ICU Visits at Piedmont, Northside & Emory CS-8803 HEF Adriana Fuentes, Akshay Joglekar, Geetanjali Ningapa, Jeff Jopling, Karsten Jensen, Lars Christensen, Luxmi Saha

An Outline ICUs visited: Piedmont, Northside, Emory Few Issues to deal with: Medical records Medical equipment interfaces Lighting Noise level Airflow Family accommodations Storage facilities Patient Room Layout X-ray facility Privacy Visibility Monitors Water Supply

Medical Records Issues Most of the records are still on paper Mandatory paper records: technology orders, satellite pharmacies Integration of medical records from the different departments has not been achieved

Technology/Medical Records Issues Due to the increase in technology, doctors seem to be spending most of their time in front of the computer. Not good communication with patients

Technology/Medical Records Issues Problems: From past experiences at Piedmont, when a new software packet that is targeted to help healthcare operations has been implemented, it has not really improved or helped

Medical Records Possible Solutions: Have a centralized system which integrates data from all the departments within the hospitals and from other hospitals Have a microphone that will put everything into a medical record so that there is more communication between patients and doctors.

Medical equipment data Problems: The medical data generated by the electronic equipment needs to be manually fed into the information system by the nurses. Manual data entry leads to waste of time as well as it increases the probability of human errors. Possible Solutions: All medical equipment should be designed to automatically feed the generated medical data into the hospital information system.

Alarms Problems: Every equipment has its own alarms. Difficult to distinguish between various alarms. Sometimes it also becomes difficult to judge the source of the alarm. Possible Solutions: Standardization of medical equipment alarms. A central terminal where all the equipment can be connected.

Medical equipment interfaces Problems: Poor human interfaces for the medical equipment Nurses spend lot of time using and adapting to the equipment. Poor interfaces lead to human errors e.g. entering incorrect input parameters for IV pumps. The various medical equipment do not talk to each other.

Medical equipment interfaces Possible Solutions: More intuitive medical interfaces. Focus on making data entry easier. Compatibility between different equipment. Establishment of a standard for equipment communication.

Lighting Problems: Some rooms provided more light than others Windows were small in some ICUs Some windows were punctured and dirty Others were half covered by "un-trimmed" trees The light switch at Northside hospital was placed right behind the door due to which it was not easily accessible and it was a single switch controlling 6 kinds of lights in the room.

Noise Level Problems: The noise level was high at the nurse station There was a beeping sound during the entire time All the patient rooms were open. The noise level might disturb patient's sleep The noise and screams from one patient's room might disturb other patients.

Noise Level Possible Solutions: Some kind of visual signal instead of beep sound to be incorporated Use of good acoustical materials

Noise level Problems: Noisy transportation trolleys at the hallways Possible Solutions: Should the wheels be exchanged/redesigned? Or is it a maintenance question?

Airflow Problems: Airflow is very crucial in a hospital group for the health of the patient. A few rooms have to be positive pressure rooms, a few of them need to be negative pressure rooms while others can be neutral room (for contagious patients). Possible Solutions: Pre-planning must be done to accomodate these conditions. Airflow duct can be a good source of infection so necessary precautions must be taken.

Family Accomodations Problems: The piedmont hospital had no family space in the patient room The family had no different entrance to enter the patient room which meant more disturbance at the nurse station and other patient's privacy is not maintained well. Possible Solutions: Provide space to accommodate patient's family in the exam room Have a separate periphery entrance to the patient room

Storage Facility Problems: Storage facility in patient room is redundant as the supplies are rendered contaminated once they enter the patient room o Supplies can not be used on the next patient o Supplies have to be disposed Possible Solutions: Do away with any supply storage space This problem was better handled at the Northside Hospital. The ICU rooms had a supply storage rack in one of the walls facing the corridor and the rack had two doors on each side (one inside the ICU room and the other one opening on the corridor). In this way the supplies could be loaded from outside and kept safe in the store and used as and when required.

Patient room Layout Problems: Some of the patient rooms were laid in a circular plan The rooms were too small The walls were at odd angles No additional structure could be built over this structure because of the shape of the building and foundations not being deep enough. Possible Solutions: Avoid small rooms and odd angles of walls Always plan the designs for future expansions

X-Ray viewing Facility Problems: The Piedmont had the option of viewing X-Ray's on any computer in the computer The physician did not have to go the X-Ray room to view them However, the patient rooms did not have computers. Hence the physicians have to go to the nurse's station to view the X-Rays Possible Solutions: Have computers in the patient room Or, Have computers on the wheels that can be moved all around the facility

Visibility of Patients Problems: At the Piedmont hospital, some of the regular rooms are converted into ICU rooms due to shortage of rooms No visibility of patient to nurse. Hence cameras are used The rooms are too small Possible Solutions Design patient rooms to provide flexibility in use Assign enough area to accommodate the patient, the doctor, the equipments, family etc

Privacy of the Patients Problems: The Curtains around the W/C are taken out to avoid infections which might affect the privacy of the patient Possible Solutions: Use of a better alternative to curtain o should provide required privacy o should be quick and easy to clean

Privacy of the Patients Problems: The ICU room windows at Northside Hospital did not have curtains to avoid contamination with infection The curtains were replaced with blinds placed between two layers of glass of the window. The control of the blinds was only in the hands of nurses sitting out on the desk. The patient may feel uncomfortable due to lack of privacy and the nurse can't keep the blinds closed since it would hinder monitoring the status of the patient from outside

Privacy of the Patients Possible Solution: Electronically controlled curtains can be installed so that the patient as well as the nurse can control them. Video cameras can be installed inside the room so that privacy is not compromised.

Concrete Walls The old building at the Piedmont hospital has concrete walls, so it takes a lot of work to hide new cables, as their rules demands.

Remembering all the small things Problems: Everyday tasks like putting intravenous lines into patients have a lot of small, but important, things the personal needs to remember Wash hands, sterilizing the skin, using sterile gown and gloves.

Remembering all the small things Possible Solutions: Packets with all the sterile items Checklist

No checklist Piedmont does not provide any checklist only a protocol Instead they follow up on cases of infection

Water Supply Problems: Some pumps and other devices at the Piedmont hospital are driven by water A few years ago the water supply failed Possible Solutions: Storage tanks on the roofs

Vital Sign Display Monitors Current display paradigm is Single Sensor Single Indicator (SSSI) Old but functional design serves as basis for clinical decision making.

Monitors - Current State Displaying waveforms per time - Blood pressure - Heart rate - Oxygen saturation SSSI paradigm (Single Sensor Single Indicator)

Monitors - History History: SSSI monitor paradigm was developed in the 1970's Over last ~40 years progress has only led to modifications of this existing paradigm.

Monitors - Problems Our understanding of physiology has changed greatly over the last 40 years. The problem: o These advances in understanding are not reflected in the SSSI display paradigm

Monitors - Problems Normal physiology is not regular Measuring with sufficient resolution, meaningful variation can be seen in: o intervals between heart beats o volumes of spontaneous breaths o hormone secretion

Monitors - Problems Nonlinear dynamics, complex systems, and the patho-biology of critical illness. Buchman, Timothy Current Opinion in Critical Care. 10(5): , October Variability is lost as patients descend into critical illness Recovery from critical illness is characterized by recovery of irregularity in physiologic time series.

Monitors - Problems Intermittent collection of patient variables (e.g. hourly) Recorded as single numbers in paper chart or computer database No information about relationship between variables

Monitors - problems Timescales: Often the timescales of the display waveforms are not the same.

Monitors - Solutions Working within the SSSI paradigm…  Could the interfaces be made more intuitive? Or create a new paradigm?  With new data displays  Such as those falling within complex systems paradigm

Monitors - Solutions Could the systems provide early alarms, from the monitored parameters? e.g. By monitoring and intuitively displaying complex physiologic relationships… we could predict when a patient will move from a stable state to an unstable one… and intervene before the patient codes.

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