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Sengetun / bed courts and nurse calls

Lill Kristiansen Telematics, ntnu / NSEP

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The old nurse call system simplified

Manual presence!(on the door frame !inside patient room !

Manual whiteboard!(showing! responibilities!

Opt.:ʼOverhead pageʼ!/ Intercom!

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The building changes

From Florence Nightingale ward Via multi-bedded rooms with long corridors

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Old / new buildings

•  Old bildings: – Multibedded rooms – Long corridors / long walking distances

•  New buildings: – Only singled bedded rooms (better privacy)

•  a challenge with walking distances!

– One answer is to separate the bed ward (24 beds) into 3 bed courts (sengetun) (3 x 8 beds)

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The sengetun /bed court

•  A ward (sengepost) is approx. 3 x 8 beds (St-Olav: all single bedded rooms) –  Each with local supply/storage etc –  Aimed to minimize walking distances

•  The org. unit is the sengepost (m/“avd.s.pleier”)

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Design question/ challenge!

•  How do build a new nurse call system where wireless (smart-)phones are utilized? – Brainstorm!

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The old/ new nurse call system simplified

Manual presence !

Manuell whiteboard!

Opt.:ʼOverhead pageʼ!/ Intercom!

/ display!

Nurse call plan!

Receive nurse call/signal!

Telephony!

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Picture from training material

•  I am presenting a CSCW-study, but here HCI seems to be a problem as well!

•  In the real system things are different, remember the phone is inside the pocket! (see animation next slide)

Tone Tonsrud

Tilkalling rom 204

OK Reject

14:45 12-05

room 102 14:40

This nurse call I must

reject

Pasientsignal

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Pasient

PC på sengetun

Vaktromsapparat

PC-client to set up the responsibilities per room (i hht bemaningsplan)

Rompanel

Pasientterminal

Anropspanel Våtsone

Pasientpanel

Nurse call system: animation

Ignore / timeout!

Reject!

Accept!

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Research questions

•  How does the bed court (sengetun) work in praxis and how does it relate to the organization of the bed ward?

•  How does the fixed nurse call system (BEST) and the wireless system (Imatis) support (or hinder) the work organization that clinicians use?

•  From a technology viewpoint: –  What are the implications for design of ICT systems?

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Theory / Frameworks

•  Awareness (perifer oppmerksomhet) – Mobility has a special attention in this study

due to the combination of fixed devices and wireless devices

•  Redundancy •  Flexibility / generality

– From architecture

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Awareness

•  A classical definition of (group) awareness (or peripheral awareness) is the following:

•  “[A]n understanding of the activities of others, which provides a context for your own activity.”

•  Dourish P and Bellotti. V (1992). Awareness and coordination in shared workspaces. In Proc. CSCW '92. ACM, 107-114.

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Redundancy (Cabitza et al, 2005)

•  Redundancy of function Redundancy of function refers to cases where several entities (humans or computers) are capable of carrying out the same function

•  All nurses have redundancy of function regarding basic nursing functions –  But need to consider also continuity of care –  PN (Primary nursing)

•  Redundancy of data (obvious meaning) •  Redundancy of work (/effort)

–  Ex:

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Redundancy cont’d

•  Tjora (2004) found that interpretation of ICT-mediert kontekstual informasjon between Emergency center (AMK-113) and ambulance personell is better when both parties has knowledge of the work task of teh others (i.e. Some funksjonal redundancy)

•  Redundancy of function is linked to load balancing and to continuity of care.

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Method: Rapid ethnography

•  Observations •  Interviews •  Study of relevant documents

•  Incl. Change requests

•  Similarities with contextual design •  Study approved by REK (ethical approval)

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Fra intervjuguide 1 (Adapted from training material Ringerike sykehus)

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Framework from architecture •  The architectural concepts

for adaptability (as used in Scandinavia) –  Generalitet (generality) –  Fleksibilitet (flexibility) –  Elastisitet (elasticity)

•  (not much in focus in my study, S. Brand is an excellent source)

From Arge and Landstad (2002) Generalitet, fleksibilitet og elastisitet i bygninger, Sintef Rapport 336, http://www.sintef.no/upload/Byggforsk/Publikasjoner/Prosjektrapport-336.pdf

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Adaptability / (tilpasningsdyktighet)

•  General building (/artefact) –  Same artefact for various

use (building unchanged) –  (The furniture is not part of

the artefact) •  Flexible building /artefact

–  to be changed (at low cost) during operation

–  By endusers –  Or by janitor/caretaker

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Definition of flexibility

•  With flexibility we mean the property an artefact has to adapt to various use and various contexts –  through changing properties. –  I.e., to change the properties with minimal

cost and minimal disturbance in the daily operation.

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The case as seen from written documents

•  St.Olavs Hospital •  Bed courts •  Fixed and wireless delivery of nurse calls

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The sengetun /bed court

•  A ward (sengepost) is approx. 3 x 8 beds (St-Olav: all single bedded rooms) [4 tun used at Ahus, some d-bed]

•  The bed court is not an organizational unit –  From Solumsmo&Aslaksen (2009) St Olav’s Hospital, Trondheim,

Norway, In Capital Investment for Health, 159-172

•  The org. unit is the bed ward(w/head nurse)

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The nurse call system overview (adapted from training material)

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Another system overview (simplified)

Imatisclient

Messageserver

BEST part

Imatis-server

Work station panel

Panel

BESTserver

Imatis part

Pasient

View/ Answer

Accept/Reject/Ignore

View

View

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Available 1 Available 2 Available 3

Call Plan

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4 ways to look at sengetun

•  As they appear in the organisation •  As they appear in the physical

building •  As they are defined in Imatis system

(handling of the wireless part) •  As they are defined in BEST system

(the fixed system /cables in the walls)

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Fixed+wireless nurse call system

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Findings on organization

•  Sengetun work relatively independent during daytime – Redundancy and coordination within each

sengetun – But some important exceptions (Sengepost 4)

•  Extensive co-operation between sengetuns at night, due to lower staffing – Sengepost 3 has ambulant personnel

between two floors

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”Typical” use at daytime Ward-1

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Sengepost 1

•  Building is general: allows to “move” one room without changing the artefact

•  ICT-system does not support this, mapping room-sengetun req. a CR

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Mobility

•  “The best thing with the system is that I am available everywhere. “ – Useful to receive phone calls when mobile

•  When following a patient to X-ray in other building

•  No function inside the system for lunch break, meetings or other “pause”-function –  Interruptive during some patient conversations

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Sengepost 4 mobile patients

NB: No staff staying permanently at Sengetun-1 (impact on ICT needs)

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Sengepost 4 (mobility of patients across sengetun + focus on PN)

•  Kort fortalt må hver pleier på Sengepost-4 registrere seg via 3 skjermbilder i 3 forskjellige tun i Imatis bemanningsplan.

•  Dette da samme pleier kan ha ansvar for 3 pasienter i hver sin fase (se nummer 1, 2 og 3 på tidligere illustrasjon).

•  På Sengepost-4 virker det som dette gjøres veldig konsekvent.

•  Pasientsignalene besvares raskt, dvs, innen 20-30 sekunder slik vi har observert det.

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Sengepost 1 •  They often do not register in the Imatis call plan

–  A negative spiral, the fewer listed, the more those phones are ringing

•  Earlier (2010) they often turned the phone on silence/vibrating, now (2012) often not logging onto the phone at all –  Unable to use the phones as a phone as well

•  Asks for dispay in the corridor ceiling •  Nurse calls may stay active for 3-4 minutes

before answered •  Some special issues with isolation rooms

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Issues when IP-network is down

•  Wireless part (Imatis) will not work •  Fixed system by BEST will work alone in

this case •  Example of useful redundancy in the ICT

systems •  But may not cover the same distances

•  May cause problems at the ”satelite” (sengetun-1) •  Also problems across floors (more later Sengepost

3)

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A change request from Ward-3 •  ”Now we have 1 - 3 disp (available) roles, we

want 1 - 6 disp (available) roles” •  Alternative 1, implement this •  Alternative two:

–  try to understand WHY –  Do they need this change, or is there a lack in the

training material? –  Can other changes be better?

•  Maybe redesign the system for nighttime use •  Look more carefully into emergency nurse calls (may be

useful for physicians to received emergencies)

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Assistance if emergency call across floors

BEST system sends signal only on one floor (in current configuration) Imatis / wireless phones are used to ward all 6 persons at night NB: requires that each nurse registers at all 6 sengetun in Imatis client (no sep. GUI for night)

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More on emergencies cooperation between two floors

•  Change req.: 6 availability roles

6 persons here Used

during night

Used during

daytime

general artefact not tailored fr day, not tailored for night

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Findings relating to delay / dependability

•  Up to 30 sec. delay has been measured by us –  From ”pull the string” –  To wireless phone is ringing/ showing nurse call

•  Same delay for ordinary nurse calls and for emergency calls

•  Nurses talked about the delays (for ordinary calls), but never measured. ICT-Support works on this issue now, after I reported the problem

•  Even though BEST and Imatis have some redundancy features, we see that they are not ”equivalent” –  Both mobility, group aspects and delay varies

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Detailed design proposals

•  Rewrite training material to show that BEST and Imatis are two different systems – Explain that BEST (fixed) may work alone – Highlight issues with delay/outage of IP-nw

•  Carefully concider a general system vs a flexible system – A configurable system is not flexible if the

change takes 4 weeks (as we have observed)

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Interrupts from nurse calls during phone conversations:

•  The most important negative finding highlighted by almost all of the nurses was the following:

•  It is interruptive and also rude to the communication partner to receive nurse calls during a phone call.

Bip! Bip! Bip!

  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 in silent mode for peripheral group awareness !

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Introduce ”pause” / go off system

•  Introduce presence – Lunch (skip nurse calls, allow phone calls) – Meeting – VIP (Very Important Patient conversation)

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What if nurses gets an E-white-board (instead of call plan on PC)?

How to use awareness and redundancy when designing such a system?

From Imatis.no (Visi) See also Cetrea.dk or other vendors

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Conclusions

•  A general artefact may allow for a flexible orgnisation – also in ICT in healthcare

•  Flexibility in an ICT artefact is related to configurability – The new (current) nurse call system is

configrable, but not flexible according to the definition here

– The configuratons/ changes takes too long time

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Conclusions

•  Fixed-Mobile-Convergence (FMC) is not true: –  various affordances, various effects on group

awareness and co-operation •  Some mobility findings from Sengepost-4 may

be relevant for other ICT-systems –  How to delive medicine via robotic post, Where? –  Should sengetun be added in PAS (patient

Admin.System? •  My answer is: No! Use the bed ward as the official

organizational Unit (add bed court info locally on a e-whiteboard, where nurses themselves can change it)

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Future work / CoCoCo project

•  Working on reducing (unwanted) interrupts and/or mediating relevant contextual info inside the nurse/phone call system (and via line of sight i.e. Utalizing also the buiding’s ”affordances”) –  Via various ”ubiquitous” devices –  Via the use of the patient terminal

•  Using action research (some changes are now carried out at St.olav)

•  Using PD /low-fi + hi-fi prototyping in workshops

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Low prio messages from patient to responsible nurse (and only to her)

Workshops with real nurses in an empty sengetun with ”patients” at St.Olav has taken place this week(low-fi) and will take place in May (as hi-fi for real interrupts)

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A PhD student works on ”ubiquitousness” /context mediation

Short paper to appear at MIE 2012

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In a corridor shaped sengetun

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Awareness? Line of sight?