020-0093 Mobile Device Applications to Improve Operating Room Safety and Efficiency Through Transparency and Situational Awareness Brian Rothman Vanderbilt University School of Medicine 1301 Medical Center Drive, 4648 TVC Nashville, TN 37232-5614 Brian.rothman@vanderbilt.edu (615) 343-9419 POMS 22nd Annual Conference Reno, Nevada, U.S.A. April 29 to May 2, 2011
Motivation A single anesthesiologist supervising 2-4 anesthetic sites has become more prevalent and is becoming dominant as a practice model in the United States. During unique, critical and near critical, events, the notification of the supervising attending by the CRNA or resident in a timely manner can be delayed. Delays can occur for several reasons including the requirement staff to stop clinical work to send a page, and the evolving event is unrecognized by the in-room provider. Situational awareness has been defined as the perception of environmental elements, the comprehension of their meaning and the prediction of a future state based on those elements and their meaning, 1 and transparency is defined as making information visible without searching. Providing transparent, situational awareness to those who supervise in-room providers would allow them to receive information regarding multiple cases in near real-time, virtually eliminating the need for providers to stop their care and call out to their supervisors. While situational awareness is generally defined as a point of care concept, it can extend out to the entire perioperative environment with the correct combined application of software and hardware. This extension could facilitate greater safety and efficiency during perioperative care. This paper will briefly discuss the data needed in the perioperative environment for situational awareness and how transparency can be achieved followed by the past attempts at using mobile technology to accomplish these goals, and why mobile technology had been only marginally
successful until recently. Our recent work developing VigiVU TM at Vanderbilt University School of Medicine to transparently deliver situational awareness at the point of care and in the Perioperative arena will then be discussed. Research Problem We believe that the application of our work will promote near real-time physician involvement in directing proactive treatment of evolving events for multiple care sites. Through mobile devices that deliver transparent, real-time notifications and situational awareness, greater safety and OR efficiency should follow. Methodology Components of Situational Awareness and Transparency To accomplish situational awareness during the perioperative period, we identified live video of care sites, patient health information, graphical vital signs trends, out-of-range vital signs and medication administration notifications, and communication as critical components of the application. As for transparency, we are currently able to present this data on any desktop computer in the institution through our Vigilance TM situational awareness application. [Fig. 1] However, the desktop environment requires that the supervising attending leave the care area to work areas
where the computers are located. For years, the team at Vanderbilt attempted to use state-of-theart mobile technology to match the mobile nature of the attending anesthesiologist work pattern. Figure 1 - An example of Vigilance live video. Shown is multiview mode with 4 rooms viewed simultaneously. Each room s most current vitals are beneath each view and status notifications can be seen in the upper right corners. Limitations of Prior Mobile Technology Prior to the release of the iphone, specifically the 3G iphone, mobile solutions were advanced for their time but suboptimal. Until recently, mobile device weight, size, battery life, and hardware and software feature and interface limitations prevented meaningful use in a healthcare environment. Mobile technology advances in the form of smart devices and tablets have
prompted the healthcare industry to embrace and more widely implement these hardware and software platforms. VigiVU TM Hardware and Operating System We developed VigiVU TM as an iphone application to provide integrated situational awareness of multiple locations for our staff. ios is a somewhat closed system that can be restricting with respect to certain areas of development and deployment. However, the operating system is without fragmentation, running reasonably well on the last two generations of Apple hardware. These attributes streamlined our development process allowing us to utilize the iphone, ipod Touch, and ipad devices. Development of our first VigiVU TM version took 3 weeks and significant refinements and improvements continue currently. VigiVU TM Clinical Features Our goals were to provide mobile situational awareness during the perioperative period and utilize the strengths of mobile devices and match the clinical workflow of Perioperative care. Using the development pillars noted above, we created a mobile application that delivered these inputs organized in a fashion that followed common clinical care pathways to further support data visibility without searching. Our clinical workflow begins with the supervising provider subscribing to multiple points of care for which they are responsible. Simultaneous live video for up to 4 subscribed rooms, consistent with the maximum number of rooms that can be supervised, with current vital signs can be
presented. [Fig. 2] Selection of any one of the video windows provides a full screen view with camera control and an opportunity for direct linkage to each of the room s case views. Case views provide a summary problem list, detailed electronic history and physical, graphical vital signs, medication with doses, additional measured values [Fig. 3], and again, live video. Figure 2 Screen shot of the iphone application VigiVU: Multiview, showing four rooms simultaneously
Figure 3 - Graphical Vital Signs View (left) the top grid represents blood pressure, oxygen saturation, and pulse values collected directly from the physiologic monitor. The bottom grid (blue) represents medication doses administered in 15-minute increments. (right) The grid continues with additional measured intraoperative values (yellow) and Subscriptions also identify rooms for which the provider wants to receive out-of-range vital signs via push notification throughout the perioperative process. [Fig. 4] The default ranges, determined by the provider, are applied to every subscribed case. On a case-by-case basis, the provider can then customize these ranges according to the patient s specific requirements.
Figure 4 Out of range vital signs Rooms are subscribed to so the user can receive push notifications of vitals that are out of range. Conventional pages are also received. The notifications history contains relative links based on the notification received to match clinical workflow. For example, selecting vitals will immediately take the user to the graphical vital signs of the room that the notification is for. Communication is facilitated through a centralized xml phone list of all anesthesia staff that is updated each time the application is started. The interface for the full list uses filters and an active search to find the intended recipient quickly. Messaging is made even more efficient with customizable preset messages. We also provide room specific communication information,
providing links to text page any provider who has signed into the case. Cellular and Skype calls can also be initiated from the communication section to directly speak with staff. VigiVU TM OR Management Features An operating room (OR) case board with perioperative admission, discharge, and transfer (ADT) indicators is a necessary management tool. Our eorboard [Fig. 5] makes this data available to all perioperative staff in a graphical format. The boards are placed throughout the perioperative environment and displayed on 40 flat panel televisions in support areas that require detailed, real-time, patient location data. Their presence is a significant tool to provide transparency. The color legend allows providers to quickly identify a patient's status throughout the perioperative process. Room status during turnover, identifying dirty, clean, and ready, is also provided.
Figure 5 - An electronic schedule board provides access to current scheduling information to perioperative staff. Data presented may include patient and procedure specific information, information about patient readiness for surgery, information about room set up status, and case start or completion delays. Using this information, managers can project room occupancy and arrange the schedule to maximize efficiency while clinicians can use the same information to obtain critical patient information. Identical case board features are available in VigiVU TM [Fig. 6], and providers subscribing to the room receive room and ADT status changes as push notifications. The subscriptions also allow the creation of custom case boards to observe specific room statuses for management purposes. Figure 6 The OR case board on the VigiVU TM application shows patient and procedure specific information, information about patient readiness for surgery, room set up status, and
case start or completion delays. Managers can project room occupancy and arrange the schedule to maximize efficiency and clinicians use the same information to obtain critical patient information. VigiVU TM Security Features Security has been a priority due to the portability of the device. Multiple layers of security both in the application and at the central server effectively restrict access to patient health information to only for those it is intended. The devices are used as a thin client, and no patient health information is stored on them. Results We have been successful in developing VigiVU into a mature situational awareness application. It is now ready for implementation throughout Vanderbilt s anesthesiology department. While improved situational awareness is subjective currently, staff at all levels feel that it facilitates communication, safety, efficiency, and decreases their need to step away from their care areas to find a desktop computer. Staff also feel that the application improves transparency with the described features combined in such a fashion to follow the most common, safest, and efficient workflows. For example, the application remembers the user started at multiview before a current case view. When the
provider is finished viewing the case, they can quickly return to multiview and see video for up to 4 of the rooms to which they have subscribed. The acceptance rate has been 100% for those using the device and actively sought after by others in our department, and remarkably, by nursing management and surgeons. Discussion We recognize that situational awareness is only one important aspect of mobile practice. However, implementing a mobile solution matching our mobile practice appears to facilitate communication, safety, efficiency, and decreased desktop computer reliance for anesthesiology, surgery, and nursing teams alike. It is a challenge to provide instant, accurate, easy-access information in perioperative settings. We feel we have been initially successful in accomplishing these goals but have found that pushing usable information is data- workflow- and device-dependent. Poorly integrated systems can cause delayed, inaccurate, or incomplete data delivery. The existence of any of these conditions decreases situational awareness, transparency, acceptance of the technology, and most significantly may decrease patient safety. Steps must be taken during testing and implementation phases to ensure that data delivery is clinically timely and relevant. The VigiVU TM application transparently and reliably delivers relevant information to clinicians. However, higher-level information such as decision support algorithms could guide clinicians to
the best next steps to care for their patients. These algorithms still need to be created and implemented but could further improve patient care, safety, and possibly decrease healthcare costs. Also, development of notification escalations effectively combined with internal positioning systems is another opportunity for mobile devices to aid in resource management throughout the perioperative process. 1. Wright MC. Objective measures of situation awareness in a simulated medical environment. Quality and Safety in Health Care. 2004;13(suppl_1):i65-i71.