Mobile device improves documentation workflow and nurse satisfaction.
Alegent Lakeside Hospital in Omaha, Nebraska opened in August of 2004 and was hailed as one of the world's most technologically integrated hospitals. Alegent used a barcode medication administration and documentation system combined with use of workstations on wheels (WOWs). In 2006, soon after Alegent went live with these systems, several workflow challenges emerged that directly affected nursing satisfaction and introduced new risks for error. To address many of the identified problems, nursing and hospital leaders examined the problems more closely and decided to explore a new type of mobile device, the Motion C5 (C5). They conducted a pilot project using the C5 to assess improvements in clinician productivity, nurse satisfaction, data latency, and quality of care. Nurses had a lightweight, portable device that was theirs to use for the entire shift. They gained unimpeded access to patient information, and no longer had to contend with other clinicians for access to a device. They could document and access information when and where their workflow called for it. Since the C5 was a personal rather than a shared-access device, nurses could remain logged into their C5 between patients as they made their rounds. The C5 enabled nurses to increase documentation at the point of care, which improved accuracy of clinical documentation and reduced duplications. These changes resulted in improved nurse satisfaction and clinical productivity.
Alegent Lakeside Hospital in Omaha, Nebraska opened in August of 2004 and was hailed as one of the world's most technologically integrated hospitals. Alegent uses a barcode medication administration and documentation system combined with use of workstations on wheels (WOWs). In 2006, soon after Alegent went live with these systems, several workflow challenges emerged that directly affected nursing satisfaction and introduced new risks for error. To address many of the identified problems, nursing and hospital leaders examined the problems more closely and implemented a change in mobile devices. These changes resulted in improved nurse satisfaction and clinical productivity.
With the new system, nurses had to move the WOWs between patient rooms, and back and forth to the medication room, rather than within a central location close to their patient care assignment. Nurses began expressing concerns about back, wrist, and shoulder discomfort. The nursing leadership requested ergonomic evaluations of the two types of WOWs that were in use at Alegent Lakeside. These evaluations were performed by a Board Certified Professional Ergonomist who examined push/pull implications and height adjustment issues. The force values were recorded using the Blankenship Omni 200 force gauge, and the values varied depending on pushing speed. The faster the nurse pushed the WOW, the greater the recorded force. The maximum push force and the average force varied between carpeted and vinyl floors. The push force increased to 50 lbs of pressure when nurses pushed a WOW over a threshold between carpeted and vinyl floors.
As a result of the ergonomist's findings, larger wheels were put on WOWs, which provided some improvement to the force values. The ergonomist also reported force measurements for adjusting the height of work areas. The knob release required 15 lbs of force with one thumb and the thumb release needed 2.5 lbs of force with the entire hand. As a result of this finding, all WOWs were converted to the lever mechanism. However, these changes did little to improve clinicians' satisfaction with the workflow process.
In addition to the ergonomic issues, power management had become an issue for nursing staff. Although WOWs were to be plugged in when not in use, this did not always occur. The WOWs' batteries would lose charge without warning, even when the battery indicator showed an adequate charge, leading to loss of data. The unreliability of the WOWs' battery management set-up caused great frustration for the nursing staff. It was determined by the Alegent Lakeside technical staff that the Bluetooth scanners were drawing constant power from the WOW's battery thus shortening battery life. When batteries failed, nurses had no immediate means to replace them with a charged battery. Use of the WOW was suspended until the units were recharged. This lead to multiple nurses trying to use the remaining WOWs to complete their care activities.
Log in Process
The need to log on and off workstations multiple times a shift was inconvenient and time-consuming. Nurses locked workstations when stepping away from them, and then had to unlock again when returning. If the timeout threshold was reached, a full login was required. Observations by Alegent nursing informatics staff showed an average of 1-2 logins per hour for an average of 12-24 logins per shift. A single login process could take up to 2 minutes, consuming up to 48 minutes of nursing time waiting for computer access.
[FIGURE 1 OMITTED]
Access to data by other members of the healthcare team was impacted by data latency issues. Latency is defined as the time delay between the moment data is collected and the moment data is available in the electronic medical record (EMR). Data latency is typically the result of batch charting by the clinician. Batch charting most frequently occurs because the clinician does not have time to log on and off between every patient encounter. The clinician waits until enough patient data has been collected to justify a workflow interruption. When collecting data, information is either documented "temporarily", such as on a scrap piece of paper, or memorized for later transcription or input.
In response to nursing concerns about the various medication administration workflow issues, Alegent Lakeside's leaders decided a more mobile solution was required. At this point Alegent turned to Motion Computing, a vendor they had previously worked with and regarded positively. It was decided by the leadership of both organizations to conduct a clinician usability study of a mobility solution.
For the study, Alegent Health modified its device provisioning model so each participating nurse received a Motion[TM] C5 MCA (C5) for his or her complete shift. The C5 is the first purpose-built computing device created to meet the demands of the acute care environment. The C5 provides a sure-grip handle; a sealed case for easy disinfecting; a lightweight design for portability; a 10 inch screen for easily viewing clinical information with minimal scrolling; rugged construction that minimizes the impact of dropping the device; and pen and stylus input so clinicians can enter text and navigate the software without being tied to a keyboard. The C5 also includes features such as integrated barcode and RFID readers for patient identification and/or electronic medication administration; an integrated camera; and built-in Wi-Fi for wireless connectivity.
Nursing informatics specialists from Alegent and Motion designed a series of study parameters to examine baseline, target and actual performance measures across multiple input variables. Baseline measures for time and motion data were captured. This included frequency and time required per login; time required to complete discreet tasks, including the collection of nursing assessment data; and time documenting in the EMR application. Additional baseline measures of clinician satisfaction were measured using a Likert scale survey.
Methodology and Results
Baseline measurements of nursing activities were collected with focus on data latency and number of data transcriptions. After staff training and implementation of the C5, a trained observer collected a second set of observation data. Nurses completed an online survey regarding their satisfaction levels with the C5 mobile point-of-care solution compared to using the WOWs and desktop PCs at the nursing workstations.
Risk of error: Data Latency
During the observation period, charting was typically transcribed onto a paper note sheet at the point of care, and later transcribed into the EMR. Data latency for shift assessment averaged one hour and 37 minutes when using the WOWs and just 17 minutes when using the C5 as shown in Figure 2.
For RN-acquired vital signs, data latency averaged two hours and 48 minutes, compared to less than one minute when using the Motion C5 for point of care documentation. This is illustrated in Figure 3.
Lower Risk of Error: Data Transcription
In a recent study (Gearing, et al., 2007), researchers examined 1,463 sets of vital signs and found that between 14.9% and 25.6% of them contained one or more transcription errors when vital signs were transcribed from a temporary paper source to either a final paper or electronic source. At Alegent Lakeside, implementation of a mobile workflow reduced the number of data items transcribed, thereby reducing the potential for transcription errors. In addition, because clinicians had their own device, they were able to transcribe closer to the point of care, increasing the likelihood for accurate and complete data.
Improved Nursing Satisfaction
The success of new technology implementations requires satisfied end-users. Without satisfied users, the prime benefits of any technology-enabled process may go unrealized, jeopardizing the desired benefits, as well as contributing to staff unrest and turnover (HIMSS Nursing Informatics Taskforce, 2005). Alegent Lakeside leaders knew nursing satisfaction was a critical study component. Following the study, an anonymous online survey of Alegent Lakeside staff nurses revealed a 62% increase in overall satisfaction with the mobility workflow, work pace, ability to move in constrained areas, ease of data entry, ergonomics of data entry, ease of data access and enhancement of patient interactions as illustrated in Figure 4.
[FIGURE 4 OMITTED]
Alegent staff members were pleased that the C5 reduced infection concerns. According to the Chief Medical Informatics Officer of Alegent Health System, it was never clear who would clean the WOW, as housekeeping did not want anything to do with cleaning electronics, and nurses didn't want to clean them either; but he indicated cleaning a C5 unit is a "breeze so nurses are doing it." The C5 was designed to be cleaned with any of the standard disinfectants available in healthcare organizations. It took an average of 16 seconds to completely wipe down a C5 with disposable germicidal cloth.
Alegent determined that WOWs were not the best solution for their nurses to perform barcode medication administration or documentation. They conducted a pilot project using the C5 to assess improvements in clinician productivity, nurse satisfaction, data latency, and quality of care. Use of the C5 changed the nurses' relationship with technology in several important ways. Nurses had a lightweight, portable device that was theirs to use for the entire shift. They gained unimpeded access to patient information, and no longer had to contend with other clinicians for access to a device. The time and consternation previously associated with searching for WOWs or desktops could be reallocated to patient care, and nurses could document and access information when and where their workflow called for it. Since the C5 was a personal rather than a shared-access device, nurses remained logged into their C5 between patients as they made their rounds. Nurses often carried them between rooms and used them in a variety of settings such as the break room, medication room, and nursing station. This additional agility and portability to access and to input data from anywhere improved nursing productivity and satisfaction. The C5 enabled nurses to increase documentation at the point of care which improved accuracy of clinical documentation and reduced duplications. In addition, nurses expressed increased satisfaction, were more productive, and could spend more time with patients.
HIMSS Nursing Informatics Taskforce. (2005). Leveraging health information technology to facilitate interdisciplinary communication and workflow final results/findings. from http://www.himss.org/ASP/topics_FocusDynamic.asp?faid=150
Gearing, et. al. (2007). Enhancing patient safety through electronic medical records documentation of vital signs. Journal of Healthcare Information Management, 20(4), 40-45.
By Cheryl D. Parker, RN, PhD
Katherine Baldwin, RN, BS
Cheryl D. Parker, RN, MSN, PhD is the Senior Clinical Informatics Specialist for Motion Computing[R], Inc. She has over 30 years experience in the healthcare industry including clinical nursing, management, nursing informatics, and education both corporate and academic. She has worked in clinical system selection and implementation from both a facility and vendor perspective. She has been responsible for the development of all clinician usability studies for Motion.
Katherine Baldwin, RN, BS is a Clinical Informatics Specialist at Alegent Health System since October 2004 assisting with development and implementation of the Siemens SOARIAN application for clinical documentation as well as the implementation of the Siemens MAK system for bar coded medication administration. She has extensive clinical experience in cardiovascular and medical surgical nursing both in the hospital and the outpatient clinic environment as well as 9 years experience in the insurance industry in utilization management, quality assurance, contracting, and staff development and training.
Figure 2--Data latency for nursing shift assessment data Data Latency Shift Assessment WOWs, 1:37 Motion C5, 0:17 Note: Table made from bar graph. Figure 3--Data latency for RN acquired vital signs Data Latency RN acquired Vital Signs WOWs, 2:48 Motion C5, 0:01 Note: Table made from bar graph.
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|Author:||Parker, Cheryl D.; Baldwin, Katherine|
|Date:||Jun 22, 2008|
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