Prevalence and indications for video recording in the health care setting in North American and British paediatric hospitals

Abstract

BACKGROUND:

Health care video recording has demonstrated value in education, performance assessment, quality improvement and clinical care.

METHODS:

A survey was administered to paediatric hospitals in Great Britain, Canada and the United States. Heads of departments or delegates from six areas (emergency departments [EDs], operating rooms, paediatric intensive care units [PICUs], neonatal intensive care units [NICUs], simulation centres and neuroepilepsy units) were asked 10 questions about the prevalence, indications and process issues of video recording.

RESULTS:

Seventy hospitals were surveyed, totalling 307 clinical areas. The hospital response rate was 100%; the rate for clinical departments was 65%. Sixty-six hospitals (94%) currently use video recording. Video recording was used in 62 of 68 (91%) operating rooms; 36 of 69 (52%) PICUs; 35 of 67 (52%) NICUs; 12 of 65 (19%) EDs; seven of eight (88%) neuroepilepsy units and 13 of 14 (93%) simulation centres. Education was the most common indication (112 of 204 [55%]). Most sites obtained written consent. Since the introduction of more strict privacy legislation, 11 of 65 (17%) EDs have discontinued video recording.

CONCLUSION:

The present study describes video recording practices in paediatric hospitals in North America and Great Britain. Video recording is primarily used for education and most areas have a consent process.

Hospital video recording is used for a variety of purposes including education, performance assessment, clinical care and quality management (1–6). In 1995/1996, Ellis et al (2) conducted a multistate survey of trauma centres in the United States (US), and found that 30% (66 of 221) of all trauma centres used or had used video recording as an educational or quality assurance tool, including 34% of all level 1 centres surveyed. After this study was published in 1999, the Health Insurance Portability and Accountability Act of 1996 (HIPPA) – Privacy and Security Rules (2003) was introduced. A before-and-after study found reduced video recording use in trauma centres – from 58% to 18% (7). Similar privacy legislation now exists in Canada and Great Britain. The prevalence of video recording in other clinical areas and in paediatric hospitals is unknown. We conducted a survey of paediatric academic hospitals in North America and Great Britain pertaining to the prevalence, indications and process of video recording in paediatric health care.

METHODS

A cross-sectional survey of paediatric hospitals in Canada, the US and Great Britain was performed pertaining to the prevalence and indications of video recording. Data storage, video evaluation, staff opinion and future use were evaluated. Medical records directors were also asked about video storage in their department.

Survey design

The 10-question survey was designed by the authors for telephone administration and was pilot tested by five individuals for ease of completion. There were seven sections in the survey. The sections examined the prevalence of video recording in clinical areas (currently and previously), video storage practices, protection of identity, limitations of video recording, consent procedures, logistic issues and impact on staff performance. Respondents were asked the primary indication for recording if there was more than one.

Participants and survey administration

Eligible hospitals were identified from a database previously used by the investigative team (8), which provided contact information for North American acute care paediatric hospitals. A description of the database design is available elsewhere (9). All eligible North American hospitals surveyed had a paediatric and a neonatal intensive care unit (PICU and NICU, respectively); in the US, they also had at least 100 acute care inpatient beds for patients up to 18 years of age. In Great Britain, eligible hospitals were listed on the Paediatric Intensive Care Audit Network (PICANet), which is an audit database recording details of the treatment of all critically ill children in PICUs. All eligible British hospitals had a PICU and all but one had an NICU (10). The media departments in British hospitals were not contacted because they were difficult to identify and often not a separate department. Eligible respondents were heads of five clinical and two nonclinical areas, or a person delegated to answer the survey. The areas included operating rooms (ORs), PICUs, NICUs, emergency departments (EDs), neuroepilepsy units and paediatric simulation centres, as well as the head of media relations. Each respondent was asked 10 questions. Health records representatives were asked about video storage in their department only. The Hospital for Sick Children (Toronto, Ontario) Research Ethics Board approved the study, with consent implied by survey completion. The mean time for completion was 45 min per hospital; the average time for completion for each clinical area was 7 min.

Sample size and analysis

A sample size of 70 hospitals was planned to support subgroup analysis. Data were presented descriptively using absolute numbers and proportions for categorical data. Frequency or proportional data are expressed as percentages. Incomplete data responses are listed. Response comparisons between countries were analyzed using the χ² and Fisher’s exact tests. Statistical significance was accepted as P≤0.05.

Data and analysis

Data were entered into a custom-made Oracle database (Oracle Corporation, USA), and analyses were performed with SAS version 9.2 (SAS Institute Inc, USA).

RESULTS

The survey was conducted over a three-month period ending in March 2009. A total of 70 hospitals were contacted and all 70 were eligible (nine Canadian, 20 British and 41 American). One or more respondents were available from 70 hospitals for a hospital response rate of 100%. The number of responses from each area were 68 of 70 (97%) ORs, 69 of 70 (99%) PICUs, 67 of 68 (99%) NICUs, 65 of 69 (94%) EDs, eight of nine (89%) neuroepilepsy units and 14 of 16 (88%) simulation centres. Responses were obtained in 291 of 302 areas (area response rate 96%).

Sixty-six hospitals currently use video recording (94%): nine of nine (100%) Canadian, 17 of 20 (85%) British and 40 of 41 (98%) American. Of 291 areas, 165 were using video recording (57%). Excluding nonrespondents, video recording was used in 62 of 68 ORs (91%), 36 of 69 PICUs (52%), 35 of 67 NICUs (52%), 12 of 65 EDs (19%), seven of eight neuroepilepsy units (88%) and 13 of 14 simulation centres (93%).

Current practices

Sixty-six (94%) hospitals are using video recording, with a median of four areas per hospital (interquartile range three to five areas). Some centres reported more than one indication, with 231 indications from 165 clinical sites. The most common was education in 118 of 231 (51%) indications. The purpose reflected the nature of the area. Simulation centres reported 10 of 10 (100%) sites using video recording for education. In the clinical areas of PICU, NICU, ED and OR, the main purpose was clinical diagnosis in 60 of 231 (26%). The indications for current use for video recording are listed in Table 1. There was no difference in video recording indications based on region (P=0.30).

TABLE 1.

Indications for video recording according to clinical area^*

	Emergency room	Paediatric intensive care unit	Neonatal intensive care unit	Operating room	Neuroepilepsy	Simulation	Total
Clinical
Diagnostic	0	26	24	4	6	0	60
Quality assurance	9	0	1	1	0	0	11
Documentation
Permanent	1	0	2	0	0	0	3
Temporary	0	0	1	0	0	0	1
Education/teaching	23	21	9	55	0	10	118
Research	1	2	0	2	0	0	5
Other	0	1	0	0	0	0	1
Total	34	50	37	62	6	10	199

Data presented as n.

^*Some areas cited more than one indication. χ²=316.00381, df=36, P<0.0001

Consent was obtained in 63 of 70 hospitals: 39 of 41 (95%) in the US; nine of nine (100%) in Canada; and 15 of 20 (75%) in Great Britain. Consent was obtained in 116 of 142 clinical areas (χ²=44, df=6, P<0.0001): OR 59 of 59 (100%); PICU 20 of 28 (71%); NICU 17 of 27 (63%); ER three of nine (33%); neuroepilepsy five of seven (71%); and simulation 12 of 12 (100%). Consent was reported as written in 108 of 161 (67%) areas, oral in two of 161 (0.01%), unsure in 35 of 161 (22%) and not obtained in 16 of 161 (1%). Most respondents were uncertain of videotape storage procedures: 120 of 170 (70%). The hospital medical records department did not store any video documentation in any of the hospitals.

Access to video recording was restricted in 131 of 174 (75%) sites; only one clinical site (a NICU in the US) altered the record to protect a subject’s identity. Restricted viewing to a limited audience occurred in most geographical areas (Canada 21 of 26 [81%]; Great Britain 26 of 31 [84%]; US 84 of 117 [72%]) and in the majority of clinical areas (ER eight of 11 [73%]; PICU 25 of 36 [69%]; NICU 27 of 35 [77%]; OR 60 of 61 [98%]).

Previous and planned use

Eleven of the EDs in the US ceased video recording primarily after receiving legal advice to do so combined with poor staff acceptance.

With regard to the use of video recording, respondents described significantly improved staff performance in one of 170 (less than 1%) clinical areas, improved staff performance in 61 of 170 (36%) and no change in 108 of 170 (64%). There were no regional differences (P=0.82) or differences among clinical areas (P=0.02) regarding effects on staff performance. Of the clinical areas not currently using video recording, some intended to do so within six (n=6) or 12 months (n=3).

DISCUSSION

We conducted a three-nation survey of paediatric hospitals to describe the extent and nature of video recording practices in the current era. The key findings were that video recording is commonly used, especially for education, with quality improvement and documentation being less commonly cited indications. As expected, video recording was commonplace in simulation and neuroepilepsy settings. Attention to consent was standard practice in many hospitals, with a trend toward obtaining consent more often in Canada and the US than in Great Britain. Few centres described changing practices since privacy legislations. Most survey respondents were unaware of storage procedures.

Video recording can provide a highly accurate record of events in trauma resuscitation. A single-centre review of 178 videotaped paediatric traumas demonstrated appropriate airway management and adherence to trauma and vascular access protocols in more than 96% of cases. The use of universal precautions and personal protective equipment improved from 14% of cases at the initiation of the program to 64% of cases at the end of the review period. Team performance improved with a reduction in negative behaviours such as shouting and anger during resuscitations (5). A study from Royal Children’s Hospital (Melbourne, Australia [11]) demonstrated improved event depiction in a video recorded trauma setting compared with the written record. In 1999, Ellis et al (2) described shortened resuscitation time, fewer errors during patient care and better staff adherence to their specific roles after reviewing videotapes. Cost implications were considered to be a disincentive to implementation of the technology. Others have published simpler, commercially available systems for health care use and guides for implementation (12,13).

Each of the countries surveyed in our study has since undergone more stringent privacy legislation review: the United Kingdom Data Protection Act 2002; the Canadian federal Personal Information Protection and Electronic Documents Act and separate provincial legislation in some provinces of Canada; and HIPPA in the US (14–16). HIPPA requires providers to protect the “confidentiality, integrity and availability to patients of individually identifiable personal heath information in any form, electronic, written or oral” (11). Canadian and United Kingdom legislation similarly aims to strengthen safeguards of patients’ privacy and confidentiality (10,12).

As far as we are aware, the present survey was the first to examine video recording in paediatric hospitals, so it is difficult to know whether paediatric hospital practices have changed with new privacy legislation. US adult trauma centres have modified practices to meet these requirements (7). Most adult institutions using video recording did not obtain consent from patients or staff before this legislation (2). Post-HIPPA introduction, there has been a reduction in video recording in US adult trauma centres from 73 of 125 (58%) to 23 of 125 (18%) in 2004 (7). Procedural practice changes since HIPPA introduction include obtaining institutional ethics approval (three of 23 [13%]) and patient consent (nine of 23 [39%]) (7). These authors listed education (21 of 23 [91%]) and quality assurance (19 of 23 [83%]) as primary indications.

Ellis et al (2) reported the common barriers to participation in nonrecording hospitals to be confidentiality issues and medicolegal concerns – more than staff support and funding. Centres using the technology described lack of support from the medical staff and adequate staffing to run the program as more problematic than medicolegal concerns (2). Campbell et al (7) reported more than 55% of US level 1 trauma centres capturing a “poor patient outcome” on the videotape. Hospitals in their study ceased taping programs due to HIPPA, legal concerns and consenting issues in 31 of 50 (62%), scarce resources in 31 of 50 (62%) and ineffective technology in 14 of 50 (28%) cases (7). Our data suggest that only some US paediatric emergency departments have ceased recording and most others obtain consent consistent with the legislation.

Most surveyed clinical areas obtained consent in our study. Whether written or oral consent is preferable to satisfy the requirements of ‘informed consent’ is debatable (17,18). There was less recording in EDs in all regions where consent might be more difficult to obtain. Storage sites of video recordings were not commonly known, suggesting that ‘custodial care’ of personal health record information may be incompletely understood or not known to the delegates approached. The majority of centres used video recording as an educational aid. It may not have been considered as part of the patient’s personal health information, making storage a nonissue. Unfortunately, the survey did not ask how it was assured that recordings were appropriately erased.

Others have reported that health care staff report no change in personal satisfaction if video recorded during clinical care (19). Parents report high levels of approval for video recording for education and other clinical indications (20), but also report video recording to be more beneficial to staff than the evidence suggests (2).

Our study population consisted of specialized paediatric centres in Great Britain, the US and Canada, which may limit the study’s generalizability. Responses reflected the opinions of heads of departments or their delegates, and may differ from frontline surveys or direct observations. The media relations departments in 35 of 50 North American hospitals failed to respond to both telephone and e-mail contact. Media relations departments in Great Britain were not approached because it was difficult to access them from the main switchboard station when requesting to be connected to the media/public relations department. Possibly, this role is fulfilled in Great Britain by another department or an alternative name. We only inquired about the primary indication; thus, the present study provides a conservative description of video recording use. We did not assess the usefulness of video recording or the security of data protection, nor did we assess, in detail, the process of obtaining consent in emergencies.

CONCLUSION

We describe a high prevalence of video recording in clinical areas in paediatric hospitals in Great Britain, the US and Canada, primarily for educational purposes. Despite the recognized benefits of video recording beyond education, there was limited use for other purposes (5,11). We hope to establish practice guidelines for use in areas other than education and to establish a consenting process for difficult clinical circumstances.