Pediatric Informatics: Computer Applications in Child Health (Health ...

86 W.H. Drummond et al.
8.2.2 Formative Evaluation of the QI Initiative’s Results
After it became apparent that the protocol implementation had failed, an analysis
of the process was conducted and revealed multiple problems:
1. High Work Load: The new, more stringent oxygen saturation limits created
more monitor alarms, requiring the staff to adjust supplemental oxygen more
frequently, adding additional workload for already busy nurses. A high patient
census and many labile patients, whose saturations always fluctuate, further
magnified the staff work load.
2. Lack of “Buy-in”: Several influential staff members did not believe in the protocol’s
premises. Maintaining oxygen saturation in a more narrow range was not
seen as beneficial to patients’ outcome, so the required titration of oxygen was
considered a useless chore. Some staff members were unsure if all babies would
benefit from this protocol or only smaller premature infants.
3. Regulations: Pressured to save time in order to comply with work-hour rules, 14
residents quickly learned to ignore the time-consuming titration protocol steps
and reverted to increasing the oxygen to 100% at the beginning of a desaturation
episode, leaving the nurse or respiratory therapist to titrate the FiO 2 back down.
4. Ambiguity: Users were unclear if this protocol applied to all patients or if there
were legitimate exceptions. The resulting confusion led to inconsistent protocol
application and measurement errors. 15
5. Negative Impact of Hospital IT: One of the major obstacles discovered in the
course of the failure analysis, was the impact of a newly implemented respiratory
therapy clinical documentation system designed entirely for adult patient
care. This system was designed in response to a JCAHO mandate, and required
the respiratory therapists (RT) to document their work using a remote computer
terminal – effectively pulling the RT away from the patient bedside for extended
periods of time. The reporting system added a significant documentation burden.
The time spent documenting could be more than twice as long as the actual
patient encounter. This HIT system effectively interrupted RTs’ workflow,
increased their work load, and made it impossible for them to aid in the implementation
of the care optimization protocol.
6. Workflow and Layout: NICU B had been recently renovated, modernized, and
enlarged, using a custom architectural design focused on solving lighting, noise,
and privacy problems. Sound dampening walls, floors and translucent partitions
were used to quiet the environment and to create visual and auditory privacy
between the bed spaces (Fig. 8.3). Nurses in the new cubicles could not see, or
hear, much of what was happening elsewhere in NICU B.
The new bed space arrangement was very different from the former layout of the
NICU B (Fig. 8.4), and from the layout of NICU A. Both NICU A and the previous
design of the NICU B had a floor plan that aligned the beds in rows along counters,
about 4 ft apart. While noisy and very unpleasant for parents, visual and auditory
access to all the bed spaces was excellent with the previous design.