Negotiating capture, resistance, errors, and identity: Confessions from the operating suite.

Conducting research in medical settings can pose particular challenges for research on adoption and adaptation to new technologies, especially when medical errors are a subject of the research, or the research necessitates capture of user behaviors and interactions. A case study of research in a clinical setting explores the experience of the researcher as they negotiate the practical challenges of research and research participants’ acts of resistance. The researcher’s identity, as constructed in the medical setting, serves to make this negotiation more complex. However, this case also illustrates the practical and theoretical approaches that can be applied to overcome these challenges

DESIGN OF A MOBILE WEB-BASED DASHBOARD TO IMPROVE WORK PRACTICES OF CRNA BOARD RUNNERS

Traditional artifacts such as whiteboards serve as key tools in helping healthcare professionals keep track of frequently changing information and managing their work schedule. The simplicity of these tools has made them easy to adopt into the work culture and since these artifacts are not usually electronic, they need no external technical support or maintenance. However, these artifacts present unique challenges to their users, the primary one being lack of mobility offered. The whiteboards are usually stationary and the users will have to assemble near them to update or gather information. In a hospital, this adds significant overhead to the workflow efficiency since users will have to spend time walking from their changing locations to the whiteboards. In addition, the fact that these artifacts are not electronic means that they cannot be connected to the information technology (IT) system, meaning the information present on them are not updated in real-time. In this research, such challenges faced by certified and registered nurse anesthetists (CRNA) board runners of a large regional hospital in the south eastern United States were studied. To help address the challenges faced by the board runners in their task execution, a new web app designed for the Google Nexus 7 tablet was introduced as a potential replacement for the whiteboard. Ten board runners participated in this study to evaluate the new web app in comparison with the whiteboard in a simulated work environment. The participants were given 10 different tasks to perform with both the web app and the whiteboard. Measures such as task performance (time and errors), situational awareness (SA), needs ratings, system usability and perceived workload were collected and analyzed. Once the web app and the whiteboard were evaluated, a preference ranking for the type of device was also collected from all the participants. Time taken for overall task execution was longer for the whiteboard and the errors committed did not differ significantly among the two devices. SA was found to be similar across the devices and there were no significant differences. All 6 primary needs collected and the overall system usability were rated significantly higher for the web app. The workload indices of mental demand, physical demand, temporal demand, effort and frustration had significantly higher ratings for the whiteboard and the performance was rated significantly higher for the web app. All of the 10 participants preferred the web app over the whiteboard

An Ethnography of Care Coordination in an Integrated Practice Unit for Ventilator Dependent Patients

The growing complexity of healthcare delivery coupled with the pressures to improve cost, quality, and outcomes has healthcare leaders struggling to prioritize initiatives and programs that provide coordinated patient-centered care. It is generally accepted and most academic studies demonstrate that better care coordination will reduce redundancies, improve clinical decision making and provide patients with better care experiences. Moreover, industry leaders are pushing for reforms and policy makers have regulated structural changes aimed at improving the US healthcare system. However, to implement such changes, healthcare organizations must understand the elements of care coordination at the work flow level and how those elements are impacted by the context in which the care is being delivered. Against that backdrop, this ethnographic research of a pediatric clinic designed as an Integrated Practice Unit as defined by Porter and Teisberg examines the care coordination activities between the providers to understand how they are carried out in this specific context, and how infrastructure changes such as the implementation of an enterprise Electronic Health Record impacts the everyday practices of care coordination. As a result, we contribute to the concept of an integrated practice unit by studying it in an operational context and through the lens of Relational Coordination Theory. We make observations regarding the extent to which integrated practice units enhance care coordination and patient value. We also contribute to Relational Coordination Theory itself by demonstrating how “non-core” team members, organizational context, and worker outcomes are observed so that these measures can be addressed quantitatively in the future

Community acquired respiratory syncytial virus infections : detection by multiplex PCR and strain characterisation by partial G gene sequencing

The aim of this project was to design an assay for the detection of respiratory syncytial virus (RSV) RNA extracted directly from clinical specimens. The assay was intended to address the question of whether RSV is a significant cause of respiratory illness in all age groups of the general community. The amplification assay for the detection of RSV subtypes A and B was designed using primers located in the nucleocapsid gene. This RSV PCR was incorporated into a multiplex PCR together with primers specific to influenza A H1N1, H3N2 and influenza B, The multiplex assay was optimised and validated, and different amplicon detection methods were investigated with a view to develop a high throughput protocol. The multiplex PCR assay was then applied to combined nose and throat swabs collected from members of the general community with influenza or influenza like illness, over a three year period (1995-1998). Analysis of these results revealed the co-circulation of RSV and influenza during the winters. RSV was shown to be an important contributor to respiratory illness in all age groups, being detectable in about 20% of patients with influenza like illness. The RSV positive samples from the three winter seasons studied were processed to obtain sequence data suitable for molecular epidemiological analysis. A strategy to amplify and sequence the first variable region of the glycoprotein gene was developed. PCR amplification was successfully performed directly using stored clinical samples. Phylogenetic analyses of the amplicons revealed that different strain types circulated during each winter season

How do mobile devices support clinical work on hospital wards: an investigation of the selection and use of computing devices

The mobile and information intensive nature of clinical work in hospital settings presents a critical challenge: how to provide clinicians with access to information at the time and place of need? This challenge is particularly pertinent to decision-makers responsible for the selection of computing devices. Mobile devices are often promoted as a means to meet this challenge, with existing literature tending to portray the mobility of devices as inherently beneficial. However, evidence to clearly demonstrate how mobile devices support clinical work is limited. This research aimed to generate new knowledge to contribute to answering two significant questions: (i) how do decision-makers select computing devices? and (ii) how do mobile devices support clinical work practices? The research was conducted in two stages. In stage one, interviews were conducted with 28 individuals involved in decisions regarding the selection of computing devices for hospital wards. Decision-makers reported a range of factors that influenced device selection. Role of the user, types of tasks, and location of tasks, for example, were deemed important. In stage two, a mixed methods design comprising structured observations, interviews, and field notes was employed. A sample of 38 clinicians, on two wards of a metropolitan hospital, was observed for 90 hours. In total 4,423 clinical tasks were recorded, capturing key information about tasks doctors and nurses undertake, where, and devices used. The findings provide evidence validating core assumptions about mobile devices: namely, that they support clinicians work by facilitating access to information at patients bedsides. Notably, mobile devices also supported work away from the bedside and whilst clinicians were in transit, allowing continuity in work processes. However, mobile devices did not provide the best fit for all tasks and additional factors, such as the temporal rhythms of the ward and structure of ward round teams, affected how mobile devices supported work. Integration of findings from the two stages resulted in the development of a detailed list of factors that influence the use of mobile devices on hospital wards. This new evidence provides valuable knowledge to guide the selection of computing devices to support, and potentially optimise, clinical work

A declarative model of clinical information systems integration in intensive care

The findings of this multi-site study emphasise the importance of Organisational Culture for integrating clinical information systems into intensive care units. A novel model, the Iterative Systems Integration Model, has two principle components, these being Organisational Culture and the Actual Usefulness of the clinical information system. The model is derived from empirical data collected in four intensive care sites in England and Denmark, with one site being used to validate the model. The model highlights clinical information systems as directly affecting the work processes of the sites investigated, which in turn affect the Organisational Culture and Actual Usefulness of the clinical information system used, and these features affect clinical information system integration. This forms an iterative process of change as clinical information systems are introduced and integrated. Intensive care units are complex organisations, with complex needs and work processes. The impact of clinical information systems on these work processes is investigated in this thesis using Role Activity Diagrams. These diagrams are analysed to show that although clinical work processes are consistent at each site, the information processes differ. Intensive care information processes are found to have the potential to be much simplified with the introduction of seamless clinical information systems. Qualitative data collectio n methods were deployed, i. e., observations, interviews, and shadowing of clinical staff, together with a questionnaire at each site for further validation. Data were analysed using grounded theory to extract salient variables, which informed the development of the model. These factors were indicative of the Organisational Culture of the sites investigated and the Actual Useftilness of the clinical information systems being used. It was posited that clinical information systems that reconcile expectations of both hospital management and clinical staff - and that have the potential to adapt to their organisational environment - have a greater chance of surviving in complex environments such as intensive care. Despite decades of Health Infon-flatics, no such systems exist in their entirety; this research shows that 'ancient problems' of clinical information systems integration are still prevalent, and presents the Iterative Systems Integration Model, the application of which may assist with the integration of clinical information systems in intensive care.EThOS - Electronic Theses Online ServiceGBUnited Kingdo