Objectives Poor electronic health record (EHR) usability is associated with patient safety concerns, user dissatisfaction, and provider burnout. EHR certification requires vendors to perform user testing. However, there are no such requirements for site-specific implementations. Health care organizations customize EHR implementations, potentially introducing usability problems. Site-specific usability evaluations may help to identify these concerns, and “discount” usability methods afford health systems a means of doing so even without dedicated usability specialists. This report characterizes a site-specific discount user testing program launched at an academic medical center. We describe lessons learned and highlight three of the EHR features in detail to demonstrate the impact of testing on implementation decisions and on users. Methods Thirteen new EHR features which had already undergone heuristic evaluation and iterative design were evaluated over the course of three user test events. Each event included five to six users. Participants used think aloud technique. Measures of user efficiency, effectiveness, and satisfaction were collected. Usability concerns were characterized by the type of usability heuristic violated and by correctability. Results Usability concerns occurred at a rate of 2.5 per feature tested. Seventy percent of the usability concerns were deemed correctable prior to implementation. The first highlighted feature was moved to production despite low single ease question (SEQ) scores which may have predicted its subsequent withdrawal from production based on post implementation feedback. Another feature was rebuilt based on usability findings, and a new version was retested and moved to production. A third feature highlights an easily correctable usability concern identified in user testing. Quantitative usability metrics generally reinforced qualitative findings. Conclusion Simplified user testing with a limited number of participants identifies correctable usability concerns, even after heuristic evaluation. Our discount usability approach to site-specific usability has a role in implementations and may improve the usability of the EHR for the end user.

Introduction Successful rehabilitation of patients with burn injuries requires an in-depth occupational therapy (OT) and physical therapy (PT) evaluation early in the acute phase of a patient’s injury to develop a detailed therapy plan of care. In addition, it is a standard of the American Burn Association for verified burn centers to have a comprehensive rehabilitation program designed for burn patients within 24 hours of admission. However, there is no standardized report for tracking timeliness of issuing PT/OT orders or completion of therapy evaluations by PT/OT after a patient is admitted to a burn unit. This quality improvement study details the creation of a “Time to PT/OT Order Placement and Evaluation Completion Report” and results of a quality improvement process used to improve these metrics. Methods A multi-disciplinary workgroup was created and included a burn surgeon, PT and program nurse coordinator and an electronic report was created in collaboration with the hospital’s business intelligence team. The report included the following metrics: average time from admission to PT/OT order placement, average time from PT/OT order placement to therapist acknowledgement, and average time from PT/OT order placement to therapist completion of initial evaluation. A baseline report was run (3-months) and results were analyzed. A quality improvement process was then put into place including education of burn attending physicians, fellows, and rotating residents on timeliness of therapy order placement, therapy staff education on findings and a new process for morning coordination of burn therapist caseloads to prioritize new evaluations, and initiation of monthly reporting at the burn joint practice committee meetings. The report was then run for an additional 3-months and results were analyzed. Results Baseline and post-quality improvement process results (3-month averages) were as follows: Average time from admission to PT/OT order placement increased from 3.4 to 8.3 hrs, average time from PT/OT order placement to therapist acknowledgement decreased from 43.2 to 31.5 hrs, and average time from PT/OT order placement to therapist completion of evaluation decreased from 43.6 to 35.1 hrs. Conclusions After development of this report findings showed that the quality improvement process used to improve timeliness of inpatient PT/OT initial evaluation completion was effective. In addition, this report has been useful for metric reporting during burn joint practice committee meetings, the ABA verification process and burn therapy staffing/daily caseload management. Applicability of Research to Practice This report could be used by other burn centers to help track and improve timeliness of initial PT/OT evaluations for acute burns. In addition, metrics created from this report could be used for the ABA verification process and help justify burn unit therapy staffing needs.

Introduction Flexion gloves are a quick and easy way to provide a dynamic stretch to the digits for patients with limited composite flexion range of motion (ROM) or who are at risk for digit extension burn scar contractures. However, the flexion glove has been observed clinically to bias metacarpal phalangeal (MCP) joint flexion ROM when compared to the proximal and distal phalangeal (PIP and DIP) joints. The purpose of this case study is to demonstrate the use of a custom thermoplastic hand-based splint to block MCP joint motion in order to better isolate PIP and DIP joint ROM for a patient with primary PIP and DIP flexion ROM limitations. Methods A custom, thermoplastic, palmer hand-based splint was fabricated with an opening for the thumb and the splint extending to the proximal phalanxes stopping below the PIP joints in order to block MCP joint flexion ROM as seen in Figure 1b. Composite flexion passive ROM (PROM) measurements were taken for all MCP, PIP, and DIP joints of digits 2-4 with only the flexion glove donned and with the hand-based splint applied over the flexion glove as seen in Figure 1a and 1c. Results An increase in combined PIP and DIP joint PROM was found for all digits when the hand-based splint was donned over the flexion glove compared to the flexion glove only (see Table 1). These increases in combined PIP and DIP PROM included 35° for the index finger, 10° for the middle finger, 20° for the ring finger and 30° for the small finger, with an overall mean increase of 23.75° Conclusions This easy splinting technique combined with a flexion glove was effectively used to bias stretch of the PIP and DIP joints into flexion for a patient with adequate MCP flexion ROM and impaired PIP and DIP flexion ROM caused by burn scar contracture. Applicability of Research to Practice Using an off the shelf flexion glove and a basic hand-based splint, therapists can use this technique to easily adjust the angle of pull to maximize the benefit from a flexion glove to address specific joint limitations of the finger caused by burn scar contracture.

Introduction The use of silicone gel sheeting (SGS) has long been observed clinically as an effective modality in reducing hypertrophic scar (HTS) formation. Although the use of SGS is widely accepted, the exact mechanism is not fully understood. Prevailing theory suggests silicone suppresses collagen production in immature active scar. Collagen production is enhanced as blood flow increases in areas of scar hyperemia. Reduction of blood perfusion to the immature scar may act as a potential mechanism in limiting excessive scar proliferation. Methods Laser Doppler Imaging (LDI) was used to assess 2 areas in 2 subjects (85% TBSA w/ CEA and native skin control): A control site and SGS testing site were traced on the skin of each subject and 5 LDI scans were performed on both subjects: 1) initial without SGS; 2) initial with SGS applied; 3) 4-hours post-SGS application with SGS on; 4) 4-hours post-SGS application immediately after removal; 5) 15-minutes post-SGS removal. The control and testing site for both subjects were then analyzed using the LDI software and the average perfusion units (PU) over the region of interest (ROI1: testing site; ROI2: control site) areas were calculated for each scan. Results Perfusion within both ROI had a marked increase in perfusion for HTS scans after 4-hours when compared to the initial scan. However, after initial SGS application to ROI1, the mean PU decreased by 23.1% while the perfusion to ROI2 remained relatively constant (-5.8%). Subsequently, the ROI2 increased in mean PU by 23.4% 4-hours after the initial scan while the ROI1 showed a blunted response in perfusion in comparison increasing by only 2.3%. Conclusions Perfusion for both NS and HTS were notably decreased when SGS was applied compared to the matched ROI without SGS. In addition, prolonged SGS application created a greater difference in perfusion between silicone (less perfusion) and non-silicone sites (greater perfusion) for both NS and HTS when compared to initial SGS application demonstrating a greater effect on perfusion the longer SGS was worn.

Burn scar contracture greatly limits function for burn survivors, particularly when the scarring crosses multiple joints. Previous research has identified fields of skin recruited during single joint motion, called cutaneous functional units (CFU), indicating that impairments may be seen distal to the injured tissue. This case report connects the principles of CFU and yoga-inspired therapy modalities in improving clinical outcomes for a burn survivor. The patient is a 38-year-old male who sustained deep partial-thickness electrical burns to his neck, chest, and bilateral upper extremities, presenting with significantly decreased range of motion. The patient attended physical therapy 4 days a week, where he performed a specific yoga asana program during each session. Outcomes including standard range of motion measures, the Vancouver Scar Scale (VSS), and the Neck Disability Index (NDI), which were recorded every 10 sessions. CFUs of cervical extension and shoulder flexion were analyzed via photographs comparing cutaneous position during specified yoga poses and resting anatomical position in standing. Over 30 visits, cervical and shoulder range of motion increased, although the VSS and NDI did not show significant improvement. Yoga poses showed overall cutaneous recruitment distal to the targeted joints, and burned skin was recruited similarly to nonburned skin in positions of stretch. Incorporating multijoint approaches for stretching, like yoga, appears to contribute to improved clinical range-of-motion outcomes when paired with traditional burn-rehabilitation interventions. Yoga poses involving multiple joints align with the principle of CFUs, warranting continued investigation.