Clinical Decision-Making: Observing the Smartphone User An Observational Study in Predicting Acute Surgical Patients’ Suitability for Discharge

We observed a cohort of patients through a busy ASU in a tertiary hospital in South Australia, Australia. Acute surgical patients admitted to the hospital who were observed to be on their phones upon consultant review were more than 5 times likely to be discharged that same day. To the best of our knowledge, this is the first study to prospectively collect data to assess a frequently used but unevaluated clinical observation.

The use of a smartphone can tell us a lot about an individual’s physiology. We can assume the individual’s airway and breathing are adequate, allowing enough oxygen to reach the lungs and subsequently circulate. The individual is usually sitting up in bed and thus has an adequate blood pressure and blood oxygenation that can maintain cerebral perfusion. They have the cognitive and cerebral processing in place to function the device, and we can examine their cerebellar function by looking for fine-motor movements.

Mobile phone ownership is pervasive within Australia,⁵ with a conservative estimated 85.7% of the population (20.57 million people of a total population of approximately 24 million) owning a mobile phone and an estimated 50% to 79% of mobile phone ownership being of a smartphone.^6,7 This ownership is not just limited to the young, with 74% of Australians over 65 owning or using a mobile phone.⁸ Despite this high phone ownership among those over 65, it is still significantly less than their younger counterparts and may be one reason for the absence of spP in those older than 51 years. A key point in the study is that overall phone ownership was not known, and, thus, it is not possible to determine the proportion of spN patients who were negative because they did not own a phone. However, based on general population data, the incidence of spP patients was well below that seen in the community (11.3%)⁵ and even when excluding those over 55, the percentage of spP patients only rose to 19.1%. Unsurprisingly, increasing age was associated with a decreased likelihood of being spP (P < 0.0005), as younger people are more likely to own a phone.⁸ There was no association with gender (P = 0.18). There are a number of explanations that may explain the lower than expected percentage of spP patients, including the inability for the patient to gather their possessions during a medical emergency, patients storing their phones prior to doctor review (72%-85% of Australians report talking on phones in public places to be rude or intrusive⁵), but more importantly, that our hypothesis that patients were too unwell to use their device appears to hold true.

There are potential alternate reasons other than smartphone status that may account for patients being discharged home on day 1. While there was no association seen with gender, the need for an operation prolonged a patient’s stay (OR 1.64; 95% CI, 0.046-0.46), and there was a trend seen with increasing age (OR 0.98; 95% CI, 0.96-1.00). Neither of these 2 demographics are unsurprising: increasing age is associated with increasing medical comorbidities and thus complexity; even the simplest of operations require a postprocedure observation period, automatically increasing their LOS. Additionally, measured demographics are limited and there may be further unmeasured reasons that account for earlier discharge.

The other key component to this study is the value of the physical examination, albeit only assessing 1 component: the general inspection. In their review of the value of the physical examination of the cardiovascular system, Elder et al. highlight an important point: in traditional teaching, the value of a physical sign is compared with a diagnostic reference, typically imaging or an invasive test.⁹ They argue that this definition undervalues the physical examination and list other values aside from accuracy including accessibility, contribution to clinical care beyond diagnoses, cost effectiveness, patients’ safety, patients’ perceptions, and pedagogic value; and they argue that the physical examination should always be considered in regard to the clinical context—in this case, the newly admitted general surgical patient.

The assessment of the presence or absence of a smartphone is readily performed upon general inspection and is easily visible; general inspection of the patient and failure to observe the clinical sign when present are 2 of the greatest errors associated with physical examination.¹⁰ Furthermore, given its unique status as a physical sign, the authors’ opinion and experience is that it is readily teachable. McGee states, “…a fundamental lesson [in regards to teaching] is that the diagnosis of many clinical problems, despite modern testing, still depends primarily on what the clinician sees, hears, and feels.”¹¹ In their article, Paley et al. found that more than 80% of patients admitted from the ED under internal medicine could be accurately diagnosed based largely on history and examination alone and concluded that basic clinical skills are sufficient for achieving an accurate diagnosis in most cases.¹² Although Paley et al. were assisted with basic tests (such as electrocardiogram and basic haematological and biochemistry results), the point of clinical skills is not lost. Furthermore, this assessment was made in a group of patients generally considered to be complex in contrast to the “standard” appendicitis or cholecystitis patient that makes up a significant proportion of general surgical patients.

There are a number of limitations to this study, however, including smartphones that may have been missed during the observational period. Potential confounding variables such as socioeconomic status and the overall smartphone ownership of our subjects were not known. We did not ask all admitted patients whether they owned a phone or whether they had a phone in their possession. Knowledge of those who owned phones but were not in possession of them could strengthen our argument that spN patients were not using their phone because they were unwell, rather than just not having access to it.

However, this study has a number of strengths, including a large sample size and data that were prospectively collected by a method and in a setting that was the same for all participants. Clear and appropriate definitions were used, which minimizes misclassification bias. Participants and decision makers were blinded to the study, and potentially confounding variables such as age and sex were accounted for.

Assessing the suitability for discharge from the hospital is a decision encountered by hospital-based clinicians every day. These skills are not taught, but are rather learned as a junior doctor acquires experience. It is unlikely that protocols will be developed to aid identification of potential discharges from an acute surgical ward; acute surgical conditions are too varied and dynamic to be able to pool all data. We continue to rely on our own and fellow colleagues’ (doctors, nurses, and other staff) input and assessment. However, our study has shown that it is possible to identify and quantify clinical findings that are already regularly used, albeit potentially subconsciously, to assess suitability for discharge. We have shown in this large, prospectively collected observational study that if a surgical patient is seen using their electronic device, they are more likely to be safe to go home. Thus, surgeons can reliably use this observation as a trigger to consider discharging the patient following a more thorough assessment.