Abstract
A real-time, bedside decision support tool that provides insulin therapy instructions for intensive care unit (ICU) patients was developed at Intermountain Healthcare’s LDS Hospital. A team of clinicians, analysts and software engineers were tasked with developing the user interface to run the glucose protocol. Quick, iterative designs involving clinical end-users early in the development process resulted in a tool which was easy to use, facilitated the nursing workflow and was successfully implemented in the hospital’s five adult ICUs.
Background/Problem
Intermountain Healthcare promotes best practices through Board Goals developed by clinical programs. One board goal from the Intensive Medicine Clinical Program set in 2005 was to achieve a high level of glucose control for the ICU population; maintaining glucose levels within a tight normal range.
A team of clinicians, analysts and software engineers worked together to developed a user interface for a bedside decision support tool designed to assist clinicians in aggressively managing blood glucose for ICU patients. The goal was to replace the paper –based glucose protocols with a bedside decision support tool.
Description
An initial prototype of the glucose protocol tool was developed prior to completing any substantial nursing workflow analysis. While the tool was able to accomplish the necessary decision support, the nurses identified many aspects of the prototype which were confusing, cumbersome and inadequate to meet the desired nurse workflow. The problems identified included a 17-step process to initiate the protocol and documentation of the POC glucose in one program while retrieving the insulin instructions in another program. The nurses also identified a need for a visible ‘timer’ to assist them in managing their work and prompting for the next required glucose assessment. The clinician feedback was used to refine the tool in subsequent iterations. Nurses were brought in frequently to participate in individual and focus group evaluations of the tool during each of the iterations in order to validate that the tool was meeting their requirements.
Result
The resulting tool improved upon the initial prototype by consolidating the original multi-step initiation process into a simple 3 step process and combining documentation and decision support instructions into a single, manageable bedside workflow process for the nurse. A special timer display clock was also developed and runs on the bedside workstation monitor showing the time remaining to the next glucose assessment. Other characteristics of the interface included the display of current protocol data and easy access to historical protocol data. The program was implemented successfully in the 5 adult ICUs at LDS hospital between February and July 2005 and is now being implemented throughout Intermountain Healthcare adult intensive care units.
Conclusion
Developing clinical computing tools for use by clinicians requires early and frequent involvement of clinical end-users in the development process. The early involvement and iterative design is critical in order to maximize the efficiency of the development process and subsequent user acceptance. In this project we were able to design a tool which was accepted by the clinicians and effectively replaced paper-based glucose protocols.