System ergonomic analysis of the morning ward round in an intensive care unit.

OBJECTIVE: Our objective was to find out what is discussed during a bedside morning ward round (MWR), whether there are any weak points, and if a standard work process structure can be recommended. METHODS: An intensive care unit (ICU) consultant recorded in a predefined form the topics that were discussed in 225 bedside discussions. RESULTS: The median length of discussions was 5 min. In more than 60% of the discussions, items were considered related to the respiratory, neurological, and cardiovascular systems, as well as to surgical and nursing problems. Specific variables relating to organ system conditions were seldom used (e.g., inspired O2 concentration, 35%; temperature, 28%; ventilation mode, 25%). We recorded two interruptions per MWR; only 17% of them were related to urgent decisions. Information that could not be found in the patient's file usually concerned microbiology findings (10%) or surgical procedures (6%). CONCLUSIONS: We recommend the following structure: (1) Addressing the patient by saying "hello"; (2) presentation of information related to case history, acute status (findings and strategy) (including the function of the main organ systems), infection status, and nursing problems; (3) patient-related discussion; and (4) discussion of general treatment rules, triggered by individual patient condition.

Information transfer in high dependency environments: an ergonomic analysis.

We have studied the information flow in HDE (with special focus on the information transfer process) using data provided by a group of experienced health care professionals. A model of the information flow in HDE was built up. It postulates the existence of quanta of information (due to the artificial fragmentation of the information flow produced by the clinical working processes: organization in shifts, demand of simultaneous activities from different staff members, etc.). This fragmentation is described by using the so-called Clinical Information Process Units (CIPUs), which correspond to patient care activities going on in parallely and serially linked blocks, performed by the staff in the specific environments. Due to a transfer in responsibility over the patient the CIPUs are linked by information transfer events which are described using transfer modules (TraMs). We exemplified 32 CIPUs related to the clinical environments (PreOp, Surgery, Recovery Intensive Care, Ward, Diagnostics, Outpatient) and the health care professional groups (Anesthesiologist/Intensivist, Surgeon, Nurse, Physician, Diagnostic Physician, Physical Therapist). A matrix was established providing the transfer situations among the CIPUs enabling a systematic classification of the TraMs. The contents of the TraMs are built up of information link elements, which are assembled according to the specific settings of the transfer situation given by the emitter, receiver and purpose. In summary we modelled the process of information transfer in HDE through CIPUs, TraMs and information links in a way, which may be useful to design information technology applications or to reorganize the information management in HDE.

Data quality of bedside monitoring in an intensive care unit.

Computerized record keeping promises complete, accurate and legible documentation. Reliable measurements are a prerequisite to fulfill these expectations. We analyzed the physiological variables provided by bedside monitoring devices in 657 bedside visits performed by an experienced Intensive Care nurse during 75 Intensive Care rounds. We registered which variables were displayed. If a variable was displayed, we assessed whether it could be used for documentation or should be rejected. If a value was rejected the reason was registered as: the measurement was not intended (superfluous display), the current clinical situation did not allow proper measurement, or other reasons. Basic variables (vital signs and respiration related variables) were displayed in more then 90%, specific variables (e.g. intracranial pressure) were displayed in less than 50% of the situations. Displayed variables were superfluous on an average of 11% because measurement was not intended. Variables like heart rate, temperature, airway pressure, minute volume of ventilation, arrhythmia, pulmonary arterial pressure, non-invasive blood pressure, and intracranial pressure provide high quality measured values (acceptance of more than 90%). Invasive arterial pressure, central venous pressure, respiration rate and oxygen saturation (via pulse oximetry) provided lower quality values with a rejection rate higher than 10%. Inappropriate sensor technology to match the clinical environment seems to be the root cause. In future the request for automatic documentation will increase. In order to avoid additional staff workload and to ensure reliable documentation, sensor technology especially related to respiration rate, blood pressure measurements, and pulse oximetry should be improved.

Lessons learned while building an integrated ICU workstation.

The project LUCY (Linked Ulm Care sYstem) is described. The goal of this project was to build a research workstation in an Intensive Care Unit which enables evaluation of data/information processing and presentation concepts. Also evaluation of new devices and functions considering not only one device but the workplace as an entirety was an aim of the project. We describe the complete process of building from the stage of design until its testing in clinical routine. LUCY includes a patient monitor, a ventilator, 4 infusion pumps and 8 syringe pumps. All devices are connected to a preprocessing computer via serial interfaces. A high performance graphic workstation is used for central display of physiological and therapeutic variables. A versatile user interface provides touch screen, keyboard and mouse interaction. For fluid administration a bar code based control and documentation facility was included. While our scheduled development efforts were below 4 man-years, the overall man-power needed until the first routine test amounts to 8 man-years. Costs of devices and software sum up to 160,000 US$. First experiences in clinical routine show good general acceptance of the workplace concept. Analysing the recorded data we found 90% of the items to be redundant: individual filtering algorithms are necessary for each of nowaday's devices. The flexibility of the system concerning the implementation of new features is far from our expectations. Technical maintenance of the system during clinical operation requires continuous effort which we cannot afford in the current situation.

Decision making in high dependency environments--can we learn from modern industrial management models?

Increasing complexity and increased restraints affect the task of patient management in High Dependency Environments, which has become intricate and difficult. Medical knowledge alone is not enough any longer for proper patient care. Management ability and facilities are required. Current medical knowledge should be expanded by management methods and techniques. By looking at management models in the industry, we found striking similarities between the industrial management situation and clinical patient management. Both systems share complexity in structure, complexity in interaction and evolutionary character. Clinical patient management can be compared with a navigation process. The patient is steered by a control system, and course information is given by control dimensions. Clinical patient management becomes a succession of steering activities influenced by the surrounding systems. This system can be structured in three interacting layers: an operational level, in which information is collected and actions executed; a strategic level in which strategies based on goal-oriented mental anticipation of a probabilistic system are formulated; and a normative level at which principles and norms are defined. It is possible then, to define the tools which have to be developed and implemented to improve clinical management capabilities. At the operational level these tools are addressed to improve clinical decision making by providing information in an ergonomical way. They include artifact elimination, data reduction, increase in meaningful information and unwanted data filtering. At the strategic level, tools to check the feasibility of the applied strategies have to be developed, such as: ideal patient course plots and increased training in strategic thinking.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical information process units (CIPUs) - a system ergonomic approach to medical information systems.

This article constitutes an introduction to the basic tools necessary to understand Systems Ergonomics applied to the development of clinical systems. A basic description of clinical patient care in the system ergonomics language is provided, and the current situation found in hospital information management is criticized from an ergonomic point of view. We have laid out a model of the information flow in the clinical environment, which breaks the complex process of patient care in clearly defined elements: the Clinical Information Process Units. Presented here as an example of the application of Systems Ergonomics to the clinical working processes, the Clinical Information Process Units constitute the central element in the system ergonomic model of the information flow in the clinical environment.

Analysis of the chest X-ray conference in an intensive care unit.

Bed chest X-rays carried out in an Intensive Care Unit (ICU) are an important means of patient monitoring. To get the starting points for standardization of the documentation of X-ray findings, we examined course and contents of the daily X-ray conference in an ICU. We video-taped the conferences and registered its vocabulary.Mean entire duration to comment on the X-rays of one patient was 150 s. On an average, discussion between radiologist and anaesthetist lasted 40 s, dictation of findings 50 s. Sorting and viewing the X-rays took 60 s. Main disruptions were related to non-availability of X-rays and clinical patient data. Clinical information reported during the discussion is rarely mentioned in the dictated findings.

Ergonomics applied to anaesthesia record keeping.

For almost 100 years, the anaesthesia record has been the sole information tool trying to fulfill an ample catalogue of functions related to the anaesthesia information processes. Automated anaesthetic record systems have evolved around data being available online, as an imitation of the handwritten record. None has developed an information tool capable of an efficient utilization of the wide range of resources provided by modern technology to fulfill the information requirements of the anaesthetic environment. We used a system ergonomic analysis trying to find the best solutions. As a result of it we drafted an Anaesthesia Information Concept (AIC) in which the complexity of data & information (D&I) processes is broken down to modules called Clinical Information Process Units (CIPUs). A CIPU is mainly defined by the responsibility of a staff member and focuses on the basic system patient, staff and machine (all devices). The internal functions of a CIPU are treatment control and medicolegal documentation. The external functions are fulfilled by transferring required sets of D&I for subsequent treatment control (next CIPU), audit, quality control, cost calculation, etc. Using such an approach, an Anaesthesia Information Concept (AIC) can be realized by a wide range of modular and hybrid systems (combination of different tools such as paper records, computers, etc), as opposed to universal and single automated documentation systems, which up to now have failed to fulfill the information demands of the anaesthetic environment.

[Experimental studies on the recovery of anesthetic gases]. / Experimentelle Untersuchungen zur Rückgewinnung von Narkosegasen.

The volatile anesthetic agents halothane, enflurane, and isoflurane are chlorofluorocarbons (CFC) and contribute to ozone depletion. Although the contribution is small, its importance is rising, as technical CFCs will be phased out according to the Montreal protocol (1987) and the London conference (1990) by the year 2000. Alternative procedures and CFC-free volatile agents such as des- and sevoflurane do not contribute to depletion of the ozone layer, but will not replace standard methods using volatile anesthetic agents in the near future. METHODS. In an experimental setup, we filtered anesthetic waste gases from scavenging systems of rebreathing circles by activated carbon filters. The filtered substances were desorbed by a heat chamber and condensed in a cold trap. RESULTS. By this method, it was possible to retrieve 50%-60% of the applied gases. Gas chromatographic analysis showed halothane containing traces of pollutants and isoflurane and enflurane as pure substances. DISCUSSION. The retrieval of anesthetic waste gases is easy; no sophisticated technical equipment is necessary. Purity of substances could make recycling possible and offer a method to avoid environmental pollution by volatile anesthetics.