Vinay Vaidya

Systems ambiguity and guideline compliance: a qualitative study of how intensive care units follow evidence-based guidelines to reduce healthcare-associated infections

Background: Consistent compliance with evidence-based guidelines is challenging yet critical to patient safety. We conducted a qualitative study to explore the underlying causes for non-compliance with evidence-based guidelines aimed at preventing four types of healthcare-associated infections in the surgical intensive care unit (SICU) setting. Methods: Twenty semistructured interviews were conducted with attending physicians (3), residents (2), nurses (6), quality improvement coordinators (3), infection control practitioners (2), respiratory therapists (2) and pharmacists (2) in two SICUs. Using a grounded theory approach, we performed thematic analyses of the interviews. Results: The concept of systems ambiguity to explain non-compliance with evidence-based guidelines emerged from the data. Ambiguities hindering consistent compliance were related to tasks, responsibilities, methods, expectations and exceptions. Strategies reported to reduce ambiguity included clarification of expectations from care providers with respect to guideline compliance through education, use of visual cues to indicate the status of patients with respect to a particular guideline, development of tools that provide an overview of information critical for guideline compliance, use of standardised orders, clarification of roles of care providers and use of decision-support tools. Conclusions: The concept of systems ambiguity is useful to understand causes of non-compliance with evidence-based guidelines aimed at reducing healthcare-associated infections. Multi-faceted interventions are needed to reduce different ambiguity types, hence to improve guideline compliance.

Implementation and evaluation of a comprehensive system to deliver pediatric continuous infusion medications with standardized concentrations

PURPOSE The development, implementation, and evaluation of a comprehensive pediatric medication management system based on computerized orders with standardized concentrations for pediatric continuous infusions are described. SUMMARY To attain the Joint Commission mandate of using a few standardized concentrations for pediatric continuous infusion medications, a multidisciplinary team at the University of Maryland Medical Center pediatric intensive care unit restructured the medication management of continuous infusions from the handwritten rule-of-6 method to computerized orders with standardized concentrations. Development of the new system required creating a mathematical algorithm to automatically produce two to four standardized concentrations for 39 continuous infusion medications used in pediatrics, incorporating mnemonics that represent standard drug concentrations into the pharmacy medication-processing system, designing a computerized provider-order-entry program, and introducing smart infusion pumps that were programmed with standardized concentrations. System creation and implementation were completed hospitalwide over 16 months. The system successfully determined two to four standardized concentrations for each continuous infusion medication and allowed application of consistent dose, weight, and fluid restrictions when determining standardized concentrations. Preimplementation and postimplementation evaluation revealed that the new system eliminated several types of medication errors and was well received by all health care team members in pediatrics units. CONCLUSION A technology-based, scientific, comprehensive yet simplified solution to attain the Joint Commission mandate concerning standardized concentrations was developed, implemented, and evaluated. The system successfully determined a limited number of concentrations for each continuous infusion medication for pediatrics and improved safety by eliminating medication errors when delivering these medications.

Dissecting Multidisciplinary Cardiac Surgery Rounds

BACKGROUND Multidisciplinary rounds in the critical care environment have demonstrated increased communication, a reduction in medical errors, a shorter hospital stay, and consequently, economic savings. We attempt to assess the cost of this intervention, and to review the time utilization of professionals participating in the process. METHODS We analyzed video-recorded weekly multidisciplinary teaching rounds on cardiac patients in a pediatric intensive care unit (n = 22). Rounding time was categorized as presentation or discussion and was measured in minutes. The cost of a round was calculated by multiplying the hourly salary of all healthcare professionals present by the time spent rounding and measured in US dollars. RESULTS Median rounding time per patient was 15 minutes (range, 5 to 29). Patient presentation took between 2 and 8 minutes (median 4), or 26% of the rounding time. Time needed for discussion, including teaching and planning, varied between 2 and 25 minutes (median 10.5). Median number of participants was 13.5 (range, 11 and 16). Mean cost in salaries per patient rounded was

Computerisation of a paper-based intravenous insulin protocol reduces errors in a prospective crossover simulated tight glycaemic control study

140.87 (95% confidence interval:

Impact of Computerized Orders for Pediatric Continuous Drug Infusions on Detecting Infusion Pump Programming Errors: A Simulated Study

106.80 to

Artifacts Use in Safety Critical Information Transfer: A Preliminary Study of the Information Arena

174.90). CONCLUSIONS Multidisciplinary rounds are a low-cost medical intervention with proven benefits. Available tools and rounding cultural changes should be adopted to shorten data retrieval and presentation time to the benefit of discussion and teaching. Current billing requirements for rounding multidisciplinary teams do not reflect the realities of their time use.

A Distributed Cognition Approach to Understanding Information Transfer in Mission Critical Domains

BACKGROUND Paper-based continuous intravenous insulin protocols for tight glycaemic control (TGC) are typically complex, error-prone, time-consuming and burdensome. Little is known about the errors that occur as a result of misinterpretation and whether computerised protocols reduce errors. OBJECTIVE To compare the errors resulting from protocol misinterpretation, time required to manage insulin infusions and nursing satisfaction between a computerised insulin protocol and a paper-based protocol. METHODS In a crossover study, 62 ICU nurses completed 10 TGC simulated scenarios for the computerised and paper protocols. Scenarios evaluated three phases of insulin management: initiation, titration and transition. Scenarios response errors, time to completion and user satisfaction were examined. RESULTS A total of 620 responses were recorded using both protocols. The computerised protocols were associated with higher user satisfaction, as well as: fewer errors in the titration (13 vs. 113 errors, p=.0001) and transition phases (9 vs. 23 errors, p=.001), fewer dosing errors, although not statistically significant (p=.096), in the initiation phase, and less time to complete in the titration phase (6 vs. 9.5 min, p=.0001). CONCLUSIONS In a simulated environment, a computerised protocol for TGC resulted in significant insulin dosing error reduction, saved time and improved nurse satisfaction.

Systems Ambiguity: A Framework to Assess Risks and Predict Potential Systems Failures

Continuous infusion medications are associated with fatal adverse events in pediatric intensive care units. The effect of computerized orders on detecting infusion pumps programming errors has never been studied. Using a crossover design, we examined the effect of using computerized orders for continuous infusions as compared with that of using handwritten orders on nurse ability to detect infusion pump programming errors, time required to verify pump settings, and user satisfaction. The computerized orders saved nurses time but did not improve their ability to detect infusion pumps programming errors. Nurses preferred computerized orders. High error rate was related to manual calculations and inconsistent use of computerized orders.

Three perspectives of rounds: Choreographing information flow in an intensive care unit

Highly skilled professionals in mission critical work domains communicate complicated, critical information, frequently under time pressure. For example, sustained operations require shift work, which results in hand-offs of responsibilities and need of information transfers. There is a growing interest to support their communications through advanced information technology. We observed usage of information artifacts in a pediatric intensive care unit to study information transfers to guide the design of support technology. In contrast to published studies, we examined the context of supporting environment that contains rich information sources gathered or tailored for verbal discourses. We called the supporting environment “information arena.” Clinicians prepare for their personal information arena as well as the shared information arena (e.g., paper notes, charts, mobile computers). Patterns of artifact uses during discourses revealed several distinct roles of artifacts, as well as constraints on design of such artifacts. For example, artifacts in shared information arena should be easily manageable to support fluid and dynamic conversation flow. We also uncover several potential future roles for information artifacts to support information transfer.

Evaluating the safety and efficiency of a CPOE system for continuous medication infusions in a pediatric ICU.

We developed a conceptual framework that describes how information transfer occurs in mission critical domains using a distributed cognition approach. According to this framework, information tools and the physical workspace comprise an “information arena”, which plays a crucial role in information transfer. Information tools and the information arena support joint work and may improve efficiency and reliability by providing visual cues to collaborators, by getting everyone on the same page, by helping collaborators focus on critical information, by facilitating attention management under time pressure, and by providing an evanescent (transient) communication space. We illustrate the concepts in this framework using an example from multidisciplinary rounds, an information transfer mechanism common in the intensive care unit, a mission critical domain. The framework can be used as a guide to further understanding of information transfer in mission critical domains and to develop information tools that facilitate and enhance discourse.