Mobile application-based guidelines to enhance patient care and provider education in trauma and acute care surgery.

INTRODUCTION: Providing up-to-date, universally accessible care guidelines and education within a quaternary care center is challenging. At our institution, trauma and acute care surgery guidelines have historically been published using a paper-based format. Mobile application-based guidelines were developed to address the shortcomings of paper-based guidelines.
METHODS: We assessed the utility, usability, and satisfaction of healthcare providers towards paper-based versus mobile application-based guidelines. A survey was administered to providers within the emergency department and intensive care unit.
RESULTS: Fifty of 137 providers responded (36.5% response rate). Nearly half (47.4%, 9 of 19) of those who received a copy of the paper-based guidelines lost the guidelines at least once. Regarding usage of the mobile application-based guidelines, 92.6% (25 of 27) were aware of the application; 92.6% (25 of 27) considered the application comprehensive, 85.2% (23 of 27) thought the application was organized, and 66.7% (18 of 27) thought the application was easy to use. Additionally, 88.9% (24 of 27) found the application moderately, very, or extremely helpful and 85.2% (23 of 27) judged the application moderately, very, or extremely necessary. Overall, 88.9% (24 of 27) were satisfied with the application and indicated likeliness to recommend to a colleague. Seventeen of 27 (63.0%) agreed or strongly agreed that the application improved their provision of trauma and acute care.
CONCLUSION: This survey demonstrates positive usability, utility, and satisfaction among trauma healthcare providers with the mobile application-based guidelines. Additionally, this quality improvement initiative highlights the importance of having comprehensive, organized, and easy-to-use trauma and acute care surgery guidelines and targeted educational materials available on demand. The successful transition from paper to mobile application-based guidelines serves as a model for other institutions to modernize and improve patient care and provider education. LEVEL OF EVIDENCE: IV. © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Introduction

With nearly 3 billion smartphones and 3 million mobile applications in existence, mobile technology is revolutionizing healthcare.1 Medical professionals are increasingly incorporating mobile technology into clinical practice, research, and education. By 2022, an estimated 98% of physicians and 97% of nurses will be using mobile devices at the point of care.2

The acuity and highly protocolized nature of trauma and acute care surgery catalyzed the need for a mobile application to assist in decision-making at the point of care. While a small number of mobile applications for trauma guidelines exist, provider adherence with established guidelines from institutions and professional organizations is highly variable.3–12 Additionally, continuous quality improvement means that protocols are frequently changing, inhibiting trauma providers from remaining up to date on the most recent guidelines.3 At Stanford Health Care, trauma and acute care surgery guidelines have historically been published in a paper-based format. An updated copy is printed every 2 years—limiting our ability to update guidelines in real time.

The primary goal of this quality improvement project was to develop mobile application-based guidelines as a comprehensive, organized, and easy-to-use alternative. The platform was designed to provide current, evidence-based protocols, educational materials, active research opportunities, and links to frequently used resources.

Methods

Needs assessment

The Stanford Health Care trauma medical director, trauma faculty, trauma leaders from different disciplines, and resident physicians unanimously agreed on the need for mobile application-based guidelines.

We evaluated the needs of emergency medicine, trauma, critical care, and acute care surgery providers via electronic survey. The electronic survey was designed to assess the usability, utility, and satisfaction among healthcare providers with the mobile application-based guidelines. The anonymous, 22-question survey used a 5-point Likert scale and was analyzed using descriptive statistics. The survey was administered to providers within the emergency department and intensive care unit: paramedics, nurses, advanced practice providers, resident physicians, fellows, and attending physicians. The Stanford University Institutional Review Board exempted the anonymous survey as a quality improvement initiative.

Application development

Development of the mobile application-based guidelines was performed by a resident physician at our institution using Flutter (https://flutter.dev), a cross-platform mobile, web, and desktop user interface toolkit developed by Google; Firebase (https://firebase.google.com), a real-time database management solution; and Flamelink.io (https://flamelink.io), a Firebase content management service. The aforementioned tools provided the necessary framework for a cross-platform mobile application that enabled rapid prototype to production development. Once the application was developed, a team of resident physicians and medical students migrated the content from the paper-based guidelines to the mobile application-based guidelines. Content was re-reviewed by an independent physician for accuracy via independent review of each topic. The components and layout of the mobile application-based guidelines were discussed and decided at our monthly trauma quality improvement meeting. Figures 1–3 illustrate the design and organization of the current application version.

Guidelines tab of mobile application-based guidelines, displaying general organization of topics, including favorited topics and flagged topics for adult, pediatric, and intensive care unit patients.

Blunt splenic trauma topic, including decision-making flowchart and injury grading scale.

Education tab of mobile application-based guidelines, displaying educational videos on how to insert a chest tube and how to discuss difficult treatment decisions.

The mobile application-based guidelines, named Trauma Guide, are publicly available on both the Apple App Store (https://apps.apple.com/us/app/trauma-guide/id1462123331) and the Android App Store (https://play.google.com/store/apps/details?id=com.stanfordtrauma.guide). The mobile application-based guidelines were broadly advertised to providers within Stanford Health Care and the prehospital system. Trauma Guide is also available to emergency medical services, such as local fire departments and air ambulances, and hospitals that frequently transfer patients for a higher level of care.

Results

Fifty of 137 providers responded (36.5% response rate), though 23 submitted partial responses. All responses to a particular question were analyzed; the partial responses led to differing denominators. The majority of providers (37 of 46, 80.4%) were resident physicians. Of the respondents, 70.4% (19 of 27) were aware of the paper-based guidelines, with 55.6% (15 of 27) having received a copy. Over half (60.0%, 9 of 15) of those who received a copy lost the guidelines at least once. When asked how many times the paper-based format was referenced in the past 6 months, responses ranged from never to more than 100 times.

Regarding usage of the mobile application-based guidelines, the mobile application has been actively used by a total of 203 individuals, 64 (31.5%) and 139 (68.5%) on Apple or Android devices, respectively, within the last 30 days as of March 21, 2020. Of surveyed users, 92.6% (25 of 27) were aware of the application, with 66.7% (18 of 27) using the application sometimes or often. A large majority (25 of 27, 92.6%) considered the application comprehensive, whereas 85.2% (23 of 27) thought the application was organized and 66.7% (18 of 27) thought the application was easy to use. Additionally, 88.9% (24 of 27) found the application moderately, very, or extremely helpful and 85.2% (23 of 27) judged the application moderately, very, or extremely necessary. Overall, 88.9% (24 of 27) were satisfied with the application, with 63.0% (17 of 27) rating the quality above average and 88.9% (24 of 27) indicating likeliness to recommend to a colleague. Seventeen of 27 (63.0%) agreed or strongly agreed that the application improved their provision of trauma care. The application contains 105 topics which were viewed approximately 6000 times. The most viewed topic, which can be employed to target education, was C-spine evaluation with approximately 400 views.

Discussion

Trauma and acute care surgery guidelines have historically suffered from inadequate availability and accessibility. Paper-based guidelines are frequently misplaced and not readily available at the point of care. With an updated copy being printed every 2 years, established and rotating trauma providers alike are challenged to remain up to date on the most recent guidelines. We found that mobile application-based guidelines addressed the shortcomings of paper-based guidelines.

There is a paucity of literature on the design and implementation of mobile application-based guidelines in clinical practice. However, the principal finding of our study—that mobile application-based guidelines are helpful and facilitate the provision of patient care—is consistent with current research. A recent study concluded that urological mobile-based guidelines could be improved by increased adherence to recommendations based on up-to-date evidence, especially for the management of recurrent urinary tract infections.13 The findings support our commitment to including and continuously updating the mobile application-based guidelines with current recommendations and evidence-based guidelines. Another recent study found that medically accurate content and sufficient usability are imperative for providers addressing complex situations like cardiac arrest.14 For mobile application-based guidelines designed for use in time-sensitive situations, such as trauma resuscitation, the configuration and operation of the mobile application-based guidelines must be highly intuitive and accessible. There is no time to first become acquainted with the software. Our team recognized the importance of high usability, as demonstrated by the 85.2% (23 of 27) who considered the application organized and the 66.7% (18 of 27) who considered the application easy to use. Furthermore, the mobile application was designed such that the guidelines were available independent of internet connectivity and across mobile platforms. The importance of accessibility across platforms is witnessed by over 68.5% of providers accessing the application from Android devices.

While our study is limited by a small response rate and partial responses, the results show that mobile application-based guidelines facilitate access to clinical guidelines, research, and education within emergency medicine, trauma, critical care, and acute care surgery. This survey demonstrates positive usability, utility, and satisfaction among trauma healthcare providers with the mobile application-based guidelines. Additionally, this quality improvement initiative highlights the importance of having comprehensive, organized, and easy-to-use trauma and acute care surgery guidelines and targeted educational materials available on demand. The successful transition from paper to mobile application-based guidelines serves as a model for other institutions to modernize patient care and provider education. Further study is recommended to evaluate whether mobile application-based guidelines increase guideline adherence and improve patient outcomes.