Inter-professional delirium education and care: a qualitative feasibility study of implementing a delirium Smartphone application

Delirium is a common medical condition with a high prevalence in hospital settings, with rates ranging between 6 and 56 % depending on the patient population [1]. If not recognized early, delirium leads to increased morbidity and mortality [2]. Despite its prevalence and serious sequelae, it often goes unrecognized. Moreover, effective delirium management requires a multi-component intervention, including the use of interprofessional teams and evidence-based interventions at the point of care [3].

Given the need for improved delirium recognition and collaborative management, there has been an increasing focus on delirium education interventions. However, inter-professional delirium training is typically offered as a one-time educational intervention [4]. Whilst these conventional programs might be effective in providing clinicians and healthcare professionals with increased knowledge and skills pertaining to the recognition and the treatment of delirium, prior studies have highlighted the inherent limitations of such one-time intervention [4]. Recent studies and reviews have recommended the development of point of care practice tools that clinicians across professions could use in addition to other delirium education components [4]. It is believed that with such tools, clinicians will be more competent in managing delirium, resulting in improved health outcomes.

One vehicle for increasing access of delirium practice tools at the point of care is E-health [5]. The World Health organization defines E-health as the process in which health resources and healthcare are being communicated and transferred by electronic media [6]. Over the last decade, there has been a massive advance in E-health, which has led to the creation of multiple online learning platforms for clinicians and allied healthcare professionals to stay abreast of the latest treatment algorithms and guidelines. Since 2010, there has been an accompanying advancement in M-health as well, which refers to the usage of mobile and smartphone technologies in healthcare. With the growth and advancement in M-health, smartphone are being increasingly used medical disciplines [6], surgical disciplines [7] and psychiatry [8]. It is thus not surprising that with the introduction of smartphones, healthcare professionals are beginning to turn to smartphone applications to aid them in clinical assessment and management [6]. Prior studies have highlighted the utility of smartphone applications as quick and interactive platforms that are time saving and allow for increased confidence and accuracy, as well as error reduction in the detection and management of various clinical conditions [6]. By providing instant access to medical information, it is postulated that applications not only improve communication amongst staff, but help healthcare professionals in decision-making. The cumulative effect of these factors would be the reduction in the overall economic costs incurred by the healthcare organization [6].

A review of the current published literature using the keywords “Delirium, smartphone” revealed that there are only three studies published to date about the perception of the usefulness of a smartphone application. Zhang et al. [9] described the development of a delirium educational resource application that contains guideline-based information on the assessment and management of delirium. This delirium application also includes practice tools developed to assist clinicians at a Canadian healthcare institution. Initial results, based on a sample of 19 clinicians and allied healthcare professional demonstrated that there was a shift in the confidence level of the participants after they used the smartphone applications [9]. Zhang et al. [9] also managed to acquire healthcare user perceptions about the application in their study. Tieges Z et al. (2015) [10] described the potential of a smartphone application in the objective detection of attentional issues in delirium. Sangha S et al. (2015) [11] highlighted how a smartphone application could potentially be helpful in terms of cognitive assessment. Whilst there are to-date only these published studies, there are a multitude of delirium related applications on the respective application stores. It would be timely if there were a scoping review or a content analysis looking into the individual features of these applications and evaluating their information quality.

There are limitations that could potentially impact the receptiveness of smartphone technology in healthcare. Baig et al. (2015) [12] reviewed a series of mobile healthcare applications (aside to delirium applications) and identified several limitations that could impact the receptiveness of smartphone applications in medicine. These challenges include issues related to reliability, efficiency and acceptability. Their review identified the need for smartphone applications to be user-centered in design in order for them to be more widely used and accepted. In addition, the availability of the same application on different platforms could potentially increase its use in practice. To date, most of the smartphone applications are programmed specifically for an individual platform. Other factors such as security and privacy also limit the use of smartphone applications in medical settings.

This is one of the first studies to describe perceptions and user experiences with an inter-professionally developed smartphone application to support delirium management in an acute care setting. Our findings identified several themes related to the implementation and use of this smartphone application in an acute care clinical setting. These themes will provide clinicians preparing to use a smartphone application to support delirium care with an implementation framework.

With the massive advances in technologies, there has been increased adoption of technology for inter-professional medical education. With regard to delirium education, Chao et al. (2012) [16] have previously evaluated the potential of an online curriculum in teaching delirium management to medical students. The students were receptive to the online curriculum and this innovative teaching method was found to be equally effective to a conventional lecture. This study highlights the feasibility of having an online platform for education in delirium education and management. A more recent study by Middle and Miklancie (2015) [17], suggested that in order to improve nursing professionals’ knowledge regarding delirium recognition, educational strategies should focus more on teaching health professionals about diagnostic tools, as well as implementing a structured delirium educational program. We suggest that our findings corroborate previous research demonstrating health care professionals’ positive response to innovative educational strategies. We propose that this is due to the ability for the application to provide structured and evidence-based material in a highly accessible manner.

We have identified several challenges with its implementation. Of note, Baig et al. (2015) [12] highlighted similar challenges. They noted issues with reliability of the application and generalizability across various smartphone platforms, and highlighted the importance of having end users involved in the initial application conceptualization process to ensure that the design is user-centred.

The challenges that we elicited from our focus group data are valuable since they inform future research and application development. Focus group participants identified the need to embed smartphone applications into existing technological infrastructure, for example, through integration with electronic health records. Furthermore, participants highlighted several challenges in incorporating smartphone devices into their unit, specifically with regard to infection control and professionalism. They also highlighted and surfaced concerns regarding the breadth and depth of the information included, specifically having too much text information to apply in a meaningful way at the patient’s bedside. Despite the challenges discussed above, focus group participants highlighted the advantages of smartphone applications, including the potential for rapid access to evidence-based material regarding delirium treatment and management, both for clinical practice and patient education at the point of care.

The main strength this study is that it supports clinician acceptance and feasibility of using novel technologies for inter-professional delirium care. We have demonstrated that a smartphone application could be an intervention tool that improves helps healthcare professionals in delirium management. These results are in keeping with previous studies demonstrating the feasibility of an online educational portal for delirium education [13].

Nevertheless, there are inherent limitations in our current study. Our sample size was small, meaning that our findings should be viewed as preliminary. Furthermore, our data comes from healthcare professionals who owned a smartphone and could use it in their day-to-day clinical work. Our focus group participants were nurses who worked on the general surgery unit. Thus, additional studies are needed to determine whether our findings would generalize to other healthcare settings and specialties. Moreover, we have not managed to capture the absolute amount of time that our participants have spent using the application. We have also not compared the amount of time they have send using our application against other healthcare applications. The authors acknowledge that the questions we have asked might not be comprehensive enough to capture concerns pertaining to the integration of M-health in delirium education at the bedside. The results which the authors have acquired have not assessed how such an application could have improved clinical care, as there is no further analysis done to determine if this results in a reduction in the absolute length of stay. Lastly, the authors have not made use of validated questionnaires to determine user perception quantitatively.

While most of the current studies published have supported the efficacy of mobile applications in clinical care, our current findings demonstrate that while this modality of technology does appeal to healthcare professionals, it is also key to note potential implementation challenges. The integration of mobile applications in clinical settings needs to take into account the needs of the end user. Our findings provide insights into these potential barriers and could be used to assist healthcare professionals considering the development and use of an inter-professional clinical care application in their setting.

This study received approval by the University Health Network Research Ethic Board. All participants were explained the study details and given time to review the consent form before providing written informed consent.

Not applicable.