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

Outline

BackgroundProblem

– Context– Significance

MethodDiscussion

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.

ContextSetting: Burn ICU Patient: center of physical careFamily: represent the patientEffect of unplanned health events

– Nature of burns– Patient population

IMAGES

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

Methods

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

EatingPreparation for discharge

RECOVERY

CRITICAL

REHABILITATION

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

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.

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

EatingPreparation for discharge

RECOVERY-Shift Rounds-White Board

CRITICAL-Nurses Admission Assessment Form-Burn Unit Handbook-Shift Rounds-White Board

REHABILITATION-Shift Rounds-White Board

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?

Nursing Admission History

Data Form

Burn ICU Patient

Handbook

“People can go and read it, but, at first it’s just another confusing piece of paper.”

Charge RN BICU

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

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

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

Critical Recovery Rehabilitation HOME

Major Milestone: Get off breathing machine

YOU ARE HERE

STAFF NOTES PATIENT & 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

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

Contact Information

Susan.E.Piras@Vanderbilt.edu