ICU Visitsat

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 roomo Supplies can not be used on the next patiento 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 privacyo 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 beatso volumes of spontaneous breathso hormone secretion

Monitors - Problems

Nonlinear dynamics, complex systems, and the patho-biology of critical illness. Buchman, Timothy Current Opinion in Critical Care. 10(5):378-382, October 2004.

• 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.

THANK YOU