1. The Role of Clinical Artifacts in Achieving Patient-centered Care Delivery Susan E. Piras RN, MSN and The Shared Expectations Early (SEE) Project Team Doctoral Student HFES 2013 International Symposium on Human Factors and Ergonomics in Health Care: Advancing the Cause

2. Outline Background Problem – Context – Significance Method Discussion

3. Background Observations from Clinical Ethics consultation service: –Families were shocked, surprised, and, at times, in conflict. –Families are not equipped to make critical life decisions on behalf of the patient. –Families and healthcare team often had misaligned expectations about future care.

4. Context Setting: Burn ICU Patient: center of physical care Family: represent the patient Effect of unplanned health events – Nature of burns – Patient population IMAGES

5. Problem When trauma occurs: Patients are unable to direct their care Advance directives are not in place. Families as a surrogate to make life decisions Future course of life, family structure, finances, and routine are affected

6. Methods Field Observations Clinician and Family Interviews Analysis of Clinical Artifacts

7. Field Observations: Trajectory of Care Admission Resuscitation Surgical Debridement Intubation, Vasopressors Off Vasopressors, Extubation Stabilization Transition to Step-down unit Further surgery Discharge Off IV pain medication on po Eating Preparation for discharge RECOVERY CRITICAL REHABILITATION   

8. Clinician and Family Interviews Clinician, when speaking about family presence: “…they’re not here the hours that we round…. I think that’s probably the biggest obstacle is finding them without a whole lot of trouble.” Intensivist of BICU Family, when speaking about communication from clinician “…they found a nodule…so they decided to do a CT…to rule out malignancy which is fine but I would have expected a call cause I didn’t even know anything about a nodule, nothing.” Daughter of patient

9. Clinical Artifacts Discussion: Data was collected from families but dissemination and purposeful-use was lacking Artifacts were identified but not readily accessible, inconsistently used, or underutilized. Artifacts were integrated but not used to their full potential. Decision to systematically analyze unit artifacts.

10. Trajectory of Care: Communication Artifacts Admission Resuscitation Surgical Debridement Intubation, Vasopressors Off Vasopressors, Extubation Stabilization Transition to Step-down unit Further surgery Discharge Off IV pain medication on po Eating Preparation for discharge RECOVERY -Shift Rounds -White Board CRITICAL -Nurses Admission Assessment Form -Burn Unit Handbook -Shift Rounds -White Board REHABILITATION -Shift Rounds -White Board   

11. Analysis of Artifacts Systematic analysis of communication artifacts: – What is the purpose of this artifact? – What information does this artifact collect? – Who uses this artifact? – Who benefits from this artifact? – During which phase of care is it most utilized? – What message is the unit/institution conveying with the use of this artifact?

12. Nursing Admission History Data Form

13. Burn ICU Patient Handbook “People can go and read it, but, at first it’s just another confusing piece of paper.” Charge RN BICU

14. Unit Announcement for Multidisciplinary Rounds “I heard on the speaker that they said… “family prepare for rounds”… I didn’t hear that until maybe the second or third one and then we started walking up and…kinda being a part of that conversation physically… rather than just sitting in (the room) and listening.” Family member in BICU

15. White Board “You know it may be Sunday and the date is still Friday; they don’t change the date.” Family member in BICU “They have the dry erase board in the room and, they usually have the day written up there and the nurse and another name on there sometimes. And that doesn’t always get changed day to day.” Family member in BICU Name

16. Discussion Multiple artifacts were identified that capture and relay data in the BICU Collected data was institution-centered Interactive aspect of these artifacts has been lost Improve on present design

17. CriticalRecovery Rehabilitation HOME Major Milestone: Get off breathing machine YOU ARE HERE STAFF NOTESPATIENT & FAMILY NOTES Surgeon: Critical Care Attending Physician: Tim Jones Nurse Practitioner: Bedside Nurse: Susan Smith RN Date: November 2, 2012 KEY UPCOMING EVENTS: Surgery scheduled 11/3 at 9:00 a.m. Transfer to stepdown unit later this week TODAY’S KEY GOALS:  Decrease ventilator  Increase nutrition intake Patient’s Primary Contact Person: Betty Hopkins Contact Info: Alternate Contact Person: Bob Hopkins Contact info: If you cannot attend rounds for a daily update, please call 615.000.0000 for a daily update. Date: 11/2/2012 Please share questions/concern/observations: - How many more surgeries will he have? --He needs haircut Yesterday

18. See Project Team Members Anne Miller, Ph.D. Joe Fanning, Ph.D. David Schenck, Ph.D. Paula DeWitt, Ph.D Lee Parmley, M.D. Larry Churchill, Ph.D. Stuart McGrane, M.D. Cristina Farkas, MS2 Ricky Shinall, M.D. Sparrow Smith, M.A. Susan Piras, M.S.N. John Burnam, M.T.S. Tinsley Webster, M.A

19. Contact Information Susan.E.Piras@Vanderbilt.edu