The volume of clinical work in hospital departments is increasing year on year.^4,7–9 With an increased workload comes the need to find efficiencies in patient care, including documentation and communication. A number of technological approaches to improving efficiency have been suggested, including the use of electronic whiteboards.^1–2,10,11 Electronic whiteboards have been introduced in many hospitals over recent years, typically replacing traditional handwritten dry-erase whiteboards in areas of high patient turnover such as the emergency department.^1,2,5,9 Usually, they involve a method of entering clinical details to a central location whereupon this information is available across one or more display screens in the department. The benefits that electronic whiteboards offer include increased accuracy of documentation and the ability to access patient information from a number of locations simultaneously.^2–4 This has the combined potential of reducing medical errors, improving communication among relevant staff, and improving the efficiency of patient flow through a department.^1,4,6,9,12 Electronic whiteboards are used by various members of the multidisciplinary team, including doctors, nurses, physiotherapists and occupational therapists, and have proven to be effective in patient care.^1,2

The introduction of these systems clearly incurs a financial cost. As such it is important that the benefits of such a system be evaluated, and we sought to determine how the introduction of electronic whiteboards within a surgical department affected the patient admissions process.

FloView

Christchurch Public Hospital in New Zealand built the ‘FloView’ electronic whiteboard system for use in the general surgery admission unit in 2013. The system allows authorised users to enter information relevant to the patient from any networked computer within the Canterbury District Health Board domain, and some other users to view it, including the emergency department staff. This patient information is displayed on a central screen in the general surgery admitting unit to inform all team members of the status of current patients and to alert the team of any new referrals. A basic version of an electronic whiteboard had previously been implemented in the emergency department.

Notes were previously handwritten or documented on a physical whiteboard and suffered from two major drawbacks. Handwritten notes are prone to being lost, misplaced or thrown away and can only be viewed from one location, necessitating excessive time communicating the same information by telephone to other staff. Mislaid handover notes also represent a significant patient privacy risk, especially if alternatives exist. The FloView system was introduced to ease the flow of patients during the admission process and the quality of handover of patient details from either the emergency department or direct general practitioner referrals.

Method

Data were collected from general surgery registrars working in the department of general surgery at Christchurch Public Hospital. The registrars were asked to complete a survey of 12 questions regarding their experience of the patient admissions process. Survey questions covered a variety of topics, including ease of identifying patients, patient flow and security of patient details. A list of the questions can be found in Tables 1–3. Printed surveys were provided to every registrar within the department. The surveys were completed and returned anonymously.

The first survey was performed in 2013 prior to the introduction of electronic whiteboards within the department. A second survey consisting of identical questions was provided three years later in 2016 to a (now different) group of registrars who had been working with the electronic whiteboard system. All questions were qualitative in nature and graded from ‘high’ to ‘low’ consistently with five possible responses to each question. Surveys were completed over a one-week period. A number of acute surgical nurses were also involved but, for accurate comparisons between the two surveys, we have only discussed here the results returned by surgical registrars. The answers were collated and are shown in Tables 1–3. The total number of each response to each question was recorded, along with the percentage of respondents who chose each answer.

Analysis of qualitative survey responses required conglomeration of the data into two answer groups. The responses to each question were assessed individually. As seen in the tables, the answers to each question were grouped into ‘high’ satisfaction (those responses in the top two satisfaction brackets) and ‘low’ satisfaction (those responses in the bottom three satisfaction groups). The relative ratio of responses in the high satisfaction group was compared between the two surveys from 2013 and 2016. A Chi-squared test was conducted to return a p-value for the difference in satisfaction between the two surveys. A p-value of less than 0.05 was chosen to represent statistical significance of a difference between the data sets.

Results

In 2013, 12 surveys were completed (n= 12). In 2016, 14 surveys were completed (n=14). This represents all of the available registrars working within the department. The returned answers are displayed in Tables 1–3. It can be appreciated from the survey results that in the second survey (following introduction of the electronic whiteboards), every question shows an increase in the numbers of respondents choosing a high satisfaction response. What differs is the degree of statistical significance of these improvements. We present here four specific question results which we feel merit further discussion.

Anticipating workload

When accepting a patient referral into a department it is essential that all team members can efficiently anticipate the level of workload. This process is facilitated by access to a patient’s working diagnosis, age and comorbidities. Following the introduction of the FloView electronic whiteboard, there is an increase in the number of surgical registrars reporting that they can usually accurately or very accurately predict their level of workload for a new patient (78% vs 42% reported high satisfaction, p=0.054) (Table 1).

View Tables 1-3.

Patient flow

A smooth patient flow from admission and assessment through to management and discharge is essential in a busy department. Accurate record keeping of patient details can speed up this process and make patient transit much more efficient. Improvement is seen in registrar assessment of patient flow after the introduction of electronic whiteboards (78% vs 46% reporting high satisfaction, p=0.127) (Table 3).

Overall satisfaction with admission process

As well as questioning how registrars felt about specific aspects of the patient admission process, their overall satisfaction was evaluated. We see a significant improvement in overall satisfaction that general surgery registrars have with the ease of the process of admitting patients to hospital following the introduction of electronic whiteboards (78% vs 9% reporting high satisfaction, p=0.001) (Table 3).

Security of patient details

Due to the importance of patient confidentiality we also questioned how secure patient details were felt to be under the electronic whiteboard system. While the system reduced the need for handwritten notes, it does not replace it altogether and many of the potential lapses of security of patient details during the handover and admission process remain. Accordingly, staff in 2016 do not see an appreciable difference in security of patient details compared to their colleagues who worked prior to the introduction of electronic whiteboards. It is however important to note that both sets of registrars overwhelmingly felt that data were protected at least somewhat securely (50% vs 42% reporting high satisfaction, p=0.671) (Table 3).

Discussion

We surveyed two groups of surgical registrars both before and after implementation of electronic whiteboards to assist in the admissions process in the acute general surgery department of a major hospital in New Zealand. The registrars were asked about a range of topics, including ease of receiving a patient handover, safety of patient details and how easy it was to locate patients. Due to the low participant numbers, most of the results were not statistically significant. However our results do show a general improvement in doctors’ attitudes towards how the process of patient admission is managed. Some show an appreciable increase in doctor satisfaction, though not a statistically significant one.

When asked how satisfied they were with the whole process of patient admissions, the doctors did have a favourable opinion with a statistically significant improvement in the overall quality of patient admissions and handover. This validates the responses to other questions where the trend is towards greater satisfaction with individual aspects of the admissions process though without such a high degree of statistical significance. This may be due in part to the relatively small number of doctors involved in surveys both in 2013 and 2016. This study has shown that doctors working in acute demand feel that patient handover and the acute admissions process is improved by the use of electronic whiteboards. In the years subsequent to FloView’s introduction to the general surgical department, it has been deployed throughout all other inpatient wards, highlighting its perceived integrity to the care of patients by not only allied health, but also hospital management.

Staff have found that electronic whiteboards help with patient flow and anticipation of workload by virtue of the FloView being able to display patient information to all relevant staff. Both the 2013 and 2016 cohort noted a high degree of disruption from phone calls and thus reduced patient contact time. The disruption, and thus patient flow, could theoretically be reduced by having another staff member (for example a triage nurse) adding new referrals onto the electronic whiteboard by way of a virtual handover, thus allowing the on-call doctor to continue seeing patients, improving both staff and patient satisfaction.

The doctors’ attitudes to the safety of patient details warrants addressing as improving access to patient information on a whiteboard also risks its visibility to non-relevant staff and public. In relation to patient confidentiality, patient identifiers, diagnoses and further comments can be masked if required, especially if the display screen is located in a publicly accessible area. However, the doctors surveyed felt that the security of patient data was no better or worse than it had been prior to the introduction of electronic whiteboards. This highlights the ongoing need to be vigilant with respect to the security of patient details regardless of the medium used to record them.

It will be useful to repeat this assessment of the system as an ongoing project to determine how satisfied doctors are with the system that they use on a daily basis. In addition, for services yet to implement such a system, it may also be useful to assess whether the electronic whiteboard reduces the waiting times of patients to be seen, as implied by the improvement in workflow.

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