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      Prospective evaluation of an internet-linked handheld computer critical care knowledge access system

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          Abstract

          Introduction

          Critical care physicians may benefit from immediate access to medical reference material. We evaluated the feasibility and potential benefits of a handheld computer based knowledge access system linking a central academic intensive care unit (ICU) to multiple community-based ICUs.

          Methods

          Four community hospital ICUs with 17 physicians participated in this prospective interventional study. Following training in the use of an internet-linked, updateable handheld computer knowledge access system, the physicians used the handheld devices in their clinical environment for a 12-month intervention period. Feasibility of the system was evaluated by tracking use of the handheld computer and by conducting surveys and focus group discussions. Before and after the intervention period, participants underwent simulated patient care scenarios designed to evaluate the information sources they accessed, as well as the speed and quality of their decision making. Participants generated admission orders during each scenario, which were scored by blinded evaluators.

          Results

          Ten physicians (59%) used the system regularly, predominantly for nonmedical applications (median 32.8/month, interquartile range [IQR] 28.3–126.8), with medical software accessed less often (median 9/month, IQR 3.7–13.7). Eight out of 13 physicians (62%) who completed the final scenarios chose to use the handheld computer for information access. The median time to access information on the handheld handheld computer was 19 s (IQR 15–40 s). This group exhibited a significant improvement in admission order score as compared with those who used other resources ( P = 0.018). Benefits and barriers to use of this technology were identified.

          Conclusion

          An updateable handheld computer system is feasible as a means of point-of-care access to medical reference material and may improve clinical decision making. However, during the study, acceptance of the system was variable. Improved training and new technology may overcome some of the barriers we identified.

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          Qualitative evaluation and research methods

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            Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review.

            Intensive care unit (ICU) physician staffing varies widely, and its association with patient outcomes remains unclear. To evaluate the association between ICU physician staffing and patient outcomes. We searched MEDLINE (January 1, 1965, through September 30, 2001) for the following medical subject heading (MeSH) terms: intensive care units, ICU, health resources/utilization, hospitalization, medical staff, hospital organization and administration, personnel staffing and scheduling, length of stay, and LOS. We also used the following text words: staffing, intensivist, critical, care, and specialist. To identify observational studies, we added the MeSH terms case-control study and retrospective study. Although we searched for non-English-language citations, we reviewed only English-language articles. We also searched EMBASE, HealthStar (Health Services, Technology, Administration, and Research), and HSRPROJ (Health Services Research Projects in Progress) via Internet Grateful Med and The Cochrane Library and hand searched abstract proceedings from intensive care national scientific meetings (January 1, 1994, through December 31, 2001). We selected randomized and observational controlled trials of critically ill adults or children. Studies examined ICU attending physician staffing strategies and the outcomes of hospital and ICU mortality and length of stay (LOS). Studies were selected and critiqued by 2 reviewers. We reviewed 2590 abstracts and identified 26 relevant observational studies (of which 1 included 2 comparisons), resulting in 27 comparisons of alternative staffing strategies. Twenty studies focused on a single ICU. We grouped ICU physician staffing into low-intensity (no intensivist or elective intensivist consultation) or high-intensity (mandatory intensivist consultation or closed ICU [all care directed by intensivist]) groups. High-intensity staffing was associated with lower hospital mortality in 16 of 17 studies (94%) and with a pooled estimate of the relative risk for hospital mortality of 0.71 (95% confidence interval [CI], 0.62-0.82). High-intensity staffing was associated with a lower ICU mortality in 14 of 15 studies (93%) and with a pooled estimate of the relative risk for ICU mortality of 0.61 (95% CI, 0.50-0.75). High-intensity staffing reduced hospital LOS in 10 of 13 studies and reduced ICU LOS in 14 of 18 studies without case-mix adjustment. High-intensity staffing was associated with reduced hospital LOS in 2 of 4 studies and ICU LOS in both studies that adjusted for case mix. No study found increased LOS with high-intensity staffing after case-mix adjustment. High-intensity vs low-intensity ICU physician staffing is associated with reduced hospital and ICU mortality and hospital and ICU LOS.
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              Physician Staffing Patterns and Clinical Outcomes in Critically Ill Patients

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                Author and article information

                Journal
                Crit Care
                Critical Care
                BioMed Central (London )
                1364-8535
                1466-609X
                2004
                14 October 2004
                : 8
                : 6
                : R414-R421
                Affiliations
                [1 ]Director, Technology Application Unit and Site Director, Intensive Care Unit, Mount Sinai Hospital & Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
                [2 ]Director, Human Simulation, Technology Application Unit and Intensive Care Unit, Mount Sinai Hospital & Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
                [3 ]Research Coordinator, Technology Application Unit, Intensive Care Unit, Mount Sinai Hospital, Toronto, Ontario, Canada
                [4 ]Biostatistician, Intensive Care Unit, Mount Sinai Hospital, Toronto, Ontario, Canada
                [5 ]Research Director, Intensive Care Unit, Mount Sinai Hospital & Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
                [6 ]ICU Pharmacist, Intensive Care Unit, Mount Sinai Hospital, Toronto, Ontario, Canada
                [7 ]Director of Critical Care, Mount Sinai Hospital and University Health Network & Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
                Article
                cc2967
                10.1186/cc2967
                1065064
                15566586
                51117011-c618-4516-90fc-75723316713b
                Copyright © 2004 Lapinsky et al., licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is cited.

                History
                : 13 August 2004
                : 2 September 2004
                Categories
                Research

                Emergency medicine & Trauma
                decision support systems,critical care,simulation,handheld,clinical,point-of-care systems,internet,computer,practice guidelines

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