Transcript Strategisk plan

Nurse calls
via personal wireless devices;
some challenges
and possible design solutions
Lill Kristiansen,
Dept. of Telematics, ntnu, Norway
[email protected]
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Content
 Introduction to nurse calls in the Norwegian context
 Former work from health care and research questions
 Methods
 Findings
 Design proposals
 Future work
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The old nurse call (signal) system
(simplified)
Manual whiteboard
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Manual presence
Opt.:’Overhead page’
and/or
Intercom-calling
The old/ new nurse call system simplified
Manuell whiteboard
Nurse call plan
Receive nurse call/signal
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Manual presence / display
Opt.:’Overhead page’
/ Intercom
Telephony
Collective work vs individual phone
 Continuity of care vs quickest possible response
 Previously: Collective displays
 Nurses ’picked up’ a signal and answered
 Now: Delivery to individual personal phone
 Aim: ”Focus the delivery of the nurse call, which will again
benefit the patient”
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Former work from health care
 Interrupts and suboptimal communication is a problem
in hospitals
 Coiera and Tombs, McGillis Hall, Scholl et al. ++
 Health care workers are highly mobile
 Bardram and Bossen, ++
 Redundancy is useful in hospitals
 For coordination (Cabitza et al. )
 For reliability
Ref. Accident in Norw. hospital last week, IP-network was
down, hospital in ad hoc manner used GSM phones
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Research questions
 Are interrupts caused by nurse calls on the wireless
devices (phones) problematic?
 If yes, under what circumstances?
 What are the implications for design at a detailed level?
 Our aim (as technically skilled designers) is that the
answer to shall be useful for ICT persons in the hospital
handling changes in the existing system as well as for
vendors building new nurse call systems.
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General former work critical to ”smart
systems”
 Brown and Randell:
 Building a ”context sensitive phone” that does not ring
during a passionate embrace...
 This is a false scenario, it is equivalent to building an
intelligent computer
 Proposes to use context ’defensively’
 Ackerman: The socio-technical gap
 How can a technical system successfully ignore the need
for context and nuances
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Generalized questions for mobile workers
in tight teams, local mobility
 How does a change from fixed and public to personal
and wireless devices impact:
 Group awareness and coordination
 Including a change in unwanted interrupts and/or the
ability to handle the interrupt
 How can redundancy of data among various devices be
utilized to redunce the impact of the interrupt?
 Is ”context-awareness” (adaption inside the technical
system) needed?
 What are the success criteria for automatic context
changes and when should that be avoided and leave the
judgement to the humans?
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Analytical concept: redundancy
 Cabitza et al. (2005):
 Redundancy of effort (human or computer)
double checking of medication, two computers carrying out
independent calculations (more resources, more reliable)
 Redundancy of data (human, paper or computer)
The same nurse call is displayed on several fixed and
wireless devices.
The same (or related data) on whiteboard and in an ICT
system
Several nurses know (in their head) about the same patient
 Redundancy of function (humans or computers)
Several entities are capable of carrying out the same function
Basic nursing skills (standardization of education)
Several applications running on the same type of servers
The statistical mechanism ”the law of big numbers”
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Group Awareness
 Definition: The understanding of who is working with
you, what they are doing, and how your own actions
interact with theirs [Dourish and Bellotti, 1992].
 Group awareness may be totally ’virtual’ (ICT-mediated)
 As in distributed open source projects: emails, IM, forum,..
 Co-operation between hospital and GP/prim. Dr. is often
this way
 Formal sources inside hospital may be:
 handover meeting , EPR
 Often partly obtained via informal sources
 F2F, oral communication, visual line of sight, …
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Method: Rapid ethnography (Millen)
 3 hours passive observation during telephony training
 Document studies
 notes on experiences from nurses during phase 1
 Doc. studies of training material
 emails
 Obsevations at 2 wards (total of 12 hours approx.)
 Approved by REK (ethical commitee)
 Clarifying questions and talks when clinical status allowed
 Interviews with 2 head nurses (2 x 50 min. approx.)
 Observations and interviews were focused on
redundancy, coordination and interrupts
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Interviews and observations
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Short-name /
Role of informants
Details
St.O-1: Managerial nurse, strongly
involved in the bid-specification
(from 2003)
Contact in 2008: emails and
access to experience note
HN-1: Head nurse at WARD-1,
(WARD-1 moved into new building
April 2010)
50 min. interview with HN-1
Nov. 2009 (before the move).
HN-2: Head nurse at WARD-2,
(WARD-2 moved into new building
4 years ago)
50 min. interview with HN-2
Nov. 2009
Observation of nurses: The names
Ann, Betty etc. are placeholders for
the real names (due to anonymity).
Ward-1: 3 hours observation
May 2010
Ward-2: 3+3+3 hours of
observation spring 2010
Patient signal system: animation
PC-client to set up the responsibilities per room
(i hht bemaningsplan)
PC på sengetun
Anropspanel
Våtsone
Pasient
Rompanel
Pasientpanel
Ignore / timeout
Pasientterminal
Vaktromsapparat
Reject
Accept
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St.Olav: Call plan
 Redundancy of function is directly related to the call
plan ruling the delivery of nurse calls to the phones
(Imatis client on a PC in the nurse call station)
 Ignore, reject: Who serves as backup nurses?
 The tension between quick response and ’continuity of
care’
 Obviously also redundancy of data typically via fixed
devices contributes to awareness and flexibility in real
work (and the building’s floor plan / line of sights
matters as well)
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Bed area / bed court / ”sengetun”
(reducing walking distance)
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Unplanned business/coordination
 “The best thing with the system is that I am available
everywhere [“when I am following a patient to the X-ray
building”]
 Useful to receive phone calls when mobile
(Some issues are known by a particular person)
(Not useful to receive nurse calls when mobile ourside the
ward)
 Nurses need to work collectively:
 “The optimal solution is that the primary responsible
[nurse] follows up on a nurse call as much as possible,
and that the whole group –we are a small group- functions
as a backup”
 ”Reject” / ”Ignore” + the round robin function in the call
plan for nurse calls caters for some types of busy hands
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Interrupts during communication with
patients/relatives
 It is interruptive and also rude to the communication
partner to receive nurse calls during a phone call
 This related to an ongoing phone call interrupted by
ringing from a nurse call (signal)
 This situation may be automatically detected
 Interrupts from nurse calls (or phone calls) when having
”a difficult conversation” with patient or relative
 This related to F2F communication interrupted by ringing
Ringing may be phone call or nurse call signal
 This involves human judgement (do not automate)
 Unlikely that teh system may detect what is ”difficult” and
compare the importance of this situation with an unstable
patient on the next room
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Interrupts from nurse calls during
phone conversations: Proposal
 The most important negative finding highlighted by
almost all of the nurses was the following:
Bip! Bip!
 It is interruptive and also rude to the
Bip!communication
partner to receive nurse calls during a phone call.
 Suggestions:
 Automatically avoid the nurse
call to be delivered on phone
(server side). Or avoid the
sound on the ear (on the
endpoint)
 Use the presence panel for
peripheral group awareness
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Proposal for lunch and ”difficult
convenversation”
L: lunch
M: Meeting
IPV
Etc
(use icons)
 Allow nurses to use a status field (beyond binary Yes/ -)
 Allow other users to see this status
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Options on the status fields
 One may set timers on these:
 Lunch break:
20 min. pause from nurse calls
May allow or disallow phone calls during the lunch
 Many nurses prefer to be available for calls from physicians
during the lunch break
 ’important visit to patient’:
default 10 min,
or set other time
or maybe (?): ”until manually turned on again”
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Automatic vs human judgement
 Silent/no delivery of nurse call during phone call seems
sensible to automate, since the system knows when a
phone call is ongoing
 When hands are busy / user inside patient room:
 Impossible to ’guess’ this for the ICT system
 Do not automate this
 Do not assume manual updates at all times for all types
of status fields
 Keep the system ”fitted for all types of contexts”
 3 choices ’accept’, ’reject’ , ’ignore’ at all times during
normal yes (ja) status
 Remember that the fixed nurse call system is also
showing the nurse calls
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Future work / CoCoCo project
 CoCoCo:
Communication, coordination and context in hospitals
 1 PostDoc + 1 PhD starting now
 Study in more details how the physical layout of the bed
areas may impact the coordination / the use of ICT
 Study the values expressed by Pontin as ”human
centered nursing philosophy” and by hospital architect
as ”holistic model”
 Values focus on qualitative aspects including
Gode samtaler....med pasient og pårørende
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More future work
 More quantitative and qualitative studies of the existing
system
 Measure todays response times and quality on the nurse
calls,
as seen from the nurses and from the patients
 A nurse is doing a master thesis now on this
 Create some prototypes and test!
 As sketched in this paper
May include location, status ++
More use of teh fixed system for reduncancy
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Questions?
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