Introduced in the early 2000s, Electronic Medical Records (EMRs) are now nearly ubiquitous within hospitals. Despite their near-constant use, multiple studies show significant provider dissatisfaction with EMRs due to slowed workflow, task interruptions, and increased documentation time (Schmit-Jongbloed. Cohen-Schotanus, Borleffs, Stewart, & Schonrock-Adema, 2017). The IHICU seeks to resolve these flaws by integrating all sources of clinical information into one simple, easily accessible Intelligent Array (IA). The IA is designed to remain at bedside, but its network connectivity allows access and monitoring throughout the hospital.
A lasting lesson of EMRs is that increased functionality does not necessarily equal end-user acceptability. This is particularly true in ICUs, where markedly different provider needs are rarely satisfied by a single source. Yet, medicine continues to strive for a centralized patient hub, which is the IA’s goal. The potential benefits are enormous.
The greatest benefit is the ease of accessing comprehensive patient information anywhere in the hospital, which positively affects provider decision making. Additionally, IAs with modern aesthetics (e.g. large icons and touchscreens) provide unexpected perks. For one, patients like large, in-room informational displays and give better ratings when used in their care (Holden, Asan, Wozniak, Flynn, & Scanlon, 2016). Medical providers also prefer large arrays, particularly if the interface has an intuitive, modern feel. Among ICU nurses, IT dependence to make rapid, complex decisions causes near-constant cognitive demand which is consistently rated as their greatest work stressor (Melles, Freudenthal, & Bouman, 2002). If an IA is not only ergonomic, but designed to work with the medical team, it becomes a useful necessity and stress reducer rather than an archaic form of torture.
Common ICU patient complaints include inconsistent information and the lack of provider coordination. Patients want clear communication among their providers (Nelson et al., 2010). In-room IAs could potentially increase physician coordination, while also providing easy-access to vital information such as patient code status. End-of-life documentation is often missing from patient records and the resulting confusion in a crisis can result in horrific errors (Nelson et al., 2010). In-room IAs could ensure such information is readily available.
Ultimately, IAs could improve nursing morale; workflow; decision making time; and patient satisfaction (Melles et al., 2002). However, there are also risks to introducing new IT. Observational studies suggest the value of medical IT is not defined by what it can do. Rather, its value depends on its perceived usefulness as defined by the end-user (Holden et al., 2016). For an IA to be successful, therefore, its design must provide the following: improved patient outcomes; reasonable ease of use; positive social/peer perception; minimal training; and impeccable quality (Holden et al., 2016). Historically, medical providers are resistant to new IT, largely because manufacturers design products to improve productivity instead of meeting providers’ definition of “usefulness” (Carayon et al., 2015). Subsequently, hospitals may suffer major investment losses if IA functionality prioritizes economy over provider needs.
While IAs work with EMRs, they are compatible with more than patient records. They are designed to track labs, vitals, video, telemetry, and medication administration. While seemingly ideal, it is important to recall the famous Institute of Medicine (IOM) report which identified system failures (not provider errors) as the primary cause of medical errors (Kohn, Corrigan, & Donaldson, 2000), with 60% of the most serious adverse drug outcomes due to IV administrations (Bates, Vanderveen, & Seger, 2005). Following the study, “smart pumps” (SPs) were introduced in 2001. Despite introducing a variety of safety features, infusion pumps continue to be rated as either the second (ECRI Institute, 2013) or first (Neil, 2017) hazard in the ECRI’s “Top 10 Health Technology Hazards” lists of 2014 and 2017, respectively. Causes of continued errors include complicated interfaces; equipment breakdown; titration difficulty; nurse time constraints; pump failure at detecting dosing errors (Giuliano & Niemi, 2015); and alarm fatigue (Cvach, 2013).
Alarm fatigue is a source of many errors and was listed as the number one hazard during the 2014 ECRI review, right above infusion pumps (ECRI Institute, 2013). It is a product of SP alarms that trigger for any abnormality, even if non-critical. Providers usually opt to override alarms, if not ignore them completely, silently approving of overrides as an acceptable practice (Vanderveen, 2007). Recurrent ICU alarms also cause patient agitation and sleep cycle interruptions. Patients suffering increased sleep disturbances while hospitalized had a higher incidence of PTSD-like symptoms six months after discharge and reported a lower quality of life (Granja, Lopes, Moreira, Cias, & Costa-Pereira, et al., 2005).
Continued SP dangers are the impetus behind the next generation, called “Intelligent Infusion Pumps” (IIPs), which are designed to work with the hospital’s wireless systems and software. Ideally, IIPs will allow physicians and pharmacists more control over order entry, potentially relieving nurses from entering IV orders at all (Vanderveen, 2007).
Medical providers are not the only beneficiaries of IAs and IIPs. For some, these technologies are the perfect source of in-house data collection. Massive patient data – including all orders and errors during hospitalization – are compiled into giant databases simply referred to as “Big Data.” The data is used for Continuous Quality Improvement (CQI), meaning the entirety of the network’s information is uploaded for statistical analysis for medical and managerial decision-making. Companies are eager to amass Big Data from Intelligent Hospitals, as it guides profitable decision-making. For example, Big Data can identify the primary causes of unnecessary alarms. With proper application of CQI, system alerts can be redesigned to eliminate non-critical alarms without discarding critical ones, which in turn makes products more appealing for hospital purchase.
Another IIP advantage is their ability to be upgraded wirelessly. Current pumps must be moved for repair. When linked to an integrated network, however, IIPs can be remotely monitored and upgraded. If damaged, software can be repaired without leaving the floor (Neil, 2017).
Despite these advantages, there are concerns about combining IIPs with whole-hospital wireless systems. Hacking and system crashes are always potential problems, but the ambitious use of Big Data is also worrisome. While the intention is to use it for care advances, Big Data is still subject to the primary rule statistics: correlation is not causation. Should incorrect analysis of Big Data be used for major CQI projects, lethal mistakes are possible.
In the mission to improve safety, IIPs risk becoming more complicated. Nurses perpetually identify time constraints as the primary cause of infusion errors (Giuliano, 2015). To address these concerns, the IHICU installed IIP software called the “Guardrail System.” The program allows pharmacists to place IV orders wirelessly, allowing ICU nurses to focus on other tasks. Software, however, cannot resolve the very real problem of overworked staff. Overworked pharmacists can make the same mistakes as overworked nurses. Additionally, order entry by persons other than the ICU nurse may decrease nurse familiarity with the treatment plan.
The debate over who enters IV orders, combined with strict override or infusion limits, could interfere with emergent situations that require large boluses or above-normal infusion rates. Nurses need to administer drugs themselves during emergencies; waiting on the pharmacy to acknowledge or enter orders could cost lives. There are also unique treatments Guardrail software could delay. Norvasc overdose, for example, requires total saturation of the patient’s insulin receptors, necessitating massive insulin boluses and infusion rates. Guardrail-like software could potentially impede such treatments if unable to address unexpected clinical needs.
The degree of uncertainty regarding the consequences of hospital-wide wireless integration has many worried the complexity of hospital IT will increase, potentially worsening the problems of today’s systems. Instead, argue some, hospitals should focus on employees as the ultimate solution to efficacy and errors, not enhanced IT. In particular, the resolution of chronic understaffing of providers would solve many safety concerns. Other interventions known to improve workflow while decreasing errors include: employee education directly applicable to patient care; teaching physicians to identify cognitive and decision-making bias; teamwork training to reduce workflow interruptions; and changes in hospital culture to eliminate the blind obedience of hierarchical relationships (Nenda & Perrier, 2012).
While IT implementation has many pros and cons to consider, the IHICU is also introducing less controversial technology with established and favorable research. One of their most needed systems is an updated pneumatic tube system. Hospitals use pneumatic tubes to transfer medications; specimens; and paperwork between floors. Losing track of patient specimens and information is common, especially when providers get caught up in other tasks. The updated pneumatic system provides alerts upon arrival and delivery of specimens, while also tracking products from the ICU to other parts of the hospital. This provides an easy way for nurses to know when and where an item of need is located, rather than wasting time tracking it down.
The other introduction is electronically switchable smart glass, called “E-glass,” capable of canceling out light by running an electric current through it. The color change is immediate, making it useful for instant privacy. Studies indicate patient stress is increased by a lack of privacy; inability to control sun/window glare; and excessive noise. Traditionally, these needs are met – with various success – via combinations of curtains, glass windows, and blinds. E-glass offers benefits traditional methods cannot. For one, E-glass is a greener product. With traditional glass windows, patient room temperatures can reach rapid extremes, requiring significant heating or cooling. E-glass requires only a small electric current to filter light and minimize temperature extremes, thus minimizing heating and AC costs in general. The greatest disadvantage of E-glass, however, is the cost of installation. For most hospitals, it will remain a luxury item.
The last item being introduced – the use of bedside ultrasound – is causing great excitement within medicine. In some cases, bedside ultrasound eliminated the need for additional CT or MRI testing. It is also becoming essential in the management of acute respiratory conditions. Bedside ultrasound is quick, portable, and low-risk. It is effective for a variety of situations, including: prediction of airway difficulty prior to intubation; evaluating patients at risk of obstructive sleep apnea; assistance with intubation or urgent tracheostomy, particularly in patients with tracheal deviation; rapid, accurate diagnosis of pneumothorax; identification of internal bleeding; and safe evaluation of respiratory distress during pregnancy. Additionally, portable ultrasound is cheaper than other forms of imaging, and does not require exposure to radiation or IV contrast.
Bedside ultrasound is becoming so useful some providers claim it will eventually replace the stethoscope. Others, however, are quick to point out its limitations. Traditional stethoscope training cannot be lost, they argue, because there are many situations where ultrasound is not applicable or simply unavailable. For example, ultrasound is virtually useless in cases of COPD or asthma. And while ultrasound can rule-in solid lung abnormalities such as pneumonia or cancer, a normal ultrasound does not exclude their presence. Additionally, patients must be compliant with the exam and it may be inaccurate in morbidly obese patients.
Despite the many advantages of ultrasound, its ultimate limitation cannot be forgotten: it is operator dependent. As the reproducibility of results is an essential part of correct diagnosis, the greatest risk of ultrasound use is the production of inaccurate results. This means hospitals must be prepared to organize training and maintain skill monitoring and curriculum requirements. Therefore, the educational costs of ultrasound use may be higher than can be accurately predicted at this time.
There is no doubt modern medicine is facing a technological revolution. There is significant corporate interest and shareholder pressure to make medicine faster, more accurate, and increasingly profitable. There will always be problems when corporate manufacturers attempt to make changes within the unique realm that is medicine. While not impossible, unexpected conflicts will continue to arise. As IT advances and comprehensive medical networks seize the industry, CEOs cannot lose focus of the populations being served: medical providers and their patients. When medical technology and IT are designed with patients at their cores and providers at their peripheries, society may finally see the revolutionary medical care it so desperately needs.
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