20

arrangement of data elements might also affect the way that the forms were filled, and the ease with which recorders could find an appropriate place to write down information. 19 In addition to issues with the existing forms, the survey also asked participants about the role of technology in the documentation process. “It would be great to have some electronic recording, but the computers are too slow. It would HAVE to be extremely fast and specifically for codes - otherwise paper and pen are the best bet.” - Subject 17 Survey respondents expressed favorable attitudes towards technology-based documentation options. Nine individual participants were particularly interested in directly linking the code blue documentation to the electronic patient record. When specifically asked about technology preferences, nine participants suggested the inclusion of automated recording capabilities, such as audio recording of information, or automated capture of data from patient monitoring equipment. “Voice activated would be cool but realistically, the technology should not be too complicated to make the documentation process more complicated.” – Subject 7 Despite this widespread interest in linking computer-based documentation and automated data collection, five subjects also expressed concerns that existing computer systems were too slow and bulky to be used during an emergency. One subject commented that portable computing systems might bridge the gap between paper forms and desktop systems. However, other subjects specifically mentioned that paper was preferred to computer-based systems. Reasons cited included familiarity with existing forms and processes, as well as availability and reliability. Participants also cited usability as a problem with existing code blue documentation forms. Specifically, there were two types of comments that focused on usability issues with the existing form: those asking for a simplified form, and those asking for additional space. Those asking for a simplified form preferred the addition of structured elements such as checkboxes, as they reduced the overall amount of writing required. “Revamping the form to make it more user friendly. An example would be to have check boxes where you can add a line for stopping CPR to check for pulse.” – Subject 28 “Less writing more check boxes for what has been attempted and times.” – Subject 31 20 In these sorts of comments, participants felt that the addition of structure checkboxes would streamline the data entry process and improve their ability to capture data in real-time. However, other comments were mixed, asking for more simplicity while emphasizing the need for added whitespace. “Boxes for yes/no or quick questions for example; Intubated? CPR preformed? Did pt have a heart beat? etc. The area for writing meds should be left open. It's not easier to document drugs on lines when you don't remember or aren't familiar with the sheet. It's easier in my opinion to scribe per sequence of events as they happened.” – Subject 22 Taken together, many participants (27%) were dissatisfied with the existing forms but were unsure about how best to fix them. An equal number (27%) wanted improvements to usability, asking for a simplified layout and additional space for data entry. A handful (11%) suggested a computerized documentation alternative, but only if the computers were faster and more accessible. Focus group findings The nursing focus groups were scheduled immediately following regular group meetings and were well attended, with a dozen participants at each session. Because of their increased exposure and involvement with code blue emergencies, these sub-groups were considered representative of the potential recorder population. The patient safety and risk management meeting was smaller with a halfdozen participants. Those organizations were smaller and draw from the set of stakeholders who make secondary use of code blue documentation. The focus group findings were complementary to the qualitative survey results, confirming the concerns about workflow the role of documentation in the care process. The feedback was mostly qualitative reports about critical events and workflow practices, used to identify unusual or undocumented factors that influence the information collected during code blue events. Specifically, nurses said that the checkbox information was routinely skipped until after the event. Nurses also suggested reordering some form elements, such as blood pressure, heart rate, and heart rhythm. This would better meet 21 expectations about the order of information. Nurses valued the availability of space for free-text comments, but they also expressed interest in minimizing the amount of writing they had to do, such as pre-written medication names. The patient safety and risk managers were more interested in the way that the forms are used after the event, and so they deferred to the real-time information needs of the recorders responsible for capturing information about the types of clinical treatment and the times when they occurred. Although the initial pool of potential recorders included the entire nursing staff, the relatively low number of events per year (161 events in 2008) and distribution throughout the hospital meant that only a handful of individuals would have direct experience 

1   2    3    4    5    6   7   8   9   10   11   12   13   14   15   16   17   18   19   20   21   22   23   24   25