Utility of Daily Mobile Tablet Use for Residents on an Otolaryngology – Head & Neck Surgery Inpatient Service

Matthew G Crowson MD*, Russel Kahmke MD*, Marisa Ryan MD, Richard L Scher MDDivision of Otolaryngology – Head & Neck Surgery, Department of Surgery, Duke University Health System

Matthew G. Crowson, MDDUMC 2824, Durham, NC 27710Email: matthew.crowson@dm.duke.eduPhone: 919-681-6588

Contact1. Boruff, J.T. and D. Storie, Mobile devices in medicine: a survey of how medical students, residents, and faculty use smartphones and other

mobile devices to find information. J Med Libr Assoc, 2014. 102(1): p. 22-30. 2. Sclafani, J., T.F. Tirrell, and O.I. Franko, Mobile tablet use among academic physicians and trainees. J Med Syst, 2013. 37(1): p. 9903.3. Patel, B.K., et al., Impact of mobile tablet computers on internal medicine resident efficiency. Arch Intern Med, 2012. 172(5): p. 436-8.4. Walsh, C. and P. Stetson, EHR on the move: resident physician perceptions of iPads and the clinical workflow. AMIA Annu Symp Proc, 2012.

2012: p. 1422-30.

References

• Mobile device technology use, specifically tablets and smartphones, is widespread amongst medical students and trainees1,2

• Internal Medicine residency programs at the forefront• A recent University of Chicago survey-based study of 114

Internal Medicine residents3 demonstrated:• 84% believed the devices were a good investment for

the program in both educational and clinical productivity purposes.[3]

• 78% noted that they were more efficient on the wards, with a self-reported time saving of one hour a day

• 56% felt that they could attend more conferences by using their iPads

• 68% reported that patient care delays were averted • A study from the Columbia University Internal Medicine

Residency program demonstrated that there may be direct benefits to patient care with the use of tablets during bedside rounds notably as a non-disruptive means to access the most current patient data4

• Exists at noticeable paucity of similar studies conducted in surgical residency settings

• Most published data describes qualitative metrics without significant mention to quantitative measures like discharge rates, order input efficiency, or monies saved.

Introduction• During the two-week pre-intervention period, 607 pieces of

paper (>50% double sided) was used for patient care and hand-offs

• Pre-rounding prior to formal rounds during the pre-intervention period lasted 30.71 minutes (standard deviation 10.35) versus 37.69 minutes (SD 10.33) in the post-intervention period (p=0.046)

• The duration of formal rounds was shorter in the post-intervention period at 67 minutes (SD 67 minutes) compared to 125 minutes (SD 83 minutes) before intervention (p=0.02)

• There was a trend toward residents needing to leave formal rounds to answer a clinical question less frequently during the post-intervention period

• 2.21 times in pre-intervention (SD 3.72) versus 0.62 times (SD 1.39) in post-intervention, p=0.08

• Residents believed that the tablet device allowed them to document more detail in the medical record (p=0.02), facilitate a faster (p=0.03) and more detailed (p=0.04) transfer of information during sign-out through the use of a tablet device

• There was no significant difference in the number of patients discharged prior to 11 a.m. using tablet devices in the post-intervention period (p=0.28).

Objectives

• Prospective cohort study, 4 consecutive weeks• 2-week pre-intervention period, survey• Implementation of mobile tablet devices • 2-week post-intervention period, survey

• During the pre-intervention period, a tablet or related mobile device was not used by any member of the rounding team

• During the post-intervention period, tablet devices were used to place orders, look up pertinent clinical data, and facilitate education and patient data transfers (handoffs)

• Survey to assess resident reported educational and clinical productivity

Methods and Materials

• By extrapolating these numbers for a full 52-week year, 15,782 pieces of paper would be used

• Paper and ink cost savings• Security for protected patient health

• Pre-rounding took about 7 minutes longer using tablet devices

• Could be related to the novelty of tablet device use• Inpatient rounding was 50% shorter with the use of tablets

• Pull real-time data at point-of care for each patient• Non-significant trend (p=0.08) in the number of times a

resident had to leave rounds to look up data when a tablet was provided

• A study with tablet device use in an Internal Medicine residency program found a similar benefit and deemed the tablet as a valuable and non-disruptive tool for bedside data retrieval4

• 50% of residents believed that tablet devices allowed them to attend more educational conferences

• 70% of the residents felt that the tablets helped them spend more time with patients

• 80% of the residents felt tablets improved morale• Concerns about planned or unforeseen EMR or device

downtime resulting in detriment to patient care

Discussion

• Investigate the effects of mobile tablet technology on resident clinical productivity in an inpatient surgical setting, resident education, and resource utilization

• Evaluate potential economic benefits of the use of mobile tablet technology in place of traditional paper ‘patient list’ formats

Results

• Thirteen Otolaryngology – Head & Neck Surgery residents serving on the Duke University Medical Center inpatient service

• General Otolaryngology, Head & Neck cancer, Laryngology, Rhinology, Pediatrics, and Otology subspecialties

• Experience levels included residents from Post-Graduate Year (PGY) 1 through PGY-5.

Participants

  Mean% (Std. Dev)  Pre-Intervention Post-Intervention p-value

“I am excited to use the tablet” 1.69 1.60 0.38“Having a tablet facilitated faster patient discharges” 2.46 2.20 0.24“I feel that having a tablet facilitated more detailed transfer of information during sign-out to peers” 2.54 1.70 0.04“I feel that having a tablet facilitated faster transfer of information during sign-out to peers” 2.54 1.80 0.03

“I feel that I now document more detail in the medical record through the use of a tablet for EMR access” 2.77 1.89 0.02“I feel that I am able to execute treatment plans more quickly for inpatients now that I have a tablet” 2.08 1.78 0.23

“I feel that I am more likely to look up radiological or laboratory studies on inpatients more often now that I have a tablet” 2.08 1.56 0.09

“I feel that I am more likely to order tests or radiological studies on patients more often now that I have a tablet” 3.00 2.50 0.11

Mean (Std. Dev)Pre-Intervention Post-Intervention p-value

Duration of Pre-Rounds 30.71 mins (10.35) 37.69 mins (10.33) 0.05Duration of Formal Rounds 2:05 hours (1:23) 1:07 hours (1:07) 0.02#of inpatients 5.64 (1.65) 4.85 (1.68) 0.11# of consult patients 10.54 (2.15) 8.85 (2.44) 0.04# of times rounds left to answer clinical question 2.21 (3.72) 0.62 (1.39) 0.08# of discharges pending in 24h period 1.57 (1.50) 1.62 (1.66) 0.47# of discharges completed prior to 11:00am. 0.71 (0.91) 1.00 (1.47) 0.28

Conclusions• The utility of mobile tablet devices coupled with the

electronic medical record appeared to have both quantitative and qualitative improvements in clinical efficiency and education

• In the era of duty hour restrictions and higher clinical volumes, time saved on daily rounding and in the handoff process can be repurposed for more important clinical and educational responsibilities

• Considering the potential benefits outlined above, we feel that tablets should be encouraged but not mandated for clinical and educational use