Outcomes in the Palm of Your Hand (Improving the Quality and Continuity of Patient Care)

by Diane Doran, Lawrence Bloomberg | May 01, 2008

Main Messages

PHASE 1: CONSULTATION WITH NURSES TO INFORM SYSTEM DESIGN

  • Hospital and home care nurses wanted ongoing access to electronic drug information, including IV compatibility guidelines. Thirty-nine percent of hospital nurses’ documentation was observed to occur on “personal paper” and later transcribed to a permanent location. This represents a significant opportunity to eliminate duplicate work.
  • Hospital nurses were eager for electronic documentation of vital signs, intakes and outputs, and other routine assessments at the point of care.
  • Home care nurses currently document at the point of care and want electronic access to policies and procedures.
  • Nurses saw value in electronic forms for standard assessments.
  • Nurses valued alerts and reminders.

PHASE 2: USABILITY EVALUATION OF PDA AND LAPTOP CONDUCTED IN A LABORATORY SETTING

  • Nurses rated PDA usability the same or better than laptop usability in all areas except size and sequencing of screens.
  • Nurses wanted to be able to adjust the size of screen characters.
  • Instant transmission was important for nurses; waiting 3 or 4 seconds for a network response was not acceptable to most nurses.
  • The number of keystrokes needs to be minimized in electronic documentation.
  • Nurses wanted to be able to correct data entry errors easily; they liked the ability to save a draft assessment and complete it later in the day.
  • Learning how to use a mouse, how to use a stylus and how to use scroll bars were new skills for many nurses. This variety of skills will occur in clinical settings for the foreseeable future, necessitating multi-faceted strategies to facilitate learning.

PHASE 3: FIELD TEST OF THE PROTOTYPE SYSTEM, CONDUCTED IN THREE HOSPITALS AND THREE HOME CARE AGENCIES

  • Positive feedback was received from hospital and home care nurses about the prototype system; mean usability scores were all >5 on a 9-point Likert scale with a mean of 7.0.
  • Using the device at the point of care can eliminate duplication of documentation if there is real-time access using a secure and reliable network.
  • Fast networks with universal access are essential for point-of-care documentation.
  • Nurses who accessed the symptom trend graphs reported that they were useful, but many nurses did not view them.
  • Nurses did not routinely consult integrated best practice guidelines; presenting patient-specific best practice guidelines at the point of care did not lead to a statistically significant difference in patient/client outcomes.
  • The quality and timeliness of staff communication were statistically higher on acute care experimental units than control units.
  • Further research is needed to evaluate the effectiveness of the point-of-care decision support system for improving the timeliness and efficiency of information transfer.

Executive Summary

This research study seeks to improve the way nurses collect and record patient outcome data, and the access nurses have to health-based data directly at the point of patient care. The study supports an Ontario Ministry of Health and Long-Term Care initiative focused on Health Outcomes for Better Information and Care (HOBIC).

STUDY PURPOSE

The study evaluated the usability of handheld computers; specifically, personal digital assistants (PDAs) for nurses collecting, utilizing and communicating information about patient health outcomes. It also evaluated the feasibility of using PDAs to increase nurses’ access to, and utilization of, best-practice information available electronically to support clinical decision-making.

METHOD

The study was conducted in three phases. The objectives of Phase One were:

  • refine existing patient outcome measures for nursing assessment based on an Ontario Ministry of Health and Long-Term Care initiative for better information and care through health outcomes data collection.
    http://www.health.gov.on.ca/english/providers/project/nursing/nursing_mn.html
  • identify additional types of information that nurses need to collect and access at the point of care through the use of wireless PDA technology.
  • develop a prototype information gathering and dissemination system that will provide the software framework for PDA use.

Phase 1 included group interviews and work sampling on medical and surgical units at two acute care hospitals and at two home care organizations. The sample included 35 hospital- based participants and 16 from the home care sector. Data from focus groups, interviews and work sampling informed the development of a custom prototype system that enabled data entry for HOBIC outcomes, feedback of trend in pain and other symptom scores, presentation of client-specific best-practice guidelines for the management of pain, and prevention/management of pressure ulcers. In addition to the prototype system, each PDA was equipped with an electronic drug handbook and a map resource for community nurses.

The objective of Phase Two was to test the usability of the prototype system with a standardized patient in a laboratory setting. Forty-two nurses participated in the laboratory study: 58 percent worked in hospital settings and 42 percent worked in a home care setting. Participants used both a handheld PDA and a laptop computer to enter outcomes assessment data while assessing a standardized patient (actor) who had learned pre-determined responses to each question. A cross-over design was used, with half of the sample using a PDA first and laptop second, and half of the sample using the laptop first. Participants completed a usability questionnaire following the use of each device. PDA users had online access to client-specific clinical guidelines presented at the end of each assessment, as well as an electronic drug handbook. Laptop users had access to paper versions of the Registered Nurses’ Association of Ontario’s Best Practice Guidelines and a print copy of a popular drug compendium.

The objective of Phase Three was to evaluate the effect of the PDA outcomes application in improving nurses’ communication and their utilization of patient health information in the clinical setting. It also involved an evaluation of the PDA for improving nurses’ access to and utilization of electronically-accessible best practice information, and the effectiveness of PDAs in improving the quality of outcomes for patients. In one hospital, the PDAs were set up as Voice over Internet Protocol (VoIP) phones on the hospital network so that the nurses would not be required to carry two devices. In home care settings, additional resources included order codes for medical supplies and equipment, phone numbers of CCAC staff and quick links to websites such as city maps. The final sample consisted of 176 acute care nurses (44.3% of eligible) and 22 home care nurses (31% of eligible sample). Fifty-nine nurses volunteered to attend a workshop and then field test the prototype system.

Participating nurses used PDAs during a six-month period to conduct the standardized HOBIC data collection. Research assistants conducted assessments on control units in both acute care and in home care in order to be able to compare client outcomes when staff had either access to a PDA or when standard care was provided. A total of 384 hospitalized patients and 159 home care clients participated in the study.