ACSQHC/CEC Deteriorating Patient WorkshopACSQHC/CEC Deteriorating Patient WorkshopTuesday 10Tuesday 10thth November 2009November 2009

Mark HorswillMark Horswill11, Megan Preece, Megan Preece11, Andrew Hill, Andrew Hill11, Rozemary , Rozemary KaramaticKaramatic22, David Hewett, David Hewett2,32,3, Marcus Watson, Marcus Watson1,2,31,2,3

School of Psychology, University of QueenslandSchool of Psychology, University of Queensland11

Skills Development Centre, Queensland HealthSkills Development Centre, Queensland Health22

School of Medicine, University of QueenslandSchool of Medicine, University of Queensland33

This is a method of systematically reviewing This is a method of systematically reviewing design problems in a system.design problems in a system.

Each chart was evaluated by five independent Each chart was evaluated by five independent trained evaluators against 10 pretrained evaluators against 10 pre--determined determined human factors design categories.human factors design categories.

1189 design problems were identified, an 1189 design problems were identified, an average of 48 per chart (ranging from 35average of 48 per chart (ranging from 35--63).63).

Raters considered Raters considered information displayed information displayed numerically rather than numerically rather than plotted as a graph to be plotted as a graph to be problematic.problematic.

The majority of charts did The majority of charts did not display all vital signs as not display all vital signs as graphs. This was argued to graphs. This was argued to make it difficult to notice make it difficult to notice deterioration.deterioration.

This chart uses This chart uses graphs to show the graphs to show the same data as in the same data as in the previous slide.previous slide.Deterioration is Deterioration is easier to see.easier to see.

Many charts Many charts had graphs had graphs where 2 or where 2 or more vital more vital sign plots sign plots could be could be confusedconfusedHereHere’’s an s an example of example of how multiple how multiple plots on same plots on same graph could graph could be confusingbe confusing

The same 3 plots were considered clearer when separated.

Track and trigger systems were considered Track and trigger systems were considered valuable for helping detect deterioration but only 36% valuable for helping detect deterioration but only 36% of the 25 charts reviewed had some sort of track and of the 25 charts reviewed had some sort of track and trigger systemtrigger system

Some charts put a high cognitive load on users Some charts put a high cognitive load on users (e.g. having to compare information over different (e.g. having to compare information over different areas of the page or having to transcribe information areas of the page or having to transcribe information between two pages).between two pages).

All the charts assessed contained text regarded as All the charts assessed contained text regarded as being too small (including one chart that used 4 point being too small (including one chart that used 4 point font). This could be a particular problem under low font). This could be a particular problem under low light conditions.light conditions.

Two thirds of charts did not use colour (or used Two thirds of charts did not use colour (or used it in a nonit in a non--meaningful way) meaningful way) –– missing the missing the opportunity it provides to improve usability.opportunity it provides to improve usability.

Problems included lack of clarity in labelling Problems included lack of clarity in labelling and phrasing and lack of standardisation in and phrasing and lack of standardisation in labelling. For example, we found 18 different labelling. For example, we found 18 different terms among the 25 charts for Oxygen terms among the 25 charts for Oxygen Saturation.Saturation.

O² saturation (%)O2 SaturationsO�SatO�Sat%O�Sat.Oxygen - Saturation %

Oxygen SaturationOxygen Saturation (SpO2)SaO�Sat O�SATS (SpO2)Saturation

SpO Sats%SpO2Sp02SpO2 SatsSpO2%SPO²

We used the best features of existing charts to create We used the best features of existing charts to create a draft of a new chart. The new chart ended up being a draft of a new chart. The new chart ended up being largely based on:largely based on:

The The Prince Charles Hospital MEWS chart Prince Charles Hospital MEWS chart which in turn was which in turn was based on the based on the COMPASS chart COMPASS chart in use at Canberra Hospital.in use at Canberra Hospital.

The The Royal ChildrenRoyal Children’’s Hospital CEWT chart s Hospital CEWT chart (designed by (designed by Kevin McCaffery)Kevin McCaffery)

We have called it the Adult Deterioration Detection We have called it the Adult Deterioration Detection System (ADDS) chart.System (ADDS) chart.

Specific aim is to detect deterioration rather than Specific aim is to detect deterioration rather than being a general observation chart.being a general observation chart.

The objective was to present the The objective was to present the most most important vital signs for detecting deterioration important vital signs for detecting deterioration in most patients in most patients in a userin a user--friendly mannerfriendly manner

We wanted to avoid the temptation to include We wanted to avoid the temptation to include additional data because, from a human factors additional data because, from a human factors standpoint, every extra item on a chart will standpoint, every extra item on a chart will compete with the existing information for the compete with the existing information for the useruser’’s attentions attention

••Vital signs all plotted as graphs (arranged into ranges).Vital signs all plotted as graphs (arranged into ranges).••More critical vital signs towards the top of the page.More critical vital signs towards the top of the page.••Scales labelled on both left and right.Scales labelled on both left and right.••Bold vertical lines every 3 columns.Bold vertical lines every 3 columns.••Progression in colours increasing in severity/importance from Progression in colours increasing in severity/importance from yellow yellow orange orange red red purplepurple••Colour key is positioned close to the data area.Colour key is positioned close to the data area.

Can be used as a single parameter system Can be used as a single parameter system (MET) or multiple parameter system (MET) or multiple parameter system (ADDS).(ADDS).

Action guide can Action guide can be referred to be referred to without page without page turning.turning.

Used checkboxesUsed checkboxesso users can even so users can even

as they complete as they complete actionsactions

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The upper option gives thresholds tailored to patientThe upper option gives thresholds tailored to patient’’s usual SBP s usual SBP but is less user friendly as a result.but is less user friendly as a result.

System allows modification of the threshold scores for a System allows modification of the threshold scores for a particular patient (on the first page the user would see)particular patient (on the first page the user would see)

Online survey Online survey –– evaluating the evaluating the preferences of chart users with respect to preferences of chart users with respect to a number of different charts.a number of different charts.Experimental studies evaluating the Experimental studies evaluating the performance (in terms of response times performance (in terms of response times and errors generated) of a sample of and errors generated) of a sample of observation charts in a simulated hospital observation charts in a simulated hospital environment.environment.

Please email me (Mark Horswill) with any Please email me (Mark Horswill) with any comments or suggestions: comments or suggestions: m.horswill@psy.uq.edu.aum.horswill@psy.uq.edu.auAlso, please log on to our online survey, Also, please log on to our online survey, which is canvassing views on charts: which is canvassing views on charts: https://experiment.psy.uq.edu.au/obschart/https://experiment.psy.uq.edu.au/obschart/