Mobile computing devices, such as tablets, are increasingly being used to facilitate medical care. Tablets have been shown to be acceptable to patients when used by their clinician to access clinical information and patient data during consultation1,2; however, no literature assesses the use of tablets in the management of patients who have sustained trauma.
Trauma patients often request to view their radiographs during hospital admission, but this might not to be possible if the patient is confined to a bed and if no facility exists to show the images to the patient. Tablets are a mobile medium on which radiographic images may be displayed and shown to patients at their bedsides. The authors’ hypothesis was that patient satisfaction and understanding of the injuries and the management plan proposed at admission would be improved through using tablets to enable bedside radiograph viewing.
The objectives of this study were to assess patient-reported outcomes to confirm whether a desire existed to view radiographs after admission for trauma management; to determine whether this was perceived by patients to benefit their experience with, understanding of, and involvement in decision making regarding their injury and the proposed management plan; and, if so, to quantify any improvement in these parameters after viewing the radiographs.
Materials and Methods
Two cohorts of 50 consecutive patients who were admitted to a district general hospital trauma unit after sustaining a traumatic injury requiring radiographic evaluation via radiographs, computed tomography, or magnetic resonance imaging were prospectively selected for inclusion. All patients aged 18 years or older, or a parent or guardian accompanying an adolescent or child, were included. Patients who were unable to demonstrate capacity as a result of acute or chronic confusion, such as head injury or dementia, or who did not give consent were excluded. Approval for the study was granted by the institutional review board.
Patients in the preintervention cohort completed a questionnaire after being examined by the on-call orthopedic consultant on a standard post-take trauma ward-round. (A post-take ward round is a ward round conducted by the consultant who was on-call the previous day. It is the point at which the consultant reviews patients for the first time since their admission.) The questionnaire included questions from the U.K. National Health Service 2011 inpatient survey and was adapted to include visual analog scales (VAS) and multipoint Likert scales to assess patient satisfaction with, understanding of, and involvement in the explanation of their injury and proposed management plan.3 Questions were also included to assess whether patients perceived that having the opportunity to view their radiographs as part of the consultation would have affected these variables. Patient demographics were collected during questionnaire administration, including age, sex, and type of injury sustained.
Patients in the postintervention cohort were given the opportunity to view their radiographs as part of the consultant post-take trauma ward-round. The images relevant to their acute injury were displayed on a Motion C5t Tablet PC (Motion Computing, Austin, Texas) during the consultation. The consultant was briefed beforehand that the patient would be offered the opportunity to view their radiographic images during consultation, but it was left to the discretion of the consultant and patient as to how those images were used during the discussion of the injury and the proposed management plan. After the post-take ward-round, patients were given the same questionnaire as the preintervention cohort, with additional questions assessing any effect viewing their radiographs had on their satisfaction with, understanding of, and involvement in the explanation of their injury and proposed management plan.
All analyses were performed using SPSS version 19 software (IBM Corporation, Armonk, New York). Data were assessed for normal distribution using the Shapiro-Wilk test. Logarithmic transformation was then applied to non-normally distributed data prior to analysis. Normally distributed variables were reported as means, which were compared using Student’s t test. The significance of differences for categorical data (reported as medians) were assessed using the Mann-Whitney U test. A P value less than .05 was considered statistically significant.
The preintervention cohort included 21 women and 29 men, whose mean age was 59 years (range, 18–96 years). The postintervention cohort included 27 women and 23 men with a mean age of 67 years (range, 4–98 years). No significant difference was found in age (P=.5) or sex (P=.2) between the 2 cohorts. The results comparing survey responses without and with tablet use on the post-take ward-round are summarized in Tables 1 and 2.
Table 1: Comparison of Likert Scale Responses
Table 2: Comparison of Visual Analogue Scale Responses
Patients in the preintervention cohort reported a median score of 7.3 (interquartile range [IQR], 5.3–9.1) of 10 for involvement in decisions about their care and treatment. Forty-two patients reported receiving the right amount of information about their condition or treatment. Forty-six patients reported being told their diagnosis by the consultant on the post-take ward-round. Of the remaining 4 patients, 1 had already been told the diagnosis on admission, 1 did not wish to know the diagnosis, and 2 had not been told the diagnosis. The median score for whether the diagnosis was explained in a way that could be understood was 8.9 (IQR, 7.4–9.8).
Forty-nine patients reported speaking to a consultant during their admission. Of these 49 patients, 47 reported having the opportunity to ask questions. Forty-four patients did not have the opportunity to view their radiographic images, and 6 patients had been shown their images by the admitting team before the post-take ward-round. Of the 44 patients, 32 reported that viewing the images would have helped them understand what they were told about the diagnosis and management plan. All 6 patients who viewed their images reported that it had helped them understand what the consultant had told them on the post-take ward-round. The median score for how well the injury was explained by the consultant was 8.3 (IQR, 6.8–9.4), and the median score for explanation of the management plan was 8.4 (IQR, 7.0–9.4).
Compared with the preintervention cohort, patients in the postintervention cohort who were shown their radiographic images on the post-take ward-round reported a significant improvement (P=.0001) in perceived involvement in decisions made about their care and treatment, with a median score of 9.2 (IQR, 7.9–9.7). An improvement was also shown in the number of patients reporting being given the right amount of information about their condition or treatment (46 with tablet use vs 42 without tablet use).
All 50 patients reported being told their diagnosis by the consultant on the post-take ward-round. No difference was demonstrated between the pre- and postintervention cohorts for the diagnosis being explained in a way that could be understood by the patient, with a median score of 9.1 (IQR, 8.3–9.8) for the postintervention cohort (P=.33). Forty-six patients reported seeing their images on the post-take ward-round. One patient reported not being shown the images, and 3 patients declined to view the images. Of these 3 patients, 1 reported that it would not add anything to understanding the injury, 1 reported being squeamish and not wanting to see the images, and 1 said it would be a reminder of how unfortunate it was to dislocate his or her hip and that he or she had seen radiographs of a previous hip replacement. Of the 46 patients who were shown their images, 45 reported that it helped them understand what the consultant had told them.
Compared with the preintervention cohort, the median satisfaction score for how well the injury was explained by the consultant improved from 8.3 (IQR, 6.8–9.4) to 9.1 (IQR, 8.0–9.7) (P=.02) and the median score for explanation of the management plan improved from 8.4 (IQR, 7.0–9.4) to 8.7 (IQR, 8.0–9.7), although this only bordered on statistical significance (P=.05). Of the 46 patients who saw their images, 35 reported that an explanation of their injury would not have been as effective if they had not been shown their images, 3 were not sure, and 8 reported that it would have been as effective. Of the 46 patients who saw their images, 44 reported that doing so had a positive effect on their overall experience of their hospital treatment, and 2 were unsure. No negative experience from viewing images was reported.
Mandatory data collection in orthopedics is increasing. The U.K. Department for Health requires preoperative and 6-month postoperative recording of Oxford scores and EuroQol scores in all elective hip and knee arthroplasties, as well as procedure and implant data at the time of surgery for the U.K. National Joint Registry.4 Other patient- reported outcome measures and clinical research tools are also used to facilitate audits and research at regional and national levels.
Holzinger et al5 reported that research data collection is facilitated by the use of tablets. Data inputted by patients can be automatically transferred to a database, making the data immediately available to clinicians during consultations. For example, when a patient completes an Oxford Hip Score questionnaire in the waiting room, the result is automatically calculated and made available to view when the patient is examined and is sent to the national database simultaneously. Removing the requirement for manual data entry by clinician or research personnel is time- and cost-effective. Benefits have also been demonstrated in other clinical settings, where significant time savings have been shown with the introduction of tablets in the intensive care environment for data entry, including recording scoring tools and patient beside observations.6,7
Richter et al8 reported a patient preference to use tablets over paper-and-pencil data entry for questionnaires, including patients with little experience with computer use and those with a disability. Data collection from patients with inadequate language proficiency and health literacy can also be facilitated through tablet use.9
Tablets may be used to improve the logistics of daily patient contact in the clinical setting. They facilitate the efficiency of accessing computer records and radiographic images by reducing the need to repeatedly log in and out of static computers and by eliminating the need to travel between the patient and computer workstation. Horng et al10 showed a statistically significant reduction in logins and time spent accessing their emergency department patient information system compared with use of a static computer. This can potentially improve the throughput (ie, the time it takes to review patients’ results and images, decide their care, and decide whether to admit or discharge them) of patients in a busy clinical setting by facilitating the logistics of patient contact and computer access.
Tablets have been useful in facilitating the education of patients and clinicians. Published work has shown the benefit of tablets in the delivery of information to patients and for use in training clinicians to perform procedural skills, including bronchoscopy and ear, nose, and throat surgery.11–13
To the current authors’ knowledge, this is the first study investigating the use of tablets in the trauma setting and the effect on patient-reported outcomes of their management. Despite being well received by patients, the use of tablets as proposed may require additional time and effort undertaken by the surgical team. The authors appreciate that given the time pressures that exist in trauma care, using tablets in the way proposed in this study might not always be feasible. However, the explanation process was often more efficient with the aid of the images displayed on the tablet.
The use of tablets in the trauma setting to allow patients to view radiographic images of their injuries improves patient involvement, explanation of the injury as part of the consent process, and overall experience of care. In combination with facilitation of data collection and improved patient contact, tablets should be considered as an integral part of trauma unit hardware.
- Bullard MJ, Meurer DP, Colman I, Holroyd BR, Rowe BH. Supporting clinical practice at the bedside using wireless technology. Acad Emerg Med. 2004; 11(11):1186–1192 doi:10.1111/j.1553-2712.2004.tb00703.x [CrossRef] .
- Strayer SM, Semler MW, Kington ML, Tanabe KO. Patient attitudes towards use of tablet computers in the exam room. Fam Med. 2010; 42(9):643–647.
- Wewers ME, Lowe NK. A critical review of visual analogue scales in the measurement of clinical phenomena. Res Nurs Health. 1990; 13(4):227–236 doi:10.1002/nur.4770130405 [CrossRef] .
- Goldberg AJ, MacGregor A, Spencer SA. An information revolution in orthopaedics. J Bone Joint Surg Br. 2012; 94(4):454–458 doi:10.1302/0301-620X.94B4.28306 [CrossRef] .
- Holzinger A, Kosec P, Schwantzer G, Debevc M, Hofmann-Wellenhof R, Frühauf J. Design and development of a mobile computer application to reengineer workflows in the hospital and the methodology to evaluate its effectiveness. J Biomed Inform. 2011; 44(6):968–977 doi:10.1016/j.jbi.2011.07.003 [CrossRef] .
- Bürkle T, Beisig A, Ganslmayer M, Prokosch HU. A randomized controlled trial to evaluate an electronic scoring tool in the ICU. Stud Health Technol Inform. 2008; 136:279–284.
- Vargas PA, Robles E, Harris J, Radford P. Using information technology to reduce asthma disparities in underserved populations: a pilot study. J Asthma. 2010; 47(8):889–894 doi:10.3109/02770903.2010.497887 [CrossRef] .
- Richter JG, Becker A, Koch T, et al. Self-assessments of patients via Tablet PC in routine patient care: comparison with standardised paper questionnaires. Ann Rheum Dis. 2008; 67(12):1739–1741 doi:10.1136/ard.2008.090209 [CrossRef] .
- Horng S, Goss FR, Chen RS, Nathanson LA. Prospective pilot study of a tablet computer in an Emergency Department. Int J Med Inform. 2012; 81(5):314–319 doi:10.1016/j.ijmedinf.2011.12.007 [CrossRef] .
- Wager KA, Schaffner MJ, Foulois B, Swanson Kazley A, Parker C, Walo H. Comparison of the quality and timeliness of vital signs data using three different data-entry devices. Comput Inform Nurs. 2010; 28(4):205–212 doi:10.1097/NCN.0b013e3181e1df19 [CrossRef] .
- Finkelstein J, Lapshin O, Cha E. Feasibility of promoting smoking cessation among methadone users using multimedia computer-assisted education. J Med Internet Res. 2008; 10(5):e33 doi:10.2196/jmir.1089 [CrossRef] .
- Strauss M, Wittmann W, Strauss G, Hofer M, Lueth TC. Virtual endoscopy on a portable navigation system for ENT surgery. Stud Health Technol Inform. 2008; (132):490–492.
- Yu KC, Gibbs JD, Graham MW, Higgins WE. Image-based reporting for bronchoscopy. J Digit Imaging. 2010; 23(1):39–50 doi:10.1007/s10278-008-9170-8 [CrossRef] .
Comparison of Likert Scale Responses
|Question/Result||Answers Without Tablet Use, No. (%)||Answers With Tablet Use, No. (%)|
|How much information about your condition or treatment was given to you?|
| Not enough||6 (12)||2 (4)|
| The right amount||42 (84)||47 (94)|
| Too much||2 (4)||1 (2)|
|Have you been told your diagnosis since being admitted to hospital?|
| Yes||46 (92)||50 (100)|
| No||4 (8)|
|Were you shown your radiographs or scans when you saw the consultant?|
| Yes||6 (12)||46 (92)|
| No||43 (86)||4 (8)|
| Not answered||1 (2)|
|If you were not shown your radiographs, do you think seeing them would have helped you to understand what your consultant told you?|
| Yes (definitely or to some extent)||35 (70)||N/Aa|
| No (definitely or probably not)||9 (18)||N/Aa|
| Not answered or unsure||6 (12)||N/Aa|
|If you were were shown your radiographs, do you think seeing them helped you to understand what your consultant told you?|
| Yes (definitely or to some extent)||25 (50)||45 (90)|
| No (definitely or probably not)||5 (10)||1 (2)|
| Not answered or unsure||20 (40)||4 (8)|
Comparison of Visual Analogue Scale Responses
|Question||VAS Wthout Tablet Use||VAS With Tablet Use||Mann-Whitney U Score Result, Pa|
|Were you involved as much as you wanted to be in decisions about your care and treatment?b||7.3||9.8||(5.3–9.1)||9.2||10||(7.9–9.7)||.0001|
|Was your diagnosis explained to you in a way that you could understand?c||8.9||10||(7.4–9.8)||9.1||10||(8.3–9.8)||.33|
|How well did the consultant explain your injury to you?c||8.3||9.3||(6.8–9.4)||9.1||10||(8.0–9.7)||.02|
|How well did the consultant explain the plan for your treatment?c||8.4||8.5||(7.0–9.4)||8.7||10||(8.0–9.68)||.05|