Linking Pediatrics Patients and Nurses With the Pharmacy and Electronic Health Record System Through the Inpatient Television: A Novel Interactive Pain-Management Tool

PMI Development

The University of Minnesota Children’s Hospital is a 246-bed, free-standing, quaternary-care mother and children’s hospital. In 2011, we implemented a stand-alone television-based pediatric interactive patient care (IPC) system that is used to help inpatients and/or parents interact with their health care providers through their bedside television screens.²⁰ This system serves as the primary gateway for patient entertainment; standardized, disease-specific patient education; and care communication. In 2014, our hospital’s EHR vendor allowed for bidirectional communication with the IPC system, which provided the opportunity to develop new integrations. To determine the feasibility of integrating these technologies, we chose to create a new pain-management workflow that would allow us to pilot and evaluate the integration capabilities using patient-facing real-time feedback.

Before the implementation of the PMI, the pain-management clinical workflow involved the patient and/or parent reporting pain to the nurse directly, either by pressing the nurse call button or during routine assessments. The nurse would reassess the patient at a predefined time (depending on the route of medication) and document this reassessment in the EHR.

Our new PMI workflow integrated 4 independent inpatient technologies (the IPC system, EHR system, nursing call system, and pharmacy inventory–management system) to allow for time-triggered patient reporting of pain assessments. To set the PMI triggers, we adopted the hospital’s nursing pain reassessment policy, in which it is indicated that nurses are required to document patient response to specific medication interventions within the onset to peak effect period for the medication given in the past 24 hours (ie, between 15 minutes and 35 minutes for intravenous pain medications and between 30 minutes and 65 minutes for oral pain medication).²¹

The new PMI workflow (Fig 1) was designed to work as follows:

1. A pain medication is dispensed from the pharmacy inventory system;

2. This triggers a timer based on the medication route (ie, 15 minutes for intravenous pain medications and 30 minutes for oral pain medications);

3. After this time has elapsed, a pop-up window appears on the patient’s television screen that reads, “A little while ago, you got medication for pain. Please tell us how you’re feeling now: (a) hurts more, (b) hurts the same, or (c) hurts less”;

4. After the patient and/or parent responds to the question, results are immediately communicated to the nurse’s phone and automatically documented in the EHR. Nurses then perform a required hands-on pain reassessment and document accordingly in the EHR; and

5. The system then displays a follow-up message linking the patient and/or parent to other nonpharmacologic standardized resources embedded within the IPC system.

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FIGURE 1

Overview of the interactive PMI clinical workflow.

Evaluation

With institutional review board approval, we employed a retrospective data set analysis to calculate patient and/or parent use rates and nursing pain reassessment documentation rates by extracting records from the University of Minnesota Research Clinical Data Repository.

The data set included all pediatric inpatient records stored in an institution-based EHR covering a 22-month period (the pre-PMI implementation period was from January 1, 2014, through November 29, 2014, and the post-PMI implementation period was from January 1, 2015, through November 29, 2015). To allow for an initial startup period and for analysis purposes, December data were not included.

To calculate patient and/or parent use rates, we calculated the number of responses to the 2 questions triggered by the IPC system after medication is given. These include (1) the level of pain and (2) other nonpharmacologic strategies to help with pain. To measure the nursing pain reassessment documentation compliance rates, we calculated (1) frequency (ie, did nurses document a reassessment at all?) and (2) timeliness (ie, was compliant documentation occurring within the hospital’s pain reassessment time frame standards?).

To measure nursing pain reassessment documentation frequency, we examined the data set to identify the presence or absence of nurse documentation values stored in the EHR. To measure timeliness of documentation, we compared the time stamps of nursing pain reassessment documentation against the standard documentation time frame. Records were deemed to be compliant if they had a nursing pain reassessment documentation value present and were within the documentation standard time frame.

Analysis

We calculated frequencies and percentages on the basis of the presence or absence of nurse documentation values and patient and/or parent pain-rating responses and calculated medians and ranges for time measurements. We used the χ² test to compare the nurse documentation frequency rate and documentation compliance rate to other categorical factors. P values <.05 were considered statistically significant. Statistical analysis was performed by using SAS version 9.3 (SAS Institute, Inc, Cary, NC).