Mobile app helps trainees manage emergencies at the bedside

Abstract

Background

Although emergency departments (ED) have standardized guidelines for low‐frequency, high‐acuity diagnoses, they are not immediately accessible at the bedside, and this can cause anxiety in trainees and delay patient care. This problem is exacerbated during events like COVID‐19 that require the rapid creation, iteration, and dissemination of new guidelines.

Methods

Physician innovators used design thinking principles to develop EM Protocols (EMP), a mobile application that clinicians can use to immediately view guidelines, contact consultants (e.g., cath lab activation), and access code‐running tools. The project became an institutional high priority, because it helps EM trainees and off‐service rotators manage low‐frequency, high‐acuity emergencies at the point of care, and its COVID‐19 guidelines can be rapidly updated and disseminated in real time.

Results

This intervention was deployed across two academic medical centers during the COVID‐19 surge. Nearly 300 ED clinicians have downloaded EMP, and they have interacted with the app over 5,400 times. It continues to be used regularly, over 12 months after the initial surge. Since the app was received positively, there are efforts to build in additional adult and pediatric guidelines.

Discussion

Digital health tools like EMP can serve as invaluable adjuncts for managing acute, life‐threatening emergencies at the point of care. They can benefit trainees during normal day‐to‐day operations as well as scenarios that cause large‐scale operational disruptions, such as natural disasters, mass casualty events, and future pandemics.

NEED FOR INNOVATION

Emergency medicine (EM) trainees and off‐service rotators may not be familiar with the diagnosis, management, and workflows associated with low‐frequency, high‐acuity diagnoses. Although standardized guidelines for such illnesses exist, they are often not readily available at the patients’ bedside, potentially creating anxiety in trainees and delaying care. This problem for learners is further exacerbated during events that (1) cause large‐scale operational disruptions and (2) require the adoption of new, rapidly changing guidelines, as was the case during the COVID‐19 pandemic.

BACKGROUND

Emergency departments (ED) have standardized operational guidelines for the clinical management of many low‐frequency, high‐acuity diagnoses. Due to the relative infrequence of these diagnoses, ED clinicians, especially EM or off‐service residents, stand to benefit from having ready access to these guidelines when they occur. Unfortunately, these guidelines are often only available as PDF files, sheets of paper at the workstation, emails, or webpages within the hospital intranet. When low‐frequency, high‐acuity crises occur, clinicians need to be at their patients’ bedside managing the case and often cannot access such sources of information rapidly and reliably, which potentially could lead to diagnostic and treatment delays and errors.

This problem was present during normal day‐to‐day operations but was magnified by the arrival of the COVID‐19 pandemic. Hospitals faced an influx of patients with COVID‐19, many of whom were critically ill and in extremis. ¹ To help manage the high volume of patients and their acute care needs, some academic medical centers recalled EM intern and junior residents from elective and off‐service rotations to work clinical shifts in the ED. Additionally, other clinicians in non‐EM specialties, including from urgent care, general surgery, and orthopedic surgery, were redeployed from elsewhere in the hospital to optimize ED staffing.

EM trainees (e.g., interns, juniors, advanced practice providers) and off‐service rotators may not have substantial experience navigating hospital operational protocols and managing high‐acuity emergencies such as myocardial infarction, respiratory failure, and cardiac arrest, including among patients with COVID‐19. Additionally, as published literature on the care for COVID‐19 infections continues to grow, ED protocols regarding the diagnosis, management, and disposition for COVID‐19 patients change frequently. These challenges can potentially lead to adverse outcomes by delaying timely, appropriate patient care and create anxieties for health care clinicians. ² , ³ , ⁴ , ⁵ , ⁶ Therefore, the purpose of this project was to develop a digital health tool that could support less‐experienced clinicians involved in the management of acute, life‐threatening emergencies at the point of care.

OBJECTIVE OF INNOVATION

We sought to design, develop, and launch a mobile application that would help EM trainees and off‐service rotators (1) get immediate access to guidelines for low‐frequency, high‐acuity diagnoses and COVID‐19 at the point of care; (2) contact consultants and institutional emergency response teams directly; and (3) manage cardiac arrests with code‐running tools. The following guidelines were included: cardiac arrest, tachycardia with a pulse, bradycardia with a pulse, post–cardiac arrest care, acute aortic syndrome, difficult airway, massive transfusion protocol, pulmonary embolism, STEMI, stroke, trauma, and COVID‐19.

DEVELOPMENTAL PROCESS

This project was conducted at a large urban health system with two Level I EDs with a combined 170,000 annual visits, 114 attending physicians, and 81 physician assistants. There are 60 EM residents that rotate at both sites as part of a combined training program. Additionally, there are over 130 residents from other specialties who rotate through the ED for 2 weeks to 1 month every year. Physicians from one of the hospital's health care delivery innovation centers recognized the urgency of developing a tool that could be rapidly deployable, scalable, and intuitive for all clinicians participating in the management of life‐threatening diagnoses. The center is composed of a multidisciplinary team including doctors, software engineers, and graphic designers tasked with the rapid creation of practical solutions for large‐scale problems. This team worked closely with resident physicians and senior leadership within the department of emergency medicine at both hospitals to explore the utility of a digital intervention to address this need.

Our team employed a user‐centered design philosophy to build an iOS mobile application called Emergency Medicine Protocols (EMP for short) that clinicians could download onto their personal smartphones. This approach, which relies on multiple cycles of iterative design improvements based on user feedback, is commonly used in the contemporary, consumer‐based design industry, with the aim of providing a tool that could provide an intuitive, seamless experience for clinicians when providing bedside care. ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹ Due to the time‐sensitive nature of our problem, clinician feedback drove rapid design and content updates every few days, for a total of a half‐dozen iterative cycles. All ED protocols were carefully curated by board‐certified EM physicians in leadership roles and senior EM residents to present succinct yet accurate recommendations for each disease process. EMP also allows clinicians to directly call or page the appropriate consultants and institutional emergency response teams (e.g., cath lab activation) from the patient's bedside through the app, instead of going to a desktop computer and searching through the institutional paging directory. They can do this by pushing a button with either a phone or pager icon on select screens. EMP screenshots are depicted in Figure 1. In the COVID‐19 section within EMP, all algorithms regarding testing, clinical management, disposition, and the care for vulnerable populations are updated regularly. Additionally, in the adult cardiac life support (ACLS) section, ED providers have access to American Heart Association (AHA)‐licensed ACLS content and an updated COVID‐19–specific cardiac arrest algorithm recently published by the AHA. ¹² This section also contains tools to help log cycles of CPR, defibrillation, and epinephrine administration. These core features are designed to help less experienced clinicians navigate potential challenges that could be encountered in immediately life‐threatening patient situations.

FIGURE 1.

Screenshots of the EMP app home page, selection of emergency protocols, and cardiac arrest algorithm, respectively (from left to right). EMP, EM Protocols

THE IMPLEMENTATION PROCESS

All EMP content was reviewed and approved by departmental stakeholders. Given its potential to improve patient care in the ED, we approached leaders within the Hospital Incident Command System (HICS) to request that the launch of EMP be a high institutional priority. Our request was granted, and this allowed our project to proceed through the information technology, risk review, and enterprise app store vetting processes in only a matter of days. Without HICS approval, this timeline would have been on the order of weeks to months. To generate awareness, an e‐mail was sent to all ED providers, with a one‐page attachment detailing EMP’s purpose and features. Both EM and non‐EM trainees were encouraged to download the app during their shifts.

OUTCOMES

Based on data provided by Google Analytics, as of May 2021, a total of 280 EM and non‐EM clinicians (including faculty, fellows, and advanced practice providers) had EMP installed on their phones (it is not known how many users are EM trainees versus off‐service rotators). From May 10, 2020, through May 24, 2021, clinician‐users interacted with the app a total of 5,413 times. On average, this translates to approximately 100 interactions per week. An interaction is defined as any user‐mediated action like opening the app, pushing buttons, and navigating new screens. Figure 2 is a graphical representation of the number of interactions that users had with the app per day during this time period, and it shows the highest levels of user activity during the initial COVID‐19 surge; subsequently, it shows that ED clinicians have continued to use the app consistently, during a period that reflects more normal day‐to‐day operations. An app like EMP would likely be useful at other academic medical centers and community hospitals since the problem of accessing guidelines in real‐time and at the bedside is universal.

FIGURE 2.

Graphical representation of number of interactions that users had with the app per day from May 10, 2020, through May 24, 2021

As part of their onboarding month in July 2020, EM interns received a brief overview of EMP, and 13 out of 15 interns downloaded the app (13 iOS users, two Android users); off‐service rotators were also encouraged to download the app prior to starting their ED months. During the initial launch, EMP was only available on iOS devices, but there is now an Android version as well. Through informal interviews with EM residents and attendings, it became evident that there was a need for more low‐frequency, high‐acuity guidelines to complement existing ones. Based on this feedback, there are ongoing efforts to build additional adult guidelines, such as managing the activation of institutional systems for obstetric emergencies. Additionally, the innovation team is working with the department of pediatric emergency medicine to incorporate institutional pediatric emergency guidelines (e.g., regarding emergent newborn care, PALS, and pediatric trauma) into the app.

Informal interviews, defined as unstructured discussions of short duration, were conducted with end users either in person or over the phone, and EMP has been received positively by ED clinicians when navigating bedside emergencies. However, although it is perceived to be a valuable adjunct to patient care, its actual impact on outcomes is unknown, and further research is warranted. Direct quotes from the informal interviews are included here:

As part of our residency training, we are required to work at multiple hospitals. Given the differing emergency department workflows and protocols at our two main sites, the EMP app has significantly improved my ability to care for acutely ill patients.—PGY‐4 EM resident

EM Protocols is an easy‐to‐navigate clinical decision support aide (that is) useful for many of our sickest patients. The clear, simple UI is just right for finding time sensitive clinical information when caring for sick patients.—PGY‐3 EM resident

REFLECTIVE DISCUSSION

Based on a literature review by the authors, EMP appears to be the first native application to help ED clinicians navigate low‐frequency, high‐acuity emergencies consistent with institution‐specific guidelines, communicate directly with consultants, and access code‐running tools. Our experience highlights the importance of a user‐centered design process when building digital instruments around physicians and patient care. COVID‐19 created challenges for EDs that are unparalleled in recent history. Non‐EM clinicians and EM trainees had to face surges in COVID‐19 patient volumes, stay abreast of rapidly changing guidelines, and learn how to manage time‐sensitive critical illnesses. By enabling rapid access to up‐to‐date clinical algorithms, consultants, and code‐running tools at the bedside, EMP helped them navigate these challenges. Clinician‐users interacted with the application consistently over many months, and our results seem to suggest that apps like EMP may help clinicians treat critically ill patients at the point of care; however, formal studies must be conducted to confirm this.

There is growing evidence that health care professionals are becoming more and more open to using medical apps to help guide patient care. ¹³ , ¹⁴ , ¹⁵ , ¹⁶ Studies have also shown that residents can improve adherence to guidelines for low‐frequency, high‐acuity emergencies with the help of tech‐enabled solutions. ¹⁷ , ¹⁸ Now, more than ever, it is necessary to leverage the power of digital tools to empower all health care providers with the ability to provide the highest level of care to their patients. ¹⁹ Such tools can serve as invaluable adjuncts during routine day‐to‐day operations as well as scenarios that cause large scale operational disruptions, such as natural disasters, mass casualty events, and future pandemics. Of course, more studies will be needed to evaluate the direct impact of such interventions on patient care.

Chu AL, Keschner YG, Lai L, et al. Mobile app helps trainees manage emergencies at the bedside. AEM Educ Train. 2021;5:e10695. doi: 10.1002/aet2.10695