The period following discharge is a vulnerable time for patientsthe prevalence of medical errors related to this transition is high and has important patient safety and medico‐legal ramifications.13 Factors contributing to this vulnerability include complexity of hospitalized patients, shorter lengths of stay, and increased discontinuity of care. Hospitalists have recognized this threat to patient safety and have worked toward improving information exchange between inpatient and outpatient providers at hospital discharge.46 Nonetheless, the evidence suggests that more work is necessary. A recent study found that discharge summaries are often incomplete, and do not contain important information requiring follow‐up, such as pending tests.7 Additionally, a review by Kripalani et al. characterizing information deficits at hospital discharge found few interventions which specifically improve communication of pending tests at hospital discharge.8

In a prior study we determined that 41% of patients left the hospital before all laboratory and radiology test results were finalized. Of these results, 9.4% were potentially actionable and could have altered management. Physicians were aware of only 38% of post‐discharge test results.9 This awareness gap is a consequence of several factors including the lack of systems to track and alert providers of test results finalized post discharge. Also, it is unclear who is responsible for pending tests at discharge, since these tests are ordered by the inpatient physicians but often reported in the time period between hospital discharge and the patient's first follow‐up appointment with the primary care physician (PCP). Because responsibility is not explicitly made in the final communication between physicians at discharge, such test results may not be reviewed in a timely manner, potentially resulting in delays in treatment, a need for readmission, or other unfavorable outcomes.

Even in integrated health systems with advanced electronic health records, missed test results which result in treatment delays remain prevalent.10, 11 Test result management applications aid clinicians in reviewing and acting upon results as they become available and such systems may provide solutions to this problem. At Partners Healthcare in Boston, the Results Manager (RM) application was developed to help clinicians in the ambulatory setting safely, reliably, and efficiently review and act upon test results. The application enables clinicians to prioritize test results, utilize guidelines, and generate letters to patients. This system also prompts physicians to set reminders for future testing.12 In a 2.5‐year study evaluating the impact of this intervention, PCPs at 26 adult primary care practices were able to expedite communication of outpatient laboratory and imaging test results to patients with the help of RM. Patients of physicians who participated in the project reported greater satisfaction with test result communication and with information provided about their condition than did a control group of similar patients.13 RM has not yet been studied in the inpatient setting or at care transitions. We describe an attempt at modifying the Partners RM application to help inpatient physicians manage pending tests at hospital discharge.

Methods

Test Result Management Application

RM was originally developed by Partners Healthcare to improve timely review and appropriate management of test results in the ambulatory setting. RM was developed for and vetted by primarily ambulatory physicians. The application is browser‐based, provider‐centric, and embedded in the LMR to help ambulatory clinicians review and act upon test results in a safe, reliable, and efficient manner. Although RM has access to all inpatient and outpatient data in the Partners Clinical Data Repository (CDR), given the volume of inpatient tests ordered, hospital‐based results are suppressed by default to limit inundating ambulatory clinicians' queues. Therefore, users of RM only receive results of laboratory and radiology tests ordered in the ambulatory setting. They can track these tests for specific patients for a designated period of time by placing the patient on a watch list. Finally, RM incorporates extensive decision support features to classify the degree of abnormality for each result, presents guidelines to help clinicians manage abnormal results, allows clinicians to generate result letters to patients using predefined, context‐sensitive templates, and prompts physicians to set reminders for future testing. Because RM was developed from the ambulatory perspective, there was limited input from hospitalist physicians with regard to inpatient workflow in the original design of the module.12 See Figure 1 for a screen shot of RM and a description of its features.

Figure 1

For purposes of this pilot, we modified RM to allow results of tests ordered in the inpatient setting to be available for viewing (Hospitalist Results Manager, HRM). This feature was turned on only for inpatient physicians as previously defined. Inpatient tests, including pending tests at discharge, continued to be suppressed from PCP's RM queue (however, any physician could access a patient's test result(s) directly from the Partners CDR). Inpatient physicians could track laboratory and radiology results finalized after discharge by keeping discharged patients on their HRM watch list for a designated period of time. The finalized results would become available for review in their HRM queue and abnormal results were displayed prominently at the top of this queue. Inpatient physicians were trained to use HRM in a series of meetings and demonstrations. Although HRM could be accessed from inpatient clinical workstations, it was not part of the inpatient clinical information system.

Results

A total of 35 inpatient physicians participated in the pilot. Among 649 patients discharged during the study period, there were 1075 tests pending of which 555 were subsequently flagged as abnormal in HRM. Study surveys were sent to the 35 inpatient physician participants and 29 were completed, including partial responses (83% survey response rate). The 35 inpatient physician participants had the following characteristics: 22 were male, 13 were female; 21 were trainees and 14 were nontrainees/faculty. All 21 trainees were PGY2s. Nontrainees and faculty varied in experience level (PGY 15: 5, PGY 610: 7, PGY 1120: 1, PGY 21+: 1). Of 29 survey respondents, 7 were from hospital A and 22 were from hospital B; 19 were trainees and 10 were nontrainees/faculty. Of the 6 nonrespondents, 2 were from hospital A and 4 were from hospital B; 2 were trainees and 4 were nontrainees/faculty.

Table 1 shows the results of our survey of inpatient physicians regarding usage of HRM. Of 29 survey respondents, 14 (48%) reported never using HRM. Thirteen (45%) reported using HRM 1 to 2 times per week. None of the respondents used it more than 4 times per week. The frequency of usage was similar for hospitals A and B. Table 2 details barriers to using HRM. Twenty‐three inpatient physicians (79%) reported barriers. Seventeen (59%) thought that results in their HRM queue were not clinically relevant, 16 (55%) felt that HRM did not fit into their daily workflow, 14 (48%) had limited time to use HRM, and 12 (41%) noted that too many results in their HRM queue were on other physician's patients. Seven (24%) reported operational issues and 3 (10%) reported technical issues prohibiting use of HRM. With regard to preferred elements of an ideal results manager system, 21 (72%) inpatient physician respondents wanted to receive notification of abnormal and clinician‐designated pending test results. Four (14%) wanted to receive only abnormal results and 1 (3%) wanted to receive all results. Twenty‐seven (93%) physicians agreed that an ideally designed computerized test result management application would be valuable for managing pending tests at discharge.

Table 3 provides comments from inpatient physician respondents regarding obstacles prohibiting use of HRM and suggestions for future systems.

Discussion

We describe a pilot implementation of a computerized application for the management of pending tests at hospital discharge. From responses to post‐implementation surveys, we were able to identify multiple factors prohibiting successful implementation of the application. These observations may help inform future interventions and evaluations.

Almost half of inpatient physicians reported never using HRM despite training and reminders. The feedback provided by physicians in our study suggested that HRM was not ideally designed from an inpatient physician perspective. We discovered several barriers to its use: (1) HRM overburdened physicians with clinically irrelevant test results, suggesting that more robust filtering of abnormal but low importance test results may be required (eg, a borderline electrolyte abnormality or low but stable hematocrit); (2) HRM did not integrate well into inpatient workflowthe system was not integrated into the inpatient results viewing and computerized physician order entry (CPOE) applications, and therefore required an extra step to access; (3) there was no mechanism of alerting inpatient physicians that finalized test results were available for viewing in their HRM queues (eg, by email or by an alert in the inpatient computer system); (4) because responsibility for these results was unclear, most inpatient physicians had no formal method of managing them, and for many, using HRM represented an additional task; and finally (5) several physicians commented on finding results in their HRM queue that belonged to other physician's patients, implying that the hospital databases were inaccurate in identifying the discharging physician or that rotation schedules, and therefore patient responsibility, had changed in the intervening period. Table 4 summarizes the advantages and respective limitations of features of HRM available to inpatient physicians.

In the literature, there is little information regarding optimal features of a test result management system for transitions from the inpatient to ambulatory care setting. Prior studies outline important functions for results management systems developed for noninpatient sites of care, including the ambulatory and emergency room setting.12, 14, 15 These include a method of prioritizing by degree of abnormality, the ability to reliably and efficiently act upon results, and an automated alerting system for abnormal results. Findings from our study provide insight in defining core functions for result management systems which focus on transitions from the inpatient to ambulatory care setting. These functions include tight integration with applications used by inpatient physicians, clear assignment of responsibility for test results finalized after hospital discharge (as well as a mechanism to reassign responsibility), automated alerts to responsible providers of test results finalized post‐discharge, and ways to automatically filter test results to avoid over‐burdening physicians with clinically irrelevant results.

Almost all surveyed inpatient physicians agreed that an ideally designed electronic post‐discharge results management system would be valuable. For such systems to be successfully adopted, we offer several principles to help guide future work. These include: (1) clarifying responsibility at the time a test is ordered and again at discharge, (2) understanding workflow and communication patterns among inpatient and outpatient clinicians, and (3) integrating technological solutions into existing systems to minimize workflow disruptions. For example, if the primary responsibility for post‐discharge result follow‐up lies with the ordering physician, the system should be integrated within the EMR most often used by inpatient physicians and become part of inpatient physician workflow. If the system depends on administrative databases to identify the responsible providers, these must be accurate. Alternatively, in organizations with computerized provider order entry, responsibility for the result could be assigned when the test is ordered and confirmed at discharge (ie, the results management system would be integrated into the discharge order such that pending tests are reviewed at the time of discharge). The discharging physician should have the ability to assign responsibility for each pending test and select preferred mode(s) of notification once its result is finalized (eg, e‐mail, alphanumeric page, etc.). The system should have the ability to generate an automatic notification to the inpatient and PCP (and perhaps other designated providers involved in the patient's inpatient care), but it should not burden busy clinicians with unnecessary alerts and warnings. Finally, the rules by which results are prioritized must be robust enough to filter out less urgent results, and should be modified to reflect the severity of illness of recently discharged patients. In essence, in consideration of the time constraints of busy clinicians, an ideal results management system should achieve automated notification of test results while minimizing the risk of alert fatigue from the potentially large volume of alerts generated.

Our study has several important limitations. First, although our survey response rate was high, the sample size of actual participants was small. Second, because the study was conducted in 2 similar, tertiary care academic centers, it may not generalize to other settings (we note that hospital B included a nonteaching service similar to those in nonacademic medical centers). This may be particularly true in assessing the importance of specific barriers to use of results management systems, which may vary at different institutions. Third, the representation of survey respondents were skeweda majority of the responses were from trainees (all post‐graduate level [PGY] level 2) and from hospital B. Fourth, we did not actively monitor physician interaction with the test result management application, and therefore, we depended heavily on physician recollection of use of the system when responding to surveys. Finally, we did not convene focus groups of key individuals with regard to the factors facilitating or prohibiting adoption of the system. Use of semi‐structured, key informant interviews (ie, focus groups) before and after implementation of an electronic results management application, have been shown to be effective in evaluating potential barriers and facilitators of adoption.16 Focus groups of and/or interviews with inpatient and PCPs, physician extenders, and housestaff could have been useful to better characterize the potential barriers and facilitators of adoption noted by survey respondents in our study.

In summary, we offer several lessons from our attempt to implement a system to manage pending tests at hospital discharge. The success of implementing future systems to address this patient safety concern will rely on accurately assigning responsibility for these test results, integrating the system within clinical information systems commonly used by the inpatient physician, addressing workflow issues and time constraints, maximizing appropriateness of alerting, and minimizing alert fatigue.

The period following discharge is a vulnerable time for patientsthe prevalence of medical errors related to this transition is high and has important patient safety and medico‐legal ramifications.13 Factors contributing to this vulnerability include complexity of hospitalized patients, shorter lengths of stay, and increased discontinuity of care. Hospitalists have recognized this threat to patient safety and have worked toward improving information exchange between inpatient and outpatient providers at hospital discharge.46 Nonetheless, the evidence suggests that more work is necessary. A recent study found that discharge summaries are often incomplete, and do not contain important information requiring follow‐up, such as pending tests.7 Additionally, a review by Kripalani et al. characterizing information deficits at hospital discharge found few interventions which specifically improve communication of pending tests at hospital discharge.8

In a prior study we determined that 41% of patients left the hospital before all laboratory and radiology test results were finalized. Of these results, 9.4% were potentially actionable and could have altered management. Physicians were aware of only 38% of post‐discharge test results.9 This awareness gap is a consequence of several factors including the lack of systems to track and alert providers of test results finalized post discharge. Also, it is unclear who is responsible for pending tests at discharge, since these tests are ordered by the inpatient physicians but often reported in the time period between hospital discharge and the patient's first follow‐up appointment with the primary care physician (PCP). Because responsibility is not explicitly made in the final communication between physicians at discharge, such test results may not be reviewed in a timely manner, potentially resulting in delays in treatment, a need for readmission, or other unfavorable outcomes.

Even in integrated health systems with advanced electronic health records, missed test results which result in treatment delays remain prevalent.10, 11 Test result management applications aid clinicians in reviewing and acting upon results as they become available and such systems may provide solutions to this problem. At Partners Healthcare in Boston, the Results Manager (RM) application was developed to help clinicians in the ambulatory setting safely, reliably, and efficiently review and act upon test results. The application enables clinicians to prioritize test results, utilize guidelines, and generate letters to patients. This system also prompts physicians to set reminders for future testing.12 In a 2.5‐year study evaluating the impact of this intervention, PCPs at 26 adult primary care practices were able to expedite communication of outpatient laboratory and imaging test results to patients with the help of RM. Patients of physicians who participated in the project reported greater satisfaction with test result communication and with information provided about their condition than did a control group of similar patients.13 RM has not yet been studied in the inpatient setting or at care transitions. We describe an attempt at modifying the Partners RM application to help inpatient physicians manage pending tests at hospital discharge.

Methods

Test Result Management Application

RM was originally developed by Partners Healthcare to improve timely review and appropriate management of test results in the ambulatory setting. RM was developed for and vetted by primarily ambulatory physicians. The application is browser‐based, provider‐centric, and embedded in the LMR to help ambulatory clinicians review and act upon test results in a safe, reliable, and efficient manner. Although RM has access to all inpatient and outpatient data in the Partners Clinical Data Repository (CDR), given the volume of inpatient tests ordered, hospital‐based results are suppressed by default to limit inundating ambulatory clinicians' queues. Therefore, users of RM only receive results of laboratory and radiology tests ordered in the ambulatory setting. They can track these tests for specific patients for a designated period of time by placing the patient on a watch list. Finally, RM incorporates extensive decision support features to classify the degree of abnormality for each result, presents guidelines to help clinicians manage abnormal results, allows clinicians to generate result letters to patients using predefined, context‐sensitive templates, and prompts physicians to set reminders for future testing. Because RM was developed from the ambulatory perspective, there was limited input from hospitalist physicians with regard to inpatient workflow in the original design of the module.12 See Figure 1 for a screen shot of RM and a description of its features.

Figure 1

For purposes of this pilot, we modified RM to allow results of tests ordered in the inpatient setting to be available for viewing (Hospitalist Results Manager, HRM). This feature was turned on only for inpatient physicians as previously defined. Inpatient tests, including pending tests at discharge, continued to be suppressed from PCP's RM queue (however, any physician could access a patient's test result(s) directly from the Partners CDR). Inpatient physicians could track laboratory and radiology results finalized after discharge by keeping discharged patients on their HRM watch list for a designated period of time. The finalized results would become available for review in their HRM queue and abnormal results were displayed prominently at the top of this queue. Inpatient physicians were trained to use HRM in a series of meetings and demonstrations. Although HRM could be accessed from inpatient clinical workstations, it was not part of the inpatient clinical information system.

Results

A total of 35 inpatient physicians participated in the pilot. Among 649 patients discharged during the study period, there were 1075 tests pending of which 555 were subsequently flagged as abnormal in HRM. Study surveys were sent to the 35 inpatient physician participants and 29 were completed, including partial responses (83% survey response rate). The 35 inpatient physician participants had the following characteristics: 22 were male, 13 were female; 21 were trainees and 14 were nontrainees/faculty. All 21 trainees were PGY2s. Nontrainees and faculty varied in experience level (PGY 15: 5, PGY 610: 7, PGY 1120: 1, PGY 21+: 1). Of 29 survey respondents, 7 were from hospital A and 22 were from hospital B; 19 were trainees and 10 were nontrainees/faculty. Of the 6 nonrespondents, 2 were from hospital A and 4 were from hospital B; 2 were trainees and 4 were nontrainees/faculty.

Table 1 shows the results of our survey of inpatient physicians regarding usage of HRM. Of 29 survey respondents, 14 (48%) reported never using HRM. Thirteen (45%) reported using HRM 1 to 2 times per week. None of the respondents used it more than 4 times per week. The frequency of usage was similar for hospitals A and B. Table 2 details barriers to using HRM. Twenty‐three inpatient physicians (79%) reported barriers. Seventeen (59%) thought that results in their HRM queue were not clinically relevant, 16 (55%) felt that HRM did not fit into their daily workflow, 14 (48%) had limited time to use HRM, and 12 (41%) noted that too many results in their HRM queue were on other physician's patients. Seven (24%) reported operational issues and 3 (10%) reported technical issues prohibiting use of HRM. With regard to preferred elements of an ideal results manager system, 21 (72%) inpatient physician respondents wanted to receive notification of abnormal and clinician‐designated pending test results. Four (14%) wanted to receive only abnormal results and 1 (3%) wanted to receive all results. Twenty‐seven (93%) physicians agreed that an ideally designed computerized test result management application would be valuable for managing pending tests at discharge.

Table 3 provides comments from inpatient physician respondents regarding obstacles prohibiting use of HRM and suggestions for future systems.

Discussion

We describe a pilot implementation of a computerized application for the management of pending tests at hospital discharge. From responses to post‐implementation surveys, we were able to identify multiple factors prohibiting successful implementation of the application. These observations may help inform future interventions and evaluations.

Almost half of inpatient physicians reported never using HRM despite training and reminders. The feedback provided by physicians in our study suggested that HRM was not ideally designed from an inpatient physician perspective. We discovered several barriers to its use: (1) HRM overburdened physicians with clinically irrelevant test results, suggesting that more robust filtering of abnormal but low importance test results may be required (eg, a borderline electrolyte abnormality or low but stable hematocrit); (2) HRM did not integrate well into inpatient workflowthe system was not integrated into the inpatient results viewing and computerized physician order entry (CPOE) applications, and therefore required an extra step to access; (3) there was no mechanism of alerting inpatient physicians that finalized test results were available for viewing in their HRM queues (eg, by email or by an alert in the inpatient computer system); (4) because responsibility for these results was unclear, most inpatient physicians had no formal method of managing them, and for many, using HRM represented an additional task; and finally (5) several physicians commented on finding results in their HRM queue that belonged to other physician's patients, implying that the hospital databases were inaccurate in identifying the discharging physician or that rotation schedules, and therefore patient responsibility, had changed in the intervening period. Table 4 summarizes the advantages and respective limitations of features of HRM available to inpatient physicians.

In the literature, there is little information regarding optimal features of a test result management system for transitions from the inpatient to ambulatory care setting. Prior studies outline important functions for results management systems developed for noninpatient sites of care, including the ambulatory and emergency room setting.12, 14, 15 These include a method of prioritizing by degree of abnormality, the ability to reliably and efficiently act upon results, and an automated alerting system for abnormal results. Findings from our study provide insight in defining core functions for result management systems which focus on transitions from the inpatient to ambulatory care setting. These functions include tight integration with applications used by inpatient physicians, clear assignment of responsibility for test results finalized after hospital discharge (as well as a mechanism to reassign responsibility), automated alerts to responsible providers of test results finalized post‐discharge, and ways to automatically filter test results to avoid over‐burdening physicians with clinically irrelevant results.

Almost all surveyed inpatient physicians agreed that an ideally designed electronic post‐discharge results management system would be valuable. For such systems to be successfully adopted, we offer several principles to help guide future work. These include: (1) clarifying responsibility at the time a test is ordered and again at discharge, (2) understanding workflow and communication patterns among inpatient and outpatient clinicians, and (3) integrating technological solutions into existing systems to minimize workflow disruptions. For example, if the primary responsibility for post‐discharge result follow‐up lies with the ordering physician, the system should be integrated within the EMR most often used by inpatient physicians and become part of inpatient physician workflow. If the system depends on administrative databases to identify the responsible providers, these must be accurate. Alternatively, in organizations with computerized provider order entry, responsibility for the result could be assigned when the test is ordered and confirmed at discharge (ie, the results management system would be integrated into the discharge order such that pending tests are reviewed at the time of discharge). The discharging physician should have the ability to assign responsibility for each pending test and select preferred mode(s) of notification once its result is finalized (eg, e‐mail, alphanumeric page, etc.). The system should have the ability to generate an automatic notification to the inpatient and PCP (and perhaps other designated providers involved in the patient's inpatient care), but it should not burden busy clinicians with unnecessary alerts and warnings. Finally, the rules by which results are prioritized must be robust enough to filter out less urgent results, and should be modified to reflect the severity of illness of recently discharged patients. In essence, in consideration of the time constraints of busy clinicians, an ideal results management system should achieve automated notification of test results while minimizing the risk of alert fatigue from the potentially large volume of alerts generated.

Our study has several important limitations. First, although our survey response rate was high, the sample size of actual participants was small. Second, because the study was conducted in 2 similar, tertiary care academic centers, it may not generalize to other settings (we note that hospital B included a nonteaching service similar to those in nonacademic medical centers). This may be particularly true in assessing the importance of specific barriers to use of results management systems, which may vary at different institutions. Third, the representation of survey respondents were skeweda majority of the responses were from trainees (all post‐graduate level [PGY] level 2) and from hospital B. Fourth, we did not actively monitor physician interaction with the test result management application, and therefore, we depended heavily on physician recollection of use of the system when responding to surveys. Finally, we did not convene focus groups of key individuals with regard to the factors facilitating or prohibiting adoption of the system. Use of semi‐structured, key informant interviews (ie, focus groups) before and after implementation of an electronic results management application, have been shown to be effective in evaluating potential barriers and facilitators of adoption.16 Focus groups of and/or interviews with inpatient and PCPs, physician extenders, and housestaff could have been useful to better characterize the potential barriers and facilitators of adoption noted by survey respondents in our study.

In summary, we offer several lessons from our attempt to implement a system to manage pending tests at hospital discharge. The success of implementing future systems to address this patient safety concern will rely on accurately assigning responsibility for these test results, integrating the system within clinical information systems commonly used by the inpatient physician, addressing workflow issues and time constraints, maximizing appropriateness of alerting, and minimizing alert fatigue.

The period following discharge is a vulnerable time for patientsthe prevalence of medical errors related to this transition is high and has important patient safety and medico‐legal ramifications.13 Factors contributing to this vulnerability include complexity of hospitalized patients, shorter lengths of stay, and increased discontinuity of care. Hospitalists have recognized this threat to patient safety and have worked toward improving information exchange between inpatient and outpatient providers at hospital discharge.46 Nonetheless, the evidence suggests that more work is necessary. A recent study found that discharge summaries are often incomplete, and do not contain important information requiring follow‐up, such as pending tests.7 Additionally, a review by Kripalani et al. characterizing information deficits at hospital discharge found few interventions which specifically improve communication of pending tests at hospital discharge.8

In a prior study we determined that 41% of patients left the hospital before all laboratory and radiology test results were finalized. Of these results, 9.4% were potentially actionable and could have altered management. Physicians were aware of only 38% of post‐discharge test results.9 This awareness gap is a consequence of several factors including the lack of systems to track and alert providers of test results finalized post discharge. Also, it is unclear who is responsible for pending tests at discharge, since these tests are ordered by the inpatient physicians but often reported in the time period between hospital discharge and the patient's first follow‐up appointment with the primary care physician (PCP). Because responsibility is not explicitly made in the final communication between physicians at discharge, such test results may not be reviewed in a timely manner, potentially resulting in delays in treatment, a need for readmission, or other unfavorable outcomes.

Even in integrated health systems with advanced electronic health records, missed test results which result in treatment delays remain prevalent.10, 11 Test result management applications aid clinicians in reviewing and acting upon results as they become available and such systems may provide solutions to this problem. At Partners Healthcare in Boston, the Results Manager (RM) application was developed to help clinicians in the ambulatory setting safely, reliably, and efficiently review and act upon test results. The application enables clinicians to prioritize test results, utilize guidelines, and generate letters to patients. This system also prompts physicians to set reminders for future testing.12 In a 2.5‐year study evaluating the impact of this intervention, PCPs at 26 adult primary care practices were able to expedite communication of outpatient laboratory and imaging test results to patients with the help of RM. Patients of physicians who participated in the project reported greater satisfaction with test result communication and with information provided about their condition than did a control group of similar patients.13 RM has not yet been studied in the inpatient setting or at care transitions. We describe an attempt at modifying the Partners RM application to help inpatient physicians manage pending tests at hospital discharge.

Methods

Test Result Management Application

RM was originally developed by Partners Healthcare to improve timely review and appropriate management of test results in the ambulatory setting. RM was developed for and vetted by primarily ambulatory physicians. The application is browser‐based, provider‐centric, and embedded in the LMR to help ambulatory clinicians review and act upon test results in a safe, reliable, and efficient manner. Although RM has access to all inpatient and outpatient data in the Partners Clinical Data Repository (CDR), given the volume of inpatient tests ordered, hospital‐based results are suppressed by default to limit inundating ambulatory clinicians' queues. Therefore, users of RM only receive results of laboratory and radiology tests ordered in the ambulatory setting. They can track these tests for specific patients for a designated period of time by placing the patient on a watch list. Finally, RM incorporates extensive decision support features to classify the degree of abnormality for each result, presents guidelines to help clinicians manage abnormal results, allows clinicians to generate result letters to patients using predefined, context‐sensitive templates, and prompts physicians to set reminders for future testing. Because RM was developed from the ambulatory perspective, there was limited input from hospitalist physicians with regard to inpatient workflow in the original design of the module.12 See Figure 1 for a screen shot of RM and a description of its features.

Figure 1

For purposes of this pilot, we modified RM to allow results of tests ordered in the inpatient setting to be available for viewing (Hospitalist Results Manager, HRM). This feature was turned on only for inpatient physicians as previously defined. Inpatient tests, including pending tests at discharge, continued to be suppressed from PCP's RM queue (however, any physician could access a patient's test result(s) directly from the Partners CDR). Inpatient physicians could track laboratory and radiology results finalized after discharge by keeping discharged patients on their HRM watch list for a designated period of time. The finalized results would become available for review in their HRM queue and abnormal results were displayed prominently at the top of this queue. Inpatient physicians were trained to use HRM in a series of meetings and demonstrations. Although HRM could be accessed from inpatient clinical workstations, it was not part of the inpatient clinical information system.

Results

A total of 35 inpatient physicians participated in the pilot. Among 649 patients discharged during the study period, there were 1075 tests pending of which 555 were subsequently flagged as abnormal in HRM. Study surveys were sent to the 35 inpatient physician participants and 29 were completed, including partial responses (83% survey response rate). The 35 inpatient physician participants had the following characteristics: 22 were male, 13 were female; 21 were trainees and 14 were nontrainees/faculty. All 21 trainees were PGY2s. Nontrainees and faculty varied in experience level (PGY 15: 5, PGY 610: 7, PGY 1120: 1, PGY 21+: 1). Of 29 survey respondents, 7 were from hospital A and 22 were from hospital B; 19 were trainees and 10 were nontrainees/faculty. Of the 6 nonrespondents, 2 were from hospital A and 4 were from hospital B; 2 were trainees and 4 were nontrainees/faculty.

Table 1 shows the results of our survey of inpatient physicians regarding usage of HRM. Of 29 survey respondents, 14 (48%) reported never using HRM. Thirteen (45%) reported using HRM 1 to 2 times per week. None of the respondents used it more than 4 times per week. The frequency of usage was similar for hospitals A and B. Table 2 details barriers to using HRM. Twenty‐three inpatient physicians (79%) reported barriers. Seventeen (59%) thought that results in their HRM queue were not clinically relevant, 16 (55%) felt that HRM did not fit into their daily workflow, 14 (48%) had limited time to use HRM, and 12 (41%) noted that too many results in their HRM queue were on other physician's patients. Seven (24%) reported operational issues and 3 (10%) reported technical issues prohibiting use of HRM. With regard to preferred elements of an ideal results manager system, 21 (72%) inpatient physician respondents wanted to receive notification of abnormal and clinician‐designated pending test results. Four (14%) wanted to receive only abnormal results and 1 (3%) wanted to receive all results. Twenty‐seven (93%) physicians agreed that an ideally designed computerized test result management application would be valuable for managing pending tests at discharge.

Table 3 provides comments from inpatient physician respondents regarding obstacles prohibiting use of HRM and suggestions for future systems.

Discussion

We describe a pilot implementation of a computerized application for the management of pending tests at hospital discharge. From responses to post‐implementation surveys, we were able to identify multiple factors prohibiting successful implementation of the application. These observations may help inform future interventions and evaluations.

Almost half of inpatient physicians reported never using HRM despite training and reminders. The feedback provided by physicians in our study suggested that HRM was not ideally designed from an inpatient physician perspective. We discovered several barriers to its use: (1) HRM overburdened physicians with clinically irrelevant test results, suggesting that more robust filtering of abnormal but low importance test results may be required (eg, a borderline electrolyte abnormality or low but stable hematocrit); (2) HRM did not integrate well into inpatient workflowthe system was not integrated into the inpatient results viewing and computerized physician order entry (CPOE) applications, and therefore required an extra step to access; (3) there was no mechanism of alerting inpatient physicians that finalized test results were available for viewing in their HRM queues (eg, by email or by an alert in the inpatient computer system); (4) because responsibility for these results was unclear, most inpatient physicians had no formal method of managing them, and for many, using HRM represented an additional task; and finally (5) several physicians commented on finding results in their HRM queue that belonged to other physician's patients, implying that the hospital databases were inaccurate in identifying the discharging physician or that rotation schedules, and therefore patient responsibility, had changed in the intervening period. Table 4 summarizes the advantages and respective limitations of features of HRM available to inpatient physicians.

In the literature, there is little information regarding optimal features of a test result management system for transitions from the inpatient to ambulatory care setting. Prior studies outline important functions for results management systems developed for noninpatient sites of care, including the ambulatory and emergency room setting.12, 14, 15 These include a method of prioritizing by degree of abnormality, the ability to reliably and efficiently act upon results, and an automated alerting system for abnormal results. Findings from our study provide insight in defining core functions for result management systems which focus on transitions from the inpatient to ambulatory care setting. These functions include tight integration with applications used by inpatient physicians, clear assignment of responsibility for test results finalized after hospital discharge (as well as a mechanism to reassign responsibility), automated alerts to responsible providers of test results finalized post‐discharge, and ways to automatically filter test results to avoid over‐burdening physicians with clinically irrelevant results.

Almost all surveyed inpatient physicians agreed that an ideally designed electronic post‐discharge results management system would be valuable. For such systems to be successfully adopted, we offer several principles to help guide future work. These include: (1) clarifying responsibility at the time a test is ordered and again at discharge, (2) understanding workflow and communication patterns among inpatient and outpatient clinicians, and (3) integrating technological solutions into existing systems to minimize workflow disruptions. For example, if the primary responsibility for post‐discharge result follow‐up lies with the ordering physician, the system should be integrated within the EMR most often used by inpatient physicians and become part of inpatient physician workflow. If the system depends on administrative databases to identify the responsible providers, these must be accurate. Alternatively, in organizations with computerized provider order entry, responsibility for the result could be assigned when the test is ordered and confirmed at discharge (ie, the results management system would be integrated into the discharge order such that pending tests are reviewed at the time of discharge). The discharging physician should have the ability to assign responsibility for each pending test and select preferred mode(s) of notification once its result is finalized (eg, e‐mail, alphanumeric page, etc.). The system should have the ability to generate an automatic notification to the inpatient and PCP (and perhaps other designated providers involved in the patient's inpatient care), but it should not burden busy clinicians with unnecessary alerts and warnings. Finally, the rules by which results are prioritized must be robust enough to filter out less urgent results, and should be modified to reflect the severity of illness of recently discharged patients. In essence, in consideration of the time constraints of busy clinicians, an ideal results management system should achieve automated notification of test results while minimizing the risk of alert fatigue from the potentially large volume of alerts generated.

Our study has several important limitations. First, although our survey response rate was high, the sample size of actual participants was small. Second, because the study was conducted in 2 similar, tertiary care academic centers, it may not generalize to other settings (we note that hospital B included a nonteaching service similar to those in nonacademic medical centers). This may be particularly true in assessing the importance of specific barriers to use of results management systems, which may vary at different institutions. Third, the representation of survey respondents were skeweda majority of the responses were from trainees (all post‐graduate level [PGY] level 2) and from hospital B. Fourth, we did not actively monitor physician interaction with the test result management application, and therefore, we depended heavily on physician recollection of use of the system when responding to surveys. Finally, we did not convene focus groups of key individuals with regard to the factors facilitating or prohibiting adoption of the system. Use of semi‐structured, key informant interviews (ie, focus groups) before and after implementation of an electronic results management application, have been shown to be effective in evaluating potential barriers and facilitators of adoption.16 Focus groups of and/or interviews with inpatient and PCPs, physician extenders, and housestaff could have been useful to better characterize the potential barriers and facilitators of adoption noted by survey respondents in our study.

In summary, we offer several lessons from our attempt to implement a system to manage pending tests at hospital discharge. The success of implementing future systems to address this patient safety concern will rely on accurately assigning responsibility for these test results, integrating the system within clinical information systems commonly used by the inpatient physician, addressing workflow issues and time constraints, maximizing appropriateness of alerting, and minimizing alert fatigue.

Patients discharged from the hospital with coronary disease complications experience an increased risk of sudden cardiac arrest (SCA), which afflicts over 200,000 people in the United States each year with an 80% to 90% mortality rate.17 Prompt delivery of cardiopulmonary resuscitation (CPR) can triple the probability of survival from SCA, yet less than 25% of SCA victims receive bystander CPR.8 Given that 80% of SCA events occur in the home environment, hospitalization could serve as an important point of capture for family instruction in CPR. Prior investigations have suggested conducting conventional CPR training courses before discharge for family members. However, significant barriers exist to this approach, including the requirement for a certified instructor and a large time commitment for standard training.912

To address these resource and time barriers, the American Heart Association recently established a video self‐instruction (VSI) course in CPR, eliminating the need for an instructor and reducing the time requirement for training to 25 minutes. The course consists of a digital video disc (DVD) and low‐cost inflatable mannequin in a self‐contained kit.13 Several investigations have shown that CPR performance skills of students after VSI courses are similar to those of students after traditional CPR training programs.1417 This VSI program presents the unique opportunity for secondary training, given that the DVD and mannequin may be shared by primary trainees with family members or friends. This VSI approach has not been evaluated in the hospital setting or with family members of patients at risk for SCA. We sought to test the feasibility of an in‐hospital CPR training program using the VSI tool, with the hypothesis that VSI training would be well‐accepted by family members of hospitalized patients with known or suspected coronary disease. We further hypothesized that subjects would be able to perform skills adequately and would be motivated to subsequently share the VSI course with others after their family member's hospital discharge.

METHODS

This prospective, multicenter investigation was approved by the University of Pennsylvania Institutional Review Board (IRB) and represents the initial component of an ongoing longitudinal study testing different methods of CPR education in the hospital setting. Enrollment was conducted at 3 hospitals: The Hospital of the University of Pennsylvania (a 700‐bed tertiary‐care academic medical center), Penn Presbyterian Medical Center (a 300‐bed tertiary‐care and community hospital) and Pennsylvania Hospital (a 400‐bed community hospital).

RESULTS

Subject Characteristics and Demographics

Subjects were recruited at the 3 hospital sites between May 2009 and January 2010. A total of 756 eligible individuals were approached, and 280 accepted enrollment for CPR training, representing a 37% enrollment rate (Figure 1). Of the 280 enrolled, 136 underwent instruction using the VSI training program as described, and 144 were enrolled using an experimental method of VSI training in CPR; this second cohort will be described elsewhere. When comparing the eligible individuals who declined enrollment versus those who accepted (Table 1), no significant differences were observed with regard to age, gender or race (P = NS for each). Common reasons cited for nonparticipation included lack of interest or lack of time (data not shown).

Figure 1

Table 1.Subject Characteristics

	Enrolled (%) n = 136	Screened/Not Enrolled (%) n = 476
NOTE: Percentages are rounded to the nearest integer. CPR training history was not assessed among subjects declining enrollment. Abbreviation: CPR, cardiopulmonary resuscitation. * Immediate family denotes sibling, parent or child of patient.
Age, years	52 15	46 26
Female	94 (69)	326 (68)
Race
White	101 (74)	316 (66)
Black	30 (22)	90 (19)
Hispanic	5 (4)	8 (2)
Other/no response	0 (0)	59 (13)
Relationship to patient
Spouse	49 (36)	171 (36)
Immediate family*	58 (43)	168 (35)
Other	28 (21)	76 (16)
No response	1 (1)	61 (13)
Highest Education
Elementary	1 (1)	1 (1)
Middle schoo1	1 (1)	7 (1)
High school	46 (34)	157 (33)
Some college/vocation	36 (26)	86 (18)
College	30 (22)	92 (19)
Graduate school	22 (16)	39 (8)
No response	0 (0)	94 (20)
Previous CPR training
No	78 (57)
Yes: within past 2 years	0 (0)
Yes: within past 25 years	13 (10)
Yes: within past 510 years	5 (4)
Yes: more than 10 years ago	40 (29)

Demographics of the enrolled subject cohort are detailed in Table 1. The mean age of subjects was 52 15, and 94 of 136 (69%) were female. Enrolled subjects represented spouses or immediate family members of the hospitalized patient in 107 of 136 (79%) of cases, and the vast majority, 118 of 136 (87%), had either never received CPR training or had received it over 10 years prior to current enrollment.

Subject Perspectives

A posttraining survey revealed that most respondents, 101 of 136 (74%) felt comfortable or very comfortable learning CPR from the VSI kit, and 127 of 136 (93%) felt likely or very likely to share the VSI kit (Figure 2).

Figure 2

DISCUSSION

In the current work, we demonstrated the feasibility of using the hospital environment as a point of capture for training family members of at‐risk patients in CPR skills. Given that most SCA events occur in the home setting, family member training may hold greater potential for CPR delivery during actual events than training a similar number of younger laypersons at large. Other investigators have identified the focused identification and CPR training of populations at risk of SCA as an important and potentially efficient step to improve survival.10, 12, 18, 19 CPR education of family members before hospital discharge represents a logical extension of other cardiac risk factor‐focused health care education and services before patients are discharged home, including delivery of dietary counseling, diabetic teaching, and education regarding cardiac symptoms. To our knowledge, our work represents the first hospital‐based, adult, layperson, CPR training program using VSI as an instructional approach.

CPR training via a 25‐minute VSI program has been shown to yield CPR performance quality in trainees that is similar to that generated from formal CPR classes that require 3 hours to 4 hours.1416 While VSI training does not provide CPR certification, it is unlikely that the lack of testing and certification is a barrier to participation for the lay public. Indeed, the removal of the pressures of a formal class and testing may increase interest in CPR training through the VSI method.13, 20, 21

Several prior investigations have exploited VSI methodology as an outreach tool to teach CPR in various settings. A recent study in Norway used VSI CPR kits as refresher tools for hospital employees.22 Other work has focused on use of VSI implementation in schools.20, 21, 23 An example of this latter approach was a Danish initiative in which 35,000 VSI kits were distributed to seventh graders.20 Over 15,000 laypersons received secondary training at home by the initially trained students, highlighting a key advantage of the VSI kit approach. It has been argued that this secondary training phenomenon is among the reasons the VSI educational approach may offer a cost effective means for targeted family training.13, 20, 21

While participants in our program were able to adequately perform CPR skills and expressed self‐reported motivation and empowerment, it must be acknowledged that many trained laypersons still do not act when confronted with an actual arrest event.8 In addition, CPR quality at the time of actual performance may be variable, attenuating the survival benefit.2426 However, several population‐based observational studies have supported the notion that training more laypersons in CPR translates into improved overall survival rates from cardiac arrest.25, 27, 28 Further work will be required to follow newly trained, at‐risk family members over time to determine if SCA events occur, and if so, whether CPR was initiated.

CONCLUSIONS

In this prospective study of hospital‐based CPR training, we have shown that targeted training of families before hospital discharge is feasible, well received by trainees, and has the benefits of secondary training in the home environment, where most SCA events take place. This program could be easily implemented in other hospital or practice settings. Through targeted CPR training programs such as the one described in this investigation, at risk populations that are underrepresented in conventional CPR training classes can be equipped with important life‐saving skills. Further work on a larger scale will be required to measure the impact of such programs on patient outcomes.

Patients discharged from the hospital with coronary disease complications experience an increased risk of sudden cardiac arrest (SCA), which afflicts over 200,000 people in the United States each year with an 80% to 90% mortality rate.17 Prompt delivery of cardiopulmonary resuscitation (CPR) can triple the probability of survival from SCA, yet less than 25% of SCA victims receive bystander CPR.8 Given that 80% of SCA events occur in the home environment, hospitalization could serve as an important point of capture for family instruction in CPR. Prior investigations have suggested conducting conventional CPR training courses before discharge for family members. However, significant barriers exist to this approach, including the requirement for a certified instructor and a large time commitment for standard training.912

To address these resource and time barriers, the American Heart Association recently established a video self‐instruction (VSI) course in CPR, eliminating the need for an instructor and reducing the time requirement for training to 25 minutes. The course consists of a digital video disc (DVD) and low‐cost inflatable mannequin in a self‐contained kit.13 Several investigations have shown that CPR performance skills of students after VSI courses are similar to those of students after traditional CPR training programs.1417 This VSI program presents the unique opportunity for secondary training, given that the DVD and mannequin may be shared by primary trainees with family members or friends. This VSI approach has not been evaluated in the hospital setting or with family members of patients at risk for SCA. We sought to test the feasibility of an in‐hospital CPR training program using the VSI tool, with the hypothesis that VSI training would be well‐accepted by family members of hospitalized patients with known or suspected coronary disease. We further hypothesized that subjects would be able to perform skills adequately and would be motivated to subsequently share the VSI course with others after their family member's hospital discharge.

METHODS

This prospective, multicenter investigation was approved by the University of Pennsylvania Institutional Review Board (IRB) and represents the initial component of an ongoing longitudinal study testing different methods of CPR education in the hospital setting. Enrollment was conducted at 3 hospitals: The Hospital of the University of Pennsylvania (a 700‐bed tertiary‐care academic medical center), Penn Presbyterian Medical Center (a 300‐bed tertiary‐care and community hospital) and Pennsylvania Hospital (a 400‐bed community hospital).

RESULTS

Subject Characteristics and Demographics

Subjects were recruited at the 3 hospital sites between May 2009 and January 2010. A total of 756 eligible individuals were approached, and 280 accepted enrollment for CPR training, representing a 37% enrollment rate (Figure 1). Of the 280 enrolled, 136 underwent instruction using the VSI training program as described, and 144 were enrolled using an experimental method of VSI training in CPR; this second cohort will be described elsewhere. When comparing the eligible individuals who declined enrollment versus those who accepted (Table 1), no significant differences were observed with regard to age, gender or race (P = NS for each). Common reasons cited for nonparticipation included lack of interest or lack of time (data not shown).

Figure 1

Table 1.Subject Characteristics

	Enrolled (%) n = 136	Screened/Not Enrolled (%) n = 476
NOTE: Percentages are rounded to the nearest integer. CPR training history was not assessed among subjects declining enrollment. Abbreviation: CPR, cardiopulmonary resuscitation. * Immediate family denotes sibling, parent or child of patient.
Age, years	52 15	46 26
Female	94 (69)	326 (68)
Race
White	101 (74)	316 (66)
Black	30 (22)	90 (19)
Hispanic	5 (4)	8 (2)
Other/no response	0 (0)	59 (13)
Relationship to patient
Spouse	49 (36)	171 (36)
Immediate family*	58 (43)	168 (35)
Other	28 (21)	76 (16)
No response	1 (1)	61 (13)
Highest Education
Elementary	1 (1)	1 (1)
Middle schoo1	1 (1)	7 (1)
High school	46 (34)	157 (33)
Some college/vocation	36 (26)	86 (18)
College	30 (22)	92 (19)
Graduate school	22 (16)	39 (8)
No response	0 (0)	94 (20)
Previous CPR training
No	78 (57)
Yes: within past 2 years	0 (0)
Yes: within past 25 years	13 (10)
Yes: within past 510 years	5 (4)
Yes: more than 10 years ago	40 (29)

Demographics of the enrolled subject cohort are detailed in Table 1. The mean age of subjects was 52 15, and 94 of 136 (69%) were female. Enrolled subjects represented spouses or immediate family members of the hospitalized patient in 107 of 136 (79%) of cases, and the vast majority, 118 of 136 (87%), had either never received CPR training or had received it over 10 years prior to current enrollment.

Subject Perspectives

A posttraining survey revealed that most respondents, 101 of 136 (74%) felt comfortable or very comfortable learning CPR from the VSI kit, and 127 of 136 (93%) felt likely or very likely to share the VSI kit (Figure 2).

Figure 2

DISCUSSION

In the current work, we demonstrated the feasibility of using the hospital environment as a point of capture for training family members of at‐risk patients in CPR skills. Given that most SCA events occur in the home setting, family member training may hold greater potential for CPR delivery during actual events than training a similar number of younger laypersons at large. Other investigators have identified the focused identification and CPR training of populations at risk of SCA as an important and potentially efficient step to improve survival.10, 12, 18, 19 CPR education of family members before hospital discharge represents a logical extension of other cardiac risk factor‐focused health care education and services before patients are discharged home, including delivery of dietary counseling, diabetic teaching, and education regarding cardiac symptoms. To our knowledge, our work represents the first hospital‐based, adult, layperson, CPR training program using VSI as an instructional approach.

CPR training via a 25‐minute VSI program has been shown to yield CPR performance quality in trainees that is similar to that generated from formal CPR classes that require 3 hours to 4 hours.1416 While VSI training does not provide CPR certification, it is unlikely that the lack of testing and certification is a barrier to participation for the lay public. Indeed, the removal of the pressures of a formal class and testing may increase interest in CPR training through the VSI method.13, 20, 21

Several prior investigations have exploited VSI methodology as an outreach tool to teach CPR in various settings. A recent study in Norway used VSI CPR kits as refresher tools for hospital employees.22 Other work has focused on use of VSI implementation in schools.20, 21, 23 An example of this latter approach was a Danish initiative in which 35,000 VSI kits were distributed to seventh graders.20 Over 15,000 laypersons received secondary training at home by the initially trained students, highlighting a key advantage of the VSI kit approach. It has been argued that this secondary training phenomenon is among the reasons the VSI educational approach may offer a cost effective means for targeted family training.13, 20, 21

While participants in our program were able to adequately perform CPR skills and expressed self‐reported motivation and empowerment, it must be acknowledged that many trained laypersons still do not act when confronted with an actual arrest event.8 In addition, CPR quality at the time of actual performance may be variable, attenuating the survival benefit.2426 However, several population‐based observational studies have supported the notion that training more laypersons in CPR translates into improved overall survival rates from cardiac arrest.25, 27, 28 Further work will be required to follow newly trained, at‐risk family members over time to determine if SCA events occur, and if so, whether CPR was initiated.

CONCLUSIONS

In this prospective study of hospital‐based CPR training, we have shown that targeted training of families before hospital discharge is feasible, well received by trainees, and has the benefits of secondary training in the home environment, where most SCA events take place. This program could be easily implemented in other hospital or practice settings. Through targeted CPR training programs such as the one described in this investigation, at risk populations that are underrepresented in conventional CPR training classes can be equipped with important life‐saving skills. Further work on a larger scale will be required to measure the impact of such programs on patient outcomes.

Patients discharged from the hospital with coronary disease complications experience an increased risk of sudden cardiac arrest (SCA), which afflicts over 200,000 people in the United States each year with an 80% to 90% mortality rate.17 Prompt delivery of cardiopulmonary resuscitation (CPR) can triple the probability of survival from SCA, yet less than 25% of SCA victims receive bystander CPR.8 Given that 80% of SCA events occur in the home environment, hospitalization could serve as an important point of capture for family instruction in CPR. Prior investigations have suggested conducting conventional CPR training courses before discharge for family members. However, significant barriers exist to this approach, including the requirement for a certified instructor and a large time commitment for standard training.912

To address these resource and time barriers, the American Heart Association recently established a video self‐instruction (VSI) course in CPR, eliminating the need for an instructor and reducing the time requirement for training to 25 minutes. The course consists of a digital video disc (DVD) and low‐cost inflatable mannequin in a self‐contained kit.13 Several investigations have shown that CPR performance skills of students after VSI courses are similar to those of students after traditional CPR training programs.1417 This VSI program presents the unique opportunity for secondary training, given that the DVD and mannequin may be shared by primary trainees with family members or friends. This VSI approach has not been evaluated in the hospital setting or with family members of patients at risk for SCA. We sought to test the feasibility of an in‐hospital CPR training program using the VSI tool, with the hypothesis that VSI training would be well‐accepted by family members of hospitalized patients with known or suspected coronary disease. We further hypothesized that subjects would be able to perform skills adequately and would be motivated to subsequently share the VSI course with others after their family member's hospital discharge.

METHODS

This prospective, multicenter investigation was approved by the University of Pennsylvania Institutional Review Board (IRB) and represents the initial component of an ongoing longitudinal study testing different methods of CPR education in the hospital setting. Enrollment was conducted at 3 hospitals: The Hospital of the University of Pennsylvania (a 700‐bed tertiary‐care academic medical center), Penn Presbyterian Medical Center (a 300‐bed tertiary‐care and community hospital) and Pennsylvania Hospital (a 400‐bed community hospital).

RESULTS

Subject Characteristics and Demographics

Subjects were recruited at the 3 hospital sites between May 2009 and January 2010. A total of 756 eligible individuals were approached, and 280 accepted enrollment for CPR training, representing a 37% enrollment rate (Figure 1). Of the 280 enrolled, 136 underwent instruction using the VSI training program as described, and 144 were enrolled using an experimental method of VSI training in CPR; this second cohort will be described elsewhere. When comparing the eligible individuals who declined enrollment versus those who accepted (Table 1), no significant differences were observed with regard to age, gender or race (P = NS for each). Common reasons cited for nonparticipation included lack of interest or lack of time (data not shown).

Figure 1

Table 1.Subject Characteristics

	Enrolled (%) n = 136	Screened/Not Enrolled (%) n = 476
NOTE: Percentages are rounded to the nearest integer. CPR training history was not assessed among subjects declining enrollment. Abbreviation: CPR, cardiopulmonary resuscitation. * Immediate family denotes sibling, parent or child of patient.
Age, years	52 15	46 26
Female	94 (69)	326 (68)
Race
White	101 (74)	316 (66)
Black	30 (22)	90 (19)
Hispanic	5 (4)	8 (2)
Other/no response	0 (0)	59 (13)
Relationship to patient
Spouse	49 (36)	171 (36)
Immediate family*	58 (43)	168 (35)
Other	28 (21)	76 (16)
No response	1 (1)	61 (13)
Highest Education
Elementary	1 (1)	1 (1)
Middle schoo1	1 (1)	7 (1)
High school	46 (34)	157 (33)
Some college/vocation	36 (26)	86 (18)
College	30 (22)	92 (19)
Graduate school	22 (16)	39 (8)
No response	0 (0)	94 (20)
Previous CPR training
No	78 (57)
Yes: within past 2 years	0 (0)
Yes: within past 25 years	13 (10)
Yes: within past 510 years	5 (4)
Yes: more than 10 years ago	40 (29)

Demographics of the enrolled subject cohort are detailed in Table 1. The mean age of subjects was 52 15, and 94 of 136 (69%) were female. Enrolled subjects represented spouses or immediate family members of the hospitalized patient in 107 of 136 (79%) of cases, and the vast majority, 118 of 136 (87%), had either never received CPR training or had received it over 10 years prior to current enrollment.

Subject Perspectives

A posttraining survey revealed that most respondents, 101 of 136 (74%) felt comfortable or very comfortable learning CPR from the VSI kit, and 127 of 136 (93%) felt likely or very likely to share the VSI kit (Figure 2).

Figure 2

DISCUSSION

In the current work, we demonstrated the feasibility of using the hospital environment as a point of capture for training family members of at‐risk patients in CPR skills. Given that most SCA events occur in the home setting, family member training may hold greater potential for CPR delivery during actual events than training a similar number of younger laypersons at large. Other investigators have identified the focused identification and CPR training of populations at risk of SCA as an important and potentially efficient step to improve survival.10, 12, 18, 19 CPR education of family members before hospital discharge represents a logical extension of other cardiac risk factor‐focused health care education and services before patients are discharged home, including delivery of dietary counseling, diabetic teaching, and education regarding cardiac symptoms. To our knowledge, our work represents the first hospital‐based, adult, layperson, CPR training program using VSI as an instructional approach.

CPR training via a 25‐minute VSI program has been shown to yield CPR performance quality in trainees that is similar to that generated from formal CPR classes that require 3 hours to 4 hours.1416 While VSI training does not provide CPR certification, it is unlikely that the lack of testing and certification is a barrier to participation for the lay public. Indeed, the removal of the pressures of a formal class and testing may increase interest in CPR training through the VSI method.13, 20, 21

Several prior investigations have exploited VSI methodology as an outreach tool to teach CPR in various settings. A recent study in Norway used VSI CPR kits as refresher tools for hospital employees.22 Other work has focused on use of VSI implementation in schools.20, 21, 23 An example of this latter approach was a Danish initiative in which 35,000 VSI kits were distributed to seventh graders.20 Over 15,000 laypersons received secondary training at home by the initially trained students, highlighting a key advantage of the VSI kit approach. It has been argued that this secondary training phenomenon is among the reasons the VSI educational approach may offer a cost effective means for targeted family training.13, 20, 21

While participants in our program were able to adequately perform CPR skills and expressed self‐reported motivation and empowerment, it must be acknowledged that many trained laypersons still do not act when confronted with an actual arrest event.8 In addition, CPR quality at the time of actual performance may be variable, attenuating the survival benefit.2426 However, several population‐based observational studies have supported the notion that training more laypersons in CPR translates into improved overall survival rates from cardiac arrest.25, 27, 28 Further work will be required to follow newly trained, at‐risk family members over time to determine if SCA events occur, and if so, whether CPR was initiated.

CONCLUSIONS

In this prospective study of hospital‐based CPR training, we have shown that targeted training of families before hospital discharge is feasible, well received by trainees, and has the benefits of secondary training in the home environment, where most SCA events take place. This program could be easily implemented in other hospital or practice settings. Through targeted CPR training programs such as the one described in this investigation, at risk populations that are underrepresented in conventional CPR training classes can be equipped with important life‐saving skills. Further work on a larger scale will be required to measure the impact of such programs on patient outcomes.