1

Forstyrrelser ved bruk av trådløs telefon på sykehus: forslag til forbedring

Interrupts caused by use of wireless phones in hospitals: proposal for improvement

Henrik Gundersen, ntnu, henrikg@stud.ntnu.no

Paul Martin Lello, ntnu, paulmart@stud.ntnu.no

Arnhild Kristinsdatter Lindbach, ntnu, gadnihasj@yahoo.no

Åsmund Skjerdal, ntnu, asmundsk@stud.ntnu.no

Lill Kristiansen, Telematikk, ntnu, lillk@item.ntnu.no

(based on EiT-course Interdisciplinary project work at ntnu)

2

Forstyrrelser ved bruk av trådløs telefon på sykehus: forslag til forbedring

Interrupts caused by use of wireless phones in hospitals: proposal for improvement

Henrik Gundersen, ntnu, henrikg@stud.ntnu.no

Paul Martin Lello, ntnu, paulmart@stud.ntnu.no

Arnhild Kristinsdatter Lindbach, ntnu, gadnihasj@yahoo.no

Åsmund Skjerdal, ntnu, asmundsk@stud.ntnu.no

Lill Kristiansen, Telematikk, ntnu, lillk@item.ntnu.no

(based on EiT-course Interdisciplinary project work at ntnu)

3

Challenges and goals

”How can we reduce interruptions by telecommunication between clinicians”

How can we reduce the harm of interruptions produced by patient signal system, phone calls and pagers toward clinicians?

How can we make an economical and practical solution to the problems of interruptions in clinical settings

How can we do this without making the communication praxis more complicated?

4

What is an interruption?

According to New Oxford American Dictionary:

5

Methods

Litterature studies from research field

general on interrupts

specific for health care

Seminar at NSEP in January 09 (20+ attendees)

showed film + discussion

Interview with 1 nurse

Document studies (in particular of notes on experiences from nurses during phase 1 at St.Olav’s)

3 hours participation on telephony training for doctors

Doc. studies of training material

(Experience as mobile phone owners, partly as patients)

6

Studies dealing with interruptions

Harr and Kaptelinin (2007) classifies studies dealing with interruptions in three distinct categories dealing with: Research concerning the effects of interruptions on

the individual (1) Research concerning the ways to stop disruptive

interruptions from occurring (2) Research concerning the ways to limit the damage

caused by interruptions (3)

Based on health case research we decided that (3) was the most appropriate approach.

7

Reducing the damage of interruptions

Research trying to reduce the damage caused by interruptions is often focused on ’timing’, or ways to ’filter out’ irrelevant information in work situations.

Other methods for reducing the damages caused by interruptions are often focused on using different modalities like heat, smell, sound, vibration and light. All as a means to reduce the interruption between perceptual and cognitive processes in organizational settings.

8

”... a short postponement of upcoming interaction.” (Wiberg and Whittaker, 2005)

Note: Here A is ’callee’ and B is ’caller’

Wiberg and Whittaker (2005) calls this ‘negotiating a short postponement’. They also propose an application called ‘Negotiator’

But it might be in a phone case that the only negotiation is ‘no action’ (no explicit ‘gesture’ back to caller)

9

Interruptions in a clinical setting

Recent studies have demonstrated that the communication situation in hospitals may result in interruptions that influence the work situation (Coiera and Tombs 1998, 673), interruptions that may result in malpractice (Kevin et al. 2003).

“Selfish communication practice” (Coiera and Tombs 1998)

Coiera and Tombs propose wireless (mobile) technology as a remedy This proposal may not take into account workarounds

10

From UNN,Tromsø (Scholl et al. ,2007)

A study of doctors use of wireless phone long walking distances: a wireless phone is very convienient to

place an outgoing call (or to reply to a page) But it is interruptive in many situations

They find various workarounds such as: Not listing the wireless phone in the phone book

avoiding incoming calls

Not carrying the wireless phone (leaving it in the office) also to avoid incoming calls (avoids outgoing calls as well!)

Forwarding calls to the pager Unclear if this is ‘call forward unconditional’ (Umiddelbar

omdirigering’) or call forward on no reply the latter will probably cause some callers to hang up before the page

is initiated, i.e. serve as an additional ‘filtering mechanism’

11

St. Olavs Hospital: new ICT systems

Our investigations is based on the existing (new) ICT systems at St. Olavs Hospital in Trondheim. Focus on economical and practical solution

All clinicians (and most/all) administrative staff is equipped with wireless phone (IP-based) Used for telephony by all, messages, pager ++ Nurses use the wireless phone also a one (of several)

means to receive / be aware of patient signals.

12

New hospital – bed courts (sengetun) Short

distancesbetweennurses

Doctors are not located at the bed court

Both doctors and nurses have wireless phone in the new hospital

13

Nurses and Interrupts

Nurse with busy hands Even if she wants to accept the signal, she may be too late

15 sec. timer Screen lock on when receiving signals (from interview)

Patient signal on the phone (in the ear!) while in a phone conversation (St.Olav, 2006): Also causing interrupts for the other party on the phone

Also some some interrupts caused to phone calls towards nurses (seems less important, Sletten, 2009)

Also the general fact that many things may go on at the same time (with or without wireless phones)

14

Pasient

PC på sengetun

Vaktromsapparat

PC-client to set up the responsibilities per room (i hht bemaningsplan)

Rompanel

Pasientterminal

AnropspanelVåtsone

Pasientpanel

Patient signal system: from patient/room to ’some’ nurse

Ignore / timeout

Reject

Accept

15

Telephony: from ’some’ (doc./nurse/..) towards a clinician (here: a doctor)

(personal call or role based call)

Cisco CallManager/Soft PBX / sentralbord Red = (direct) interrupt

"My pager has gone off five times in the past 15 minutes, while I've been

trying to take Mr. Jones's history. I can't keep his complicated history straight. (Kevin et al. 2003)"”Når calling’en [personsøkeren/ pager] piper på hylla i enden av operasjonssalen er det noen som trenger din hjelp. Men pipingen fra søkeren forstyrrer ofte operasjonen du holder på med, ” (telemed.no)

Phone seems more interruptive than the pager (Scholl et al., 2007)

16

Details of the phone

Used for patient signal reception Ignore Reject Accept

Used for paging No details provided here

Used for outgoing calls Used for incoming calls

Yes (green / 13) Redirect (button 14) Silence ring signal (red / 7)

Red button is DIFFERENT from the ordinary red button on a mobile phone Silence ring signal =/= Reject the call (or redirect)

Red button allows a 10-15 sec. delay

17

Minimizing the harm of the interrupt via a Bluetooth (BT) device

Cisco Call Manager

Main focus here:on the callee side(signals, calls and pages)

Idea: Keep rest of technical systemmostly/totally unchanged

Imatis messageserver

18

Non-functional requirements

Design req. Screen upwards Two buttons Weight Water splash, falling to the floor etc.

Screen LED display

Battery Standsby time

Bluetooth HID (Human Interface Device Profile)

supports battery saving The device is not an ordinary handsfree set

BT2.0 Details on BT in the paper

19

Main Use Cases for BT device (brukstilfeller)

UC1: Connect phone and BT device

UC2:Show caller-ID on incoming call

UC34:Accept call, delay the answering (via Mute/silence) or redirect (Umiddelbar omdirigering) ( ref. req. F3, F4)

UC6:Show room number for pasient signal (ref. krav F6)

UC7:Accept pasient signal or send further to next nurse (ignore or reject) (ref. krav F7)

UC for messages.

Others

20

Simplifying the communication?

“How can we make the communication easier for all parties?”

“How can we reduce the interruptions produced?”

“...without making the communication praxis more complicating?”

The device is easily visible and available.

No new complicated negotiating back-and-forth between caller and callee

No need for all users to use the new device, offers individual advantages (no ‘critical mass issue’)

21

Reducing Interruptions / Discussion 1

“How can we reduce the impact of interruptions on clinical personnel from mediated communication, especially with important tasks and consultations in mind?”

The proposed Bluetooth-device is more easily accessible than the wireless phone, something that in turn will make it possible to quickly evade interruptions in inconvenient situations (like consultations).

The device is proposed as a solution for problems that arise with phone is inaccessible in pockets. Following one design proposal from Scholl et al.(2007)

22

Reducing Interruptions / Discussion 2

Bluetooth device offers the possibility of better timing (slight delay or reject)

mute call, (silence ring signal)redirect call, reject patient signal

23

A realistic, economic and simple solution

“How can we make a economical and practical solution to the problematics of interruptions in clinical settings “

Since the Bluetooth-device in principal functions as a supplement to existing communication systems there will be no need to replace existing systems for it to work.

Since Bluetooth is a backwards-compatible technology, the device will function with newer technology.

Since the device is firmly based on the pager, it is probable that this will improve the process of introducing new technology (since pagers already are in use in most hospitals). Therefore, the device may easily be introduced into the working environment.

24

Questions?

25

For discussion

Showstoppers?

Scenario 1: Finding the (right) BTdevice

Economy: The device is ’similar’ to a handsfree unit, but will not be a mass market device higher price

Need all nurses have their personal BT device? Main interrupt issue for nurses is patient signals during an

ongoing call Connect the BTdevice during the ongoing call? Other means to ’opt out’ (midlertidig melde seg ut) of

patient signal responsibilities? Some alternatives functionality without new devices are

proposed in Sletten (2009)

26

Low tech / low economy version (for both nurses and doctors):

Just modify the ringing sound for incoming phone calls From:

’the phone rings and rings’

To: ring, ring (almost silent 10 sec.), ring a final ring

(i.e. an automatic variant of silence the ring signal) or find a melody that acts like this

A much simpler and cheaper solution may not solve all the relevant problems But may be discussed in a cost view

27

Informing (or negotiating with) the caller: pros and cons

Relevant for phone calls (and paging) i.e. when the caller is a clinical co-worker Less relevant for patient signals

patient should not worry about total work load and organizational issues

Can be done prior to call ’active status’ in address book (’widget’) / visible cues / ++

Can be done during the call Can be done after the call in a separate message

Will this happen in a busy day in hospitals?

28

prior, during or after a call

Prior to call: Similar to AwarePhone (Bardram and Hansen, 2004)

but requires updates of the status field (i.e. manual overhead) (or the use of automatic location)

During the call Similar to SE P990 (send an SMS in return) Or via predefines voice messages like (’wait 10 seconds’,

’lunch’, ’surgery’ etc) (unpublished prototype by Ericsson) May be automated from callee (with a ’force through

option’ for caller) Some solutions are suitable for meetings, surgery etc

but probably not for nurses with both hands occupied After the call is a separate message

ref. SMS ’Forelesning’ received by my daughter. more relevant for interrupts when sitting in meetings texting for nurses with busy hands?

29

Negotiating back to caller / Negotiator (Wiberg&Whittaker)

Several ’pros’ when not negotiating back to caller (our solution) technically simpler ( cheaper) Offer instant individual relief (not depending on critical

mass to be useful) (Negotiator required that both caller and callee where

using the new feature) The ’selfish clinical worker’ get the benefit him/herself

(Coiera and Tombs, see also Grudin)

’Cons’: less rich context back to caller in order for caller to decide on further actions

30 Eller at vi hadde faste møteavtaler?

31

Further work

Build the prototype and test it Or presenting to clinicians and receive feedback

Look more into organizatinal issues, ways to avoid (some) interrupts regular meetings / scheduled events? more use of messages inside the EPR? The issue of communication between nurses and doctors

may require special attention (ref. Ero Stig Karlsen) Using redundancy is an active way coupled with the

bemanningsplan (ongoing work) redundancy of function (nurses can cover for each other) redundancy of data (fixed and wireless system offer

redundancies)