Improve Clinician Satisfaction Research Articles

Toward Alleviating Clinician Documentation Burden: A Scoping Review of Burden Reduction Efforts.

Studies have shown that documentation burden experienced by clinicians may lead to less direct patient care, increased errors, and job dissatisfaction. Implementing effective strategies within health care systems to mitigate documentation burden can result in improved clinician satisfaction and more time spent with patients. However, there is a gap in the literature regarding evidence-based interventions to reduce documentation burden. The objective of this review was to identify and comprehensively summarize the state of the science related to documentation burden reduction efforts. Following Joanna Briggs Institute Manual for Evidence Synthesis and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines, we conducted a comprehensive search of multiple databases, including PubMed, Medline, Embase, CINAHL Complete, Scopus, and Web of Science. Additionally, we searched gray literature and used Google Scholar to ensure a thorough review. Two reviewers independently screened titles and abstracts, followed by full-text review, with a third reviewer resolving any discrepancies. Data extraction was performed and a table of evidence was created. A total of 34 articles were included in the review, published between 2016 and 2022, with a majority focusing on the United States. The efforts described can be categorized into medical scribes, workflow improvements, educational interventions, user-driven approaches, technology-based solutions, combination approaches, and other strategies. The outcomes of these efforts often resulted in improvements in documentation time, workflow efficiency, provider satisfaction, and patient interactions. This scoping review provides a comprehensive summary of health system documentation burden reduction efforts. The positive outcomes reported in the literature emphasize the potential effectiveness of these efforts. However, more research is needed to identify universally applicable best practices, and considerations should be given to the transfer of burden among members of the health care team, quality of education, clinician involvement, and evaluation methods.

Back to Babies: Reducing Documentation Time in the NICU

Abstract Background There is no accepted best practice for generation and content of daily progress notes in the neonatal intensive care unit (NICU). Objectives This study aimed to implement a consistent documentation standard process for a neonatology provider group at a level IV tertiary care NICU. The primary aim was to improve timeliness of daily progress note completion. Secondary aims were to maintain or improve clinician satisfaction, reduce variability, and reduce attending neonatologist electronic medical record (EMR) documentation tasks. Methods We formed a work group including advanced practice providers (APPs) and physicians from the NICU that met over 6 months to define the ideal NICU documentation content, map the workflow for documentation, identify gaps in EMR content, and create solutions for each gap. Baseline assessment included a change readiness survey to identify barriers to workflow change and a review of neonatologist signature timestamp to determine time to note completion. Twenty random progress notes were sampled weekly for 6 months prior to implementation of new workflow as well as 6 months postimplementation. Average time to note completion was compared in the pre- and postintervention groups. Results In total, 962 notes were sampled, 481 each in the pre- and postintervention states. Twenty neonatologists were captured in the preintervention state, 24 in the postintervention state, 18 were captured in both samples. Final note completion time mean improved from 10 hours and 32 minutes (from starting note to final sign) to 8 hours and 40 minutes (p < 0.01). Those sampled in both epochs improved from 10 hours and 6 minutes to 8 hours and 30 minutes (p < 0.05). Conclusion Progress notes generated by neonatologists are completed earlier than those generated by an APP with a Neonatologist addendum. Specialty-specific education and training are critical to high satisfaction in large EMR workflow transitions.

Pairing a medical scribe with a hospitalist physician improved clinician satisfaction, increased productivity and provided a return on investment

Pairing a medical scribe with a hospitalist physician improved clinician satisfaction, increased productivity and provided a return on investment

The effect of remote scribes on primary care physicians’ wellness, EHR satisfaction, and EHR use

BackgroundPhysician burnout is a major problem in the United States. Small studies suggest scribes can improve clinician satisfaction, but scribe programs have not been evaluated using separate control groups or structured measures of electronic health record (EHR) use. MethodsWe conducted a pre-post, non-randomized controlled evaluation of a remote scribe pilot program introduced in September 2019 in an academic primary care practice. Scribes were paired with physicians via an audio-only cellphone connection to hear and document in real-time. Physician wellness was measured with the 10-item Mini-Z and 16-item Professional Fulfillment Index. EHR use was measured using vendor-derived platforms that provide routine EHR-related data. Results37 of 38 scribe users (97.4%) and 68 of 160 potential control physicians (42.5%) completed both pre and post intervention questionnaires. Compared with controls, scribe users had improvements in Mini-Z wellness metrics including Joyful Workplace (mean improvement 2.83, 95%CI 0.60, 5.06) and a single-item dichotomized burnout measure (OR 0.15, 95%CI 0.03, 0.71). There were significant reductions among scribe users compared to controls in total EHR time per 8 scheduled hours (−1.14 h, 95%CI -1.55, −0.72), and an increase in the percentage of orders with team contribution (10.4%, 95%CI 5.2, 15.6). These findings remained significant in adjusted analyses. Conclusions/implicationsA remote scribe program was associated with improvements in physician wellness and reduced EHR use. Healthcare organizations can consider scribe programs to help improve wellness among their physician workforce.

Enhancing a Rehabilitation Pathway for Pediatric Heart Transplant Recipients: An Improvement Project to Increase Adherence, Satisfaction, and Outcomes

Aims To refine a cardiac rehabilitation pathway for pediatric heart transplant recipients; assess clinician knowledge and adherence to the program; and evaluate patient outcomes. Methods The center has utilized a rehabilitation pathway for pediatric heart transplant recipients. Challenges in practice include access to centers, lack of data tracing, and adherence to the pathway. The quality initiative focused on program refinements: implementation of text templates to improve data collection, collection of the Pediatric Cardiac Quality of Life Inventory (PCQLI), Functional Independence Measure (WeeFIM) and Child Occupational Self-Assessment (COSA), development of an outreach program, and creation of an educational program for therapists to increase content knowledge and improve clinician satisfaction. Results In the evaluation of rehabilitation follow-up post-transplant, there was no statistical significance between the pre- and post-implementation groups. After the implementation of the refined pathway, there was an increase in the completion of the six-minute walk test post-transplant (p = 0.048). Clinicians’ responses post educational session noted familiarity with the pathway (88%), documentation (78.8%), and outcome measures (97%). Results of outcomes noted improvement in six-minute walk distances and a decrease in the rate of perceived exertion post-transplant. To ensure future pathway adherence, clinical support should be implemented, and key players identified to maintain sustainability.

Standardized Patient Education for Decompensated Cirrhotic Patients and Impact on Clinician Satisfaction.

The development of ascites in patients with cirrhosis can cause numerous complications including abdominal discomfort, pain, respiratory distress, decreased mobility, diminished quality of life, and contributes to an increased mortality. Symptom self-monitoring that incorporates evidence-based treatments has been effective when used by patients with noncirrhotic chronic diseases. Guided by the theory of Self-Care of Chronic Illness, a self-monitoring guide was adapted from an existing validated tool. In the context of a pilot quality initiative, staff nurses educated patients with ascites and their caregivers, with the adapted symptom self-monitoring guide using a standardized process. Clinicians were surveyed regarding their satisfaction with the patient education pre- and post-implementation. Results indicated improved clinician satisfaction with the education provided to patients and their caregivers during the clinic visit. Implementation of self-monitoring may improve clinician and patient satisfaction and clinic workflows. Additional evaluation of the self-monitoring guide and its effect on patient satisfaction, impact on hospital admissions, and outpatient paracentesis is warranted.

HITECH to 21st century cures: clinician burden and evolving health IT policy.

Adoption and use of health information technology (IT) was identified as 1 solution to quality and safety issues that permeate the United States health care system. Implementation of health IT has accelerated across the US over the past decade, in part, as a result of legislative and regulatory requirements and incentives. However, adoption of these systems has burdened clinician users due to design, configuration, and implementation issues, resulting in poor usability, challenges to workflow integration, and cumbersome documentation requirements. The path to alleviating these clinician burdens requires a clear understanding of the intent and evolution of pertinent regulations and the context in which they exist. This article reviews the Office of the National Coordinator of Health Information Technology's efforts, documents current regulatory actions, and discusses additional policy opportunities that can further improve clinician satisfaction and effectiveness in providing health care with health IT that is an asset, not an obstacle.

Reliability and validity of Midwifery - Obstetrics Collaboration (MOC) scale: A tool to improve collaborative practice

ObjectiveIn recent decades, there has been a call to foster effective collaborative models of practice between midwives and obstetricians/gynecologists (OB/GYNs) in the United States in order to improve clinician satisfaction and outcomes for childbearing women. Currently, there is no existing validated scale that measures the collaboration between obstetricians and midwives on labor and birth units. We sought to develop and validate a Midwifery- Obstetrics Collaboration (MOC) Scale that measures obstetricians’ attitudes towards collaboration between obstetricians and midwives on labor and birth units. DesignValidation study. The items in the questionnaire to be validated were developed de novo by the authors, based on their experiences and expertise in collaborative practice as well as by incorporating key principles of effective collaborative practice documented in the literature. The questionnaire was then piloted among 13 content experts. SettingAnonymous online survey conducted in the United States. ParticipantsWe validated the questionnaire among 471 obstetricians in the United States from Sept 2019 to March 2020. The respondents included general obstetrician and gynecologists (OB/GYN) attendings, OB/GYN hospitalists, maternal fetal medicine (MFM) fellows and MFM attendings who practice on a labor and birth unit in the United States. Measurements and findingsWe performed reliability analysis of the a priori items. We measured concurrent validity with an existing scale that measures inter-professional collaboration between nurses and physicians. We also correlated our scale with concerns for liability when working in a collaborative practice with midwives. Lastly, we measured discriminant validity with a single item burn out scale. The novel MOC Scale demonstrated construct and concurrent validity, and high inter-item reliability (a=0.93). The MOC Scale correlated with concerns about liability (r=0.63, p <0.001) but was not associated with burnout indicating the uniqueness of the new construct. Key conclusionsThe MOC Scale is validated to assess collaboration between obstetricians and midwives on labor and birth units from an obstetrician's perspective Implications for practiceThe MOC Scale can be used as a tool in clinical practice, to assess and foster effective collaboration between obstetricians and midwives from an obstetricians’ perspective especially when used in conjunction with other tools that take into the account the perspectives of midwives and childbearing women.

Digitizing Infectious Disease Clinical Guidelines for Improved Clinician Satisfaction.

The purpose of this project was to implement an improved rapid-deployment clinical decision support strategy for the detection and treatment of emerging and reemerging infectious diseases within an electronic health record informed by end-user satisfaction. After a review of the evidence and comprehensive workflow assessments, interdisciplinary focus groups were assembled to determine current infectious disease needs within the electronic health record and what guidance should be provided to clinicians to assist in making the best decisions for both patient care and population health. Education and reeducation issues were handled throughout the implementation process. Using the Plan-Do-Study-Act quality improvement framework for rapid cycle deployment, the design was implemented and monitored. To evaluate efficacy and clinician satisfaction of the implementation, presurvey and postsurvey measurements were employed. The Clinical Information System Implementation Evaluation Scale was used, along with demographic and qualitative textual questions, to evaluate clinician satisfaction. Findings indicate the implementation was successful (P < .05).

Characteristics of Health Care Organizations Associated With Clinician Trust

There is new emphasis on clinician trust in health care organizations but little empirical data about the association of trust with clinician satisfaction and retention. To examine organizational characteristics associated with trust. This prospective cohort study uses data collected from 2012 to 2014 from 34 primary care practices employing physicians (family medicine and general internal medicine) and advanced practice clinicians (nurse practitioners and physician assistants) in the upper Midwest and East Coast of the United States as part of the Healthy Work Place randomized clinical trial. Analyses were performed from 2015 to 2016. Clinician trust was measured using a 5-item scale, including belonging, loyalty, safety focus, sense of trust, and responsibility to clinicians in need (range, 1-4, with 1 indicating low and 4 indicating high; Cronbach α = 0.77). Other metrics included work control, work atmosphere (calm to chaotic), organizational culture (cohesiveness, emphases on quality and communication, and values alignment; range, 1-4, with 1 indicating low and 4 indicating high), and clinician stress (range, 1-5, with 1 indicating low and 5 indicating high), satisfaction (range, 1-5, with 1 indicating low and 4 indicating high), burnout (range, 1-5, with 1 indicating no burnout and 5 indicating very high feeling of burnout), and intention to leave (range, 1-5, with 1 indicating no intention to leave and 5 indicating definite intention to leave). Analyses included 2-level hierarchical modeling controlling for age, sex, specialty, and clinician type. Cohen d effect sizes (ESs) were considered small at 0.20, moderate at 0.50, and large at 0.80 or more. The study included 165 clinicians (mean [SD] age, 47.3 [9.2] years; 86 [52.1%] women). Of these, 143 (87.7%) were physicians and 22 (13.3%) were advanced practice clinicians; 105 clinicians (63.6%) worked in family medicine, and 60 clinicians (36.4%) worked in internal medicine. Compared with clinicians with low levels of trust, clinicians who reported high levels of trust had higher mean (SD) scores for work control (2.49 [0.52] vs 2.18 [0.45]; P < .001), cohesiveness (3.11 [0.46] vs 2.51 [0.51]; P < .001), emphasis on quality vs productivity (3.12 [0.48] vs 2.58 [0.41]; P < .001), emphasis on communication (3.39 [0.41] vs 3.01 [0.44]; P < .001), and values alignment (2.61 [0.59] vs 2.12 [0.52]; P < .001). Men were more likely than women to express loyalty (ES, 0.35; 95% CI, 0.05-0.66; P = .02) and high trust (ES, 0.31; 95% CI, 0.01-0.62; P = .04). Compared with clinicians with low trust at baseline, clinicians with high trust at baseline had a higher mean (SD) satisfaction score (3.99 [0.08] vs 3.51 [0.07]; P < .001; ES, 0.70; 95% CI, 0.39-1.02). Compared with clinicians in whom trust declined or remained low, clinicians with improved or stable high trust reported higher mean (SD) satisfaction (4.01 [0.07] vs 3.43 [0.06]; P < .001; ES, 0.98; 95% CI, 0.66-1.31) and lower stress (3.21 [0.09] vs 3.53 [0.09]; P = .02; ES, -0.39; 95% CI, -0.70 to -0.08) scores and had approximately half the odds of intending to leave (odds ratio, 0.481; 95% CI, 0.241-0.957; P = .04). Addressing low levels of trust by improving work control and emphasizing quality, cohesion, communication, and values may improve clinician satisfaction, stress, and retention.

Availability of Resources for After-Hours Surgical Management of Eye Injuries

Background Approximately 2.4 million eye injuries per year occur in the United States. Because of the complexity of these injuries, many of these cases present to academic institutions. Ophthalmology residency programs have a wide range of resources available for eye injuries requiring after-hours surgical intervention. Purpose The purpose of this study was to determine availability of resources for after-hours eye surgery and their effect on clinician satisfaction. Methods Association of University Professors of Ophthalmology (AUPO) program directors were surveyed to assess the availability of eye-trained operating room (OR) nurses, functional operating microscopes, and suitable surgical supplies. The primary outcome measure was the availability of resources for after-hours eye surgery. Secondary outcome measures included the impact of resources on clinician satisfaction. Results Fifty-seven program directors completed the survey. Most programs operated at level 1 trauma centers (95%), had access to a functional microscope (95%), and had frequent adequate surgical supplies (88%). On the other hand, only 28 (49%) programs reported consistent access to OR nurses with ophthalmologic training. Clinician satisfaction scores were three times higher for programs with frequent access to trained surgical OR staff than for programs without (p &lt; 0.001). Conclusion Approximately half of programs report consistent access to ophthalmologic-trained OR staff after hours. In contrast, most programs report access to a functional microscope and surgical supplies. The results of this survey suggest that directing resources toward improving access to after-hours staffing with specialty OR staff may improve clinician satisfaction.

Medical scribes in a community oncology clinic.

6585Background: Recent reports have suggested that scribes may improve clinician satisfaction, productivity, and clinic-related efficiencies, while maintaining patient satisfaction; however, there ...

Integrating Pharmacogenomics into Clinical Practice: Promise vs Reality

BackgroundLimited information is available regarding primary care clinicians' response to pharmacogenomic clinical decision support (PGx-CDS) alerts integrated in the electronic health record. MethodsIn February 2015, 159 clinicians in the Mayo Clinic primary care practice were sent e-mail surveys to understand their perspectives on the implementation and use of pharmacogenomic testing in their clinical practice. Surveys assessed how the clinicians felt about pharmacogenomics and whether they thought electronic PGx-CDS alerts were useful. Information was abstracted on the number of CDS alerts the clinicians received between October 2013 and the date their survey was returned. CDS alerts were grouped into 2 categories: the alert recommended caution using the prescription, or the alert recommended an alternate prescription. Finally, data were abstracted regarding whether the clinician changed their prescription in response to the alert recommendation. ResultsThe survey response rate was 57% (n = 90). Overall, 52% of the clinicians did not expect to use or did not know whether they would use pharmacogenomic information in their future prescribing practices. Additionally, 53% of the clinicians felt that the alerts were confusing, irritating, frustrating, or that it was difficult to find additional information. Finally, only 30% of the clinicians that received a CDS alert changed their prescription to an alternative medication. ConclusionsOur results suggest a lack of clinician comfort with integration of pharmacogenomic data into primary care. Further efforts to refine PGx-CDS alerts to make them as useful and user-friendly as possible are needed to improve clinician satisfaction with these new tools.

Expectations Among Academic Clinicians of Inpatient Imaging Turnaround Time: Does it Correlate with Satisfaction?

Imaging report turnaround time (RTAT) is an important measure of radiology performance and has become the leading priority in customer satisfaction surveys conducted among nonradiologists, who may not be familiar with the imaging workflow. Our aim was to assess physicians' expected RTAT for commonly ordered studies and determine if satisfaction correlates with met expectations. Retrospective review of inpatient imaging was conducted at a single academic institution, and RTAT for 18,414 studies was calculated. Examinations were grouped by study type, priority, and time of day. A cross-sectional survey instrument was completed by 48 internal medicine and surgery resident physicians with questions regarding RTAT and their level of satisfaction with various examinations. Actual RTAT ranged from 1.6 to 26.0 hours, with chest radiographs and computed tomographies generally faster than magnetic resonance images and ultrasounds. Urgent (STAT) examinations and those ordered during business hours have shorter RTAT. The time for image interpretation largely contributed to the RTAT because of the lack of night-time radiology coverage. Referring physician expectations were consistently shorter than actual RTAT, ranging from 30 minutes to 24 hours. Overall satisfaction scores were inversely correlated with RTAT, with a strong correlation to the time from study order to imaging (r(2) = 0.63) and a weak correlation to the image interpretation time (r(2) = 0.17). Satisfaction scores did not correlate with whether the actual RTAT met expectations (r(2) = 0.06). Referring physician satisfaction is likely multifactorial. Although RTAT has been reported as a priority, shortening turnaround time alone may not directly improve clinician satisfaction.

Effect of teaching motivational interviewing via communication coaching on clinician and patient satisfaction in primary care and pediatric obesity-focused offices

ObjectiveStudies indicate needed improvement in clinician communication and patient satisfaction. Motivational interviewing (MI) helps promote patient behavior change and improves satisfaction. In this pilot study, we tested a coaching intervention to teach MI to all clinic staff to improve clinician and patient satisfaction. MethodsWe included four clinics (n=29 staff members). In the intervention clinics (one primary care and one pediatric obesity-focused), we trained all clinic staff in MI through meetings as a group seven times, directly observing clinicians in practice 4–10 times, and providing real-time feedback on MI techniques. In all clinics, we assessed patient satisfaction via anonymous surveys and also assessed clinician burnout and self-rated MI skills. ResultsClinicians in the intervention clinics reported improvements in burnout scores, self-rated MI skills, and perceived cohesion whereas clinicians in the control clinic reported worse scores. Patient satisfaction improved in the intervention clinics more than in the control clinics. ConclusionThis is the first study to find some benefit of training an entire clinic staff in MI via a coaching model. Practice implicationsIt might help to train staff in MI to improve clinician satisfaction, team cohesion, perceived skills, and patient satisfaction.

The use of medical scribes in health care settings: a systematic review and future directions.

Electronic health records (EHRs) hold promise to improve productivity, quality, and outcomes; however, using EHRs can be cumbersome, disruptive to workflow, and off-putting to patients and clinicians. One proposed solution to this problem is the use of medical scribes. The purpose of this systematic review is to summarize the literature investigating the effect of medical scribes on health care productivity, quality, and outcomes. Implications for future research are discussed. A keyword search of the Cochrane Library, OvidSP Medline database, and Embase database from January 2000 through September 2014 was performed using the terms scribe or scribes in the title or abstract. To ensure no potentially eligible articles were missed, a second search was done using Google Scholar. English-language, peer-reviewed studies assessing the effect of medical scribes on health care productivity, quality, and outcomes were retained. Identified studies were assessed and the findings reported. Five studies were identified. Three studies assessed scribe use in an emergency department, 1 in a cardiology clinic, and 1 in a urology clinic. Two of 3 studies reported scribes had no effect on patient satisfaction; 2 of 2 reported improved clinician satisfaction; 2 of 3 reported an increase in the number of patients; 2 of 2 reported an increase in the number of relative value units per hour; 1 of 1 reported increased revenue; 3 of 4 reported improved time-related efficiencies; and 1 of 1 reported improved patient-clinician interactions. Available evidence suggests medical scribes may improve clinician satisfaction, productivity, time-related efficiencies, revenue, and patient-clinician interactions. Because the number of studies is small, and because each study suffered important limitations, confidence in the reliability of the evidence is significantly constrained. Given the nascent state of the science, methodologically rigorous and sufficiently powered studies are greatly needed.

BREATHE OUT: a randomized controlled trial of a structured intervention to improve clinician satisfaction with "difficult" visits.

Difficult patients comprise at least 15% of ambulatory visits and are associated with clinician burnout. No structured procedure has been reported to assist health care practitioners with these challenging relationships. This randomized trial evaluated whether a pre- and postvisit patient-centered and clinician-reflective technique called BREATHE OUT improved clinician satisfaction during visits with patients perceived by the clinician as difficult. Six family medicine residency clinics paired as urban, suburban, and rural sites were randomized by clinic to the BREATHE OUT intervention or usual care of difficult patients. A total of 57 physician faculty, nurse practitioners, physician assistants, and residents participated. The validated Physician Satisfaction Scale (PSS) was administered and analyzed using hierarchical linear modeling to assess differences between the intervention and control groups. The BREATHE OUT intervention improved the PSS score (P = .02) in the intervention group compared with the usual care group. Female practitioners reported worse PSS scores compared with their male counterparts despite whether they used BREATHE OUT (P = .009). Application of the BREATHE OUT questionnaire before and after visits improved clinician satisfaction with difficult patient encounters.

Implementation of a Standard Verbal Sign-Out Template Improves Sign-Out Process in a Pediatric Intensive Care Unit

Sign-out of patient data at change of shifts is vulnerable to errors that impact patient safety. Although sign-outs are complex in intensive care units (ICU), a paucity of studies exists evaluating optimal ICU sign-out. Our prospective interventional study investigated the use of a standard verbal template in a Pediatric ICU to improve the sign-out process. We designed and validated a survey tool to measure 10 items of optimal sign-out. The survey and analysis of sign-out information exchanged was performed pre- and postintervention. Forty-eight clinicians participated, with a survey response rate of 88% and 81% in the pre- and postintervention phases, respectively. Seventy-nine percent clinicians identified the need for sign-out improvement. Clinician satisfaction with sign-out increased postintervention (preintervention survey scores: 3.26 (CI: 3.09-3.43), postintervention 3.9 (CI: 3.76-4.04) [p < .01]). Three scorers analyzed the verbal and written sign-out content with good inter-rater reliability. After the intervention, sign-out content revealed increased patient identification, background description, account of system-based clinical details [p = .001] and notation of clinical details, code status, and goals [p < .002]. Interruptions decreased [p = .04] without any change in sign-out duration [p = .86]. The standard verbal template improved clinician satisfaction with sign-out, augmented the amount of information transferred and decreased interruptions without increasing the duration of sign-out.

Is Healthcare Information Technology Based on Evidence?

Is healthcare information technology (HIT) based on evidence of efficacy? Are the trillions of dollars already devoted and in the pipeline for HIT implementations based on systematic evaluations? If evaluated, would those evaluations focus on patient safety, return on investment, clinical efficiency, improved clinician satisfaction, and/or workflow integration? Do we have reliable evidence of usable interfaces, of successful implementations, of data standards allowing interoperability, of continuous improvement, of responsiveness to clinician feedback? While measurement of HIT's efficacy is extraordinarily difficult-complicated by a myriad of other factors involved in providing healthcare and in organizational dynamics-it is not impossible. But is such evidence required before most implementations? Any implementation? Or are the goals of patient safety and efficiency so self-evident, profoundly desired, and laudable that HIT's beneficence is accepted without rigorous data? Note that lack of systematic evidence does not mean HIT is ineffective. HIT may provide untold benefits even if there is no hard proof of those benefits. We find that HIT is seldom objectively measured, and that evidence of its efficacy is at best spotty, and often influenced by self-promotion. Most measures, especially those associated with cost-benefit analyses, are aspirational or hubris transubstantiated into numbers.

Methods of Bowel Management in Critical Care

The purpose of this study was to compare 3 methods of bowel management to control fecal incontinence in adult critical care patients and their effect on incontinence-associated dermatitis, pressure ulcer prevalence, and clinician satisfaction. Fifty-nine adult patients in critical care with liquid fecal incontinence were recruited from 6 critical care units in a large Midwest healthcare system. Subjects were randomly assigned to 1 of 3 groups: bowel management system catheter, rectal/nasopharyngeal trumpet, or usual care. Subjects were assessed daily for incontinence-associated dermatitis, pressure ulcer prevalence, and other clinical data. Direct care nurse satisfaction with each method was evaluated by self-administered survey. Incontinence-associated dermatitis severity and pressure ulcer prevalence did not differ across groups at baseline. Over time, the change in incontinence-associated dermatitis severity score was significantly different across groups (P < .001). There were no significant differences in proportion of patients experiencing pressure ulcers during the study among groups. Clinicians reported significantly greater satisfaction with the bowel management system (P = .007) and rectal trumpet (P = .001) as compared to usual care. In addition, economic and safety benefits were identified with use of internal fecal devices. Specifically, an economic savings of $3100 to $3400 per 29 days of care was identified. Subjects experienced no adverse side effects when internal devices were used. Results of this randomized controlled trial provide new information for the care of patients with fecal incontinence in the critical care setting. Incontinence-associated dermatitis severity scores differed across groups over time, pressure ulcer prevalence did not differ across groups over time, use of an internal device or bowel management system improved clinician satisfaction, and the use of internal fecal methods was more cost-effective than usual care.