence of advance care planning (ACP). Post-LTAD, 74% of patients had an improvement in documented ACP. Only 17% of patients died in an acute hospital, the majority dying at home or in a palliative care unit or community hospital. Conclusion The majority of patients had no complications from LTAD and it remained in situ until death, reducing hospital admissions and allowing more time at home. 74% had improvement in ACP documentation after LTAD insertion, and only 17% of patients died in an acute hospital, compared to the national figure of 73%. Having Palliative Medicine physicians running the LTAD service allows early introduction of Palliative Care for decompensated ESLD patients and offers the opportunity for holistic assessment and ACP discussions.
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