Ryan Arnold

Improving Infusion Pump Safety Through Usability Testing.

With the recognition that the introduction of new technology causes changes in workflow and may introduce new errors to the system, usability testing was performed to provide data on nursing practice and interaction with infusion pump technology. Usability testing provides the opportunity to detect and analyze potentially dangerous problems with the design of infusion pumps that could cause or allow avoidable errors. This work will reduce preventable harm through the optimization of health care delivery.

High Single-dose Vancomycin Loading Is Not Associated With Increased Nephrotoxicity in Emergency Department Sepsis Patients.

OBJECTIVE Vancomycin loading doses are recommended; however, the risk of nephrotoxicity with these doses is unknown. The primary objective of this study was to compare nephrotoxicity in emergency department (ED) sepsis patients who received vancomycin at high doses (>20 mg/kg) versus lower doses (≤20 mg/kg). METHODS A retrospective cohort study was performed in three academic EDs. Inclusion criteria were age ≥ 18 years, intravenous vancomycin order, and hospital admission. Exclusion criteria were no documented weight, hemodialysis-dependent, and inadequate serum creatinine (SCr) values for the measured outcome. Analyses compared the incidence of nephrotoxicity for patients who received vancomycin at high dose (>20 mg/kg) versus low dose (≤20 mg/kg). RESULTS A total of 2,131 consecutive patients prescribed vancomycin over 6 months were identified. Of these, 1,330 patients had three SCr values assessed for the primary outcome. High-dose initial vancomycin was associated with a significantly lower rate of nephrotoxicity (5.8% vs. 11.1%). After age, sex, and initial SCr were adjusted for, the risk of high-dose vancomycin compared to low-dose was decreased for the development of nephrotoxicity (relative risk = 0.60; 95% confidence interval = 0.44 to 0.82). CONCLUSION Initial dosing of vancomycin > 20 mg/kg was not associated with an increased rate of nephrotoxicity compared with lower doses. Findings from this study support compliance with initial weight-based vancomycin loading doses.

Interface, information, interaction: a narrative review of design and functional requirements for clinical decision support

Objective Provider acceptance and associated patient outcomes are widely discussed in the evaluation of clinical decision support systems (CDSSs), but critical design criteria for tools have generally been overlooked. The objective of this work is to inform electronic health record alert optimization and clinical practice workflow by identifying, compiling, and reporting design recommendations for CDSS to support the efficient, effective, and timely delivery of high-quality care. Material and Methods A narrative review was conducted from 2000 to 2016 in PubMed and The Journal of Human Factors and Ergonomics Society to identify papers that discussed/recommended design features of CDSSs that are associated with the success of these systems. Results Fourteen papers were included as meeting the criteria and were found to have a total of 42 unique recommendations; 11 were classified as interface features, 10 as information features, and 21 as interaction features. Discussion Features are defined and described, providing actionable guidance that can be applied to CDSS development and policy. To our knowledge, no reviews have been completed that discuss/recommend design features of CDSS at this scale, and thus we found that this was important for the body of literature. The recommendations identified in this narrative review will help to optimize design, organization, management, presentation, and utilization of information through presentation, content, and function. The designation of 3 categories (interface, information, and interaction) should be further evaluated to determine the critical importance of the categories. Future work will determine how to prioritize them with limited resources for designers and developers in order to maximize the clinical utility of CDSS. Conclusion This review will expand the field of knowledge and provide a novel organization structure to identify key recommendations for CDSS.

Sepsis alert presentation: Developing a framework to optimize alert design for clinical decision support

The Value Institute at Christiana Care Health System is developing and evaluating a framework to optimize alert design for clinical decision support (CDS) to target sepsis, the most impactful disease process to our system. Our multifaceted approach takes into account technological, organizational, and provider factors that influence how providers interact with alerts throughout the hospitalization process when appropriate clinical care can change the trajectory of a patient with a systemic infection. Effective presentation of the alert, including how and what is displayed, may help providers extract information quickly, offering better cognitive support during busy patient encounters. Our simulated usability evaluation, using real clinical scenarios, investigates how clinicians detect sepsis and respond to CDS based on the way the information is presented visually. Usability testing is designed to better understand the decision-making process analyzing varied designs that utilize various levels of visual presentations to promote situational awareness and measure diagnosis- and treatment- related variables.

Evaluation of User-Interface Alert Displays for Clinical Decision Support Systems for Sepsis

BACKGROUND Hospitals are increasingly turning to clinical decision support systems for sepsis, a life‐threatening illness, to provide patient‐specific assessments and recommendations to aid in evidence‐based clinical decision‐making. Lack of guidelines on how to present alerts has impeded optimization of alerts, specifically, effective ways to differentiate alerts while highlighting important pieces of information to create a universal standard for health care providers. OBJECTIVE To gain insight into clinical decision support systems‐based alerts, specifically targeting nursing interventions for sepsis, with a focus on behaviors associated with and perceptions of alerts, as well as visual preferences. METHODS An interactive survey to display a novel user interface for clinical decision support systems for sepsis was developed and then administered to members of the nursing staff. RESULTS A total of 43 nurses participated in 2 interactive survey sessions. Participants preferred alerts that were based on an established treatment protocol, were presented in a pop‐up format, and addressed the patients clinical condition rather than regulatory guidelines. CONCLUSIONS The results can be used in future research to optimize electronic medical record alerting and clinical practice workflow to support the efficient, effective, and timely delivery of high‐quality care to patients with sepsis. The research also may advance the knowledge base of what information health care providers want and need to improve the health and safety of their patients.

A Framework to Tackle Risk Identification and Presentation Challenges in Sepsis

Introduction Sepsis trajectories, including onset and recovery, can be difficult to assess, but electronic health records (EHRs) can accurately capture sepsis as a dynamic episode. Methods Retrospective dataset of 276,722 clinical observations (4,726 unique patients) during a two-month period in 2015 were extracted from the EHRs. A Cox proportional hazard model was built to test hazard ratios of risk factors to the first sepsis episode onset within 72 hours for patients with presumed infection. Predisposition, infection, response, and organ failure (PIRO) score-based framework was used in a logistic regression to identify factors associated with in-hospital mortality within the sepsis population. Results 47.54% of patients with an infection episode experienced at least one sepsis episode (N=1,044 out of 2,196) within 72 hours of admission. The mortality rate was higher for patients with sepsis episodes (7.24%) compared to patient with only organ dysfunction episodes (4.84%) or only with infection episodes (3.96%). Analysis identified factors associated with the first sepsis episode onset and those associated with in-hospital mortality. Discussion Our study addresses identification of infection, organ dysfunction, and sepsis as dynamic episodes utilizing EHR data and provides a systematic approach to detect risk factors related to sepsis onset and in-hospital mortality.

Applying User-Interface Design Heuristics on Computerized Clinical Decision Support Systems

Studies evaluating Computerized Clinical Decision Support Systems (CCDSS) assess success and impact by studying patient/clinician outcomes in clinician workflow. However, the literature lacks studies that evaluate CCDSSs as interactive computer systems. Evaluating the design of these systems from a human factors engineering perspective can optimize interactions between clinicians and the system, and eventually improve both patient and clinician outcomes.

Optimizing usability and signal capture: a proactive risk assessment for the implementation of a wireless vital sign monitoring system

Abstract Wearable vital sign monitors are a promising step towards optimal patient surveillance, providing continuous data to allow for early detection and treatment of patient deterioration. However, as wearable monitors become more widely adopted in healthcare, there is a corresponding need to carefully design the implementation of these tools to promote their integration into clinical workflows and defend against potential misuse and patient harm. Prior to the roll-out of these monitors, our multidisciplinary team of clinicians, clinical engineers, information technologists and research investigators conducted a modified Healthcare Failure Mode and Effect Analysis (HFMEA), a proactive evaluation of potential problems which could be encountered in the use of a wireless vital signs monitoring system. This evaluation was accomplished by focussing on the identification of procedures and actions that would be required during the devices’ regular usage, as well as the implementation of the system as a comprehensive process. Using this method, the team identified challenges that would arise throughout the lifecycle of the device and developed recommendations to address them. This proactive risk assessment can guide the implementation of wearable patient monitors, optimising the use of innovative health information technology.

Assessment of nursing response to a real-time alerting tool for sepsis : A provider survey

Background An information technology solution to provide a real-time alert to the nursing staff is necessary to assist in identifying patients who may have sepsis and avoid the devastating effects of its late recognition. The objective of this study is to evaluate the perception and adoption of sepsis clinical decision support. Methods A cross-sectional survey over a three-week period in 2015 was conducted in a major tertiary care facility. A sepsis alert was launched into five pilot units (including: surgery, medical-ICU, step-down, general medicine, and oncology). The pilot unit providers consisted of nurses from five inpatient units. Frequency, summary statistics, Chi-square, and nonparametric Kendall tests were used to determine the significance of the association and correlation between six evaluation domains. Results A total of 151 nurses responded (53% response rate). Questions included in the survey addressed the following domains: usability, accuracy, impact on workload, improved performance, provider preference, and physician response. The level of agreeability regarding physician response was significantly different between units (p=0.0136). There were significant differences for improved performance (p=0.0068) and physician response (p=0.0503) across levels of exposure to the alert. The strongest correlations were between questions related to usability and the domains of: accuracy (τ=0.64), performance (τ=0.66), and provider preference (τ=0.62), as well as, between the domains of: provider performance and provider preference (τ=0.67). Discussion Performance and preference of providers were evaluated to identify strengths and weaknesses of the sepsis alert. Effective presentation of the alert, including how and what is displayed, may offer better cognitive support in identifying and treating septic patients.

Advancing Patient Safety through the Creation of a Mobile Usability Lab

The demand for usability testing is becoming increasingly important as healthcare moves toward a commitment to zero patient harm and higher value of care provided. Usability testing and simulation, techniques used in user-centered interaction design to evaluate healthcare systems, promote safe, high-quality care for patients. We propose the concept of a “Mobile Usability Lab”, a novel way to conduct usability testing system-wide. The Mobile Usability Lab describes a unique opportunity to step away from the standard state-of-the-art usability lab and take a creative approach to usability testing. To demonstrate the utility of this concept, we present a case study detailing a hospital-wide comparative device evaluation of new defibrillators. We recommend that research and clinical teams explore the concept of a mobile usability lab to evaluate products in the clinical environment. This work can reduce preventable harm through the optimization of health care delivery.