Use of Hand Held Computers in the NICU Draft Paper

I am posting the draft of my final paper for MN530, and welcome your comments!  Thank you, Deb R.

The Nurses Use of Hand Held Computers in the Neonatal Intensive Care Unit

Abstract

The purpose of this study is to improve the timeliness of documentation at the neonates’ bedside using a hand held computer in a Level II NICU.  Through the use of a Palm Tungsten E2 personal digital assistant (PDA), the nurses enter routine vital signs, supplies used, and response to ventilator changes at the bedside.  The unit is also equipped with research software to assist in dosage calculation verification and response to parents’ medical questions.  Working at the bedside also allows for more time with the patient and family (MacDonald, 2008).  Four PDA’s were used in the unit during the 2 week trial.  Training occurred in the classrooms and on the unit utilizing super users.  The evaluation of the product was reviewed with staff and physicians prior to expanding the program to all neonates.  The ability to link data from the bedside has improved workflow process, reduced documentation errors, and improved physician rounds.

The Nurses Use of Hand Held Computers in the Neonatal Intensive Care Unit

            In the fast paced environment of a Neonatal Intensive care, documentation is often written down on anything available, post-it notes, package slips, and even scrubs.  With the enhanced technology of hand held computers, physicians have available to them the lab work, medication, and radiology reports on any neonate in the system (Drummond, 2009).  The nursing staff has requested to trial hand held computers for charting, shift report, and research on patients.  Neonatal nurses are specialists and technically competent, so the decision was made to present a proposal to Administration.

Background

            The Neonatal Intensive Care Unit (NICU) is a 16 bed level II facility within a large 400 bed teaching hospital.  There are 4 patient areas called pods comprised of 4 beds.  Each pod has a centralized computer for charting.  The current clinical information system utilizes the Siemens Patient Care Documentation System on Microsoft Access platform software (Lingren, 2010).  Charting is performed at the completion of a task, or at the end of the day prior to shift report.  Paper documentation is kept at the bedside with current changes in status or lab results, with a printout of medications with time of delivery.  Physician and resident rounds involve the use of a hand held computer, and the nurses hand written notes.  The duplicate charting often results in a nurse’s verbal interpretation of the findings to translate the handwritten notes (Fischer, 2007).

Planning

A Clinical Information (CIS) team was assembled to review the costs and benefits of instituting a hand held computer program with the nursing staff in the NICU.  The team represented administrators from the departments of information systems, pharmacy, physician, laboratory, radiology, finance, and management.  With the goal of improving work flow and data reference, the Palm Tungsten E2 (E2) was selected for its reasonable cost and bright color display screen.  The E2 also has a built in blue tooth to synchronize with the desk top.  The physicians were familiar with Palm computers, and found the medical imaging clear for rounds (Beard, 2011).  The software package is Pendragon Forms 5.1, allows the data to be automatically transferred to Microsoft Access (Schulman, 2003).  To minimize the costs, the CIS team agreed to purchase 4 hand held computers, one for each pod, and establish a wireless Bluetooth system in the NICU.  Chargers would also be purchased and located next to each standalone computer for downloading and recharging the battery.

Implementation

            As discussed in an earlier paper, training occurred over several days, and a phased in approach was utilized.  All the staff, including physicians, unit secretaries, respiratory therapists, and physical therapists were required to attend a 2 day classroom training session using case scenario’s prior to go-live on the unit.  Super users were selected for both 12-hour shifts.  Together with nursing management, the super users selected 4 long term neonates as part of the initial trial period.  The information system staff had programmed the nursing assessment, laboratory, and pharmacy screens.  The system also incorporated the OVID @ hand database for access to drug and medical information (Linquist, 2008).   Physician orders were still entered at the pod computers, as well as the therapists’ assessments.  Parents and significant others of the neonates were give a brief summary of the hand held computer by the nursing staff to reassure family members of the security measures in place and the appropriate use of the hand held computers.

Maintenance

            After a two week trial period with the four long term neonates, the system needed significant changes.  The first change was to reduce the number of screen for nursing assessment.  The IT department organized a systems approach for data entry, so if the nurses were primarily documenting ventilator changes, the information would be under the pulmonary function tab.  The second change was to improve security.  The security program at the hospital begins with background checks and employee orientation.  Based on the assigned log in, staff is assigned a level of access to patient records.  The user PIN is unique and traceable to an individual.  Audits allow a review of employees’ access to ensure appropriate user.  Encryption transmits the data from the hand held unit to the pod computer to protect patient confidentiality (Lee, 2007).  This needed to be communicated to all staff and parents.  The hand held computers need to be logged off when not in use to prevent unrestricted access (Lee, 2006). 

Evaluation

            A successful program must follow the nursing work flow, and the hand held computers have initially reduced the time spent documenting at the pod computers while increasing the amount of time at the patients’ bedside (Lee, 2006).  While there was a learning curve with the data entry, most nurses quickly adapted to documenting on a hand held computer.  The most improved area of documentation was the up to date assessment of vital signs and symptoms during ventilator changes.  This reduced the number of documentation errors, and promoted patient safety (Smith, 2009).  Physicians could review patients’ response and make adjustments according to tolerance of changes.  The reduction in the number of days on a mechanical ventilator could not be verified, but concurrent documentation during the weaning process was greatly improved (Carroll, 2000).  Medical and nursing staff is also able to review the laboratory data and trend changes in patient blood work.  This has resulted in adjustments to medication and oxygenation, with fewer changes made without current information (Carroll, 2000).

            Some of the barriers to hand held computers are the small screen size.  Rounds are down at the patient bedside, but move to the pod computer due to screen visibility with multiple practitioners during rounding.  However, all of the nursing data is available in the computer instead of hand written notes.  The automatic download through blue tooth technology needs to be monitored to ensure that the data imputed is transferred to the main computer.  Some data was lost if the hand held computer crashed or lost battery life (Beard, 2011). 

Revisions

            After reducing the number of screens for data entry and better visualization of lab work, the staff began to use the hand held computer on every patient in the unit.  As the staff became more familiar with the features of the E2, they were utilizing the research component to address parent concerns or add to the discussions at physician rounds.

Conclusion

            PDA’s have the potential to improve quality at the point-of-care by giving nurses access to patient information (Smith, 2009).  The Palm Tungsten E2 has provided the bedside nurse with the ability to chart concurrently at the patient’s bedside.  Using the E2 has shown that having an updated medical record allows for a clear review of the neonates response to changes, and a reduction in the length of stay.  Physicians can also review the record in one location, and not on multiple pieces of paper.  While there has been a reduction in time spent away from the patient, jotting down notes on paper is still occurring during codes and admissions.  It is the hope of all involved that these tasks will be incorporated in future updates after the success of hand held computers for nursing assessment.

References

Beard, K.V., Greenfield, S., Morote, E-S., & Walter, R.  (2011, May/June).  Mobile technology lessons learned along the way.  Nurse Educator, 36(3), 103-106.  doi:  10.1097/NNE.0b013e3182161016

Carroll, A.E., Saluja, S., & Tarczy-Hornoch, P. (2000).  Development of a personal digital assistant (PDA) based client/server NICU patient data and charting system.  Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2243582/pdf/procamiasymp00002-0139.pdf

Drummond, W.H. (2009, October).  Neonatal informatics dream of a paperless NICU: Part one: The emergence of neonatal informatics.  NeoReviews, 10(10), 480-487.  doi: 10.1542/neo.10-10-e480

Fisher, K.L. & Koren, A.  (2007, Summer).  Palm perspectives: The use of personal digital assistants in nursing clinical education.  A qualitative study.  Online Journal of Nursing Informatics, 11(2).  Retrieved from http://ojni.org/11_2/fisher.htm

Lindquist, A.M., Johansson, P.E., Petersson, G.I., Saveman, B-I., & Nilsson, G.C.  (2008, October-December).  The use of the personal digital assistant (PDA) among personnel and students in health care: A review.  Journal of Medical Internet Research 10(4), 31-42.  doi: 10.2196/jmir.1038

Lindgren, C.L., Elie, L.G., Vidal, E.C., and Vasserman, A.  (2010, March/April).  Transforming to a computerized system for nursing care organizational success within magnet idealism.  CIN: Computers, Informatics, Nursing, 28(2), 74-78.

Lee, T.  (2006, September/October).  Nursing administrators’ experiences in managing PDA use for inpatient units.  CIN: Computers, Informatics, Nursing, 24(5), 280-287.

Lee, T.  (2007, March/April).  Patients’ perceptions of nurses’ bedside use of PDA’s.  CIN: Computers, Informatics, Nursing, 25(2), 106-111.

MacDonald, M.  (2008, May/June).  Technology and its effect on knowing the patient a clinical issue analysis.  Clinical Nurse Specialist, 22(3), 149-155.  doi: 10.1097/01.NUR.0000311695.77414.f8

Schulman, J.  (2003). NICU notes: A palm OS and windows database software product and process to facilitate patient care in the newborn intensive care unit.  American Medical Informatics Association Annual Symposium Proceedings, 2003, 999.

Smith, L.B., Banner, L., Lozano, D., Olney, C.M., & Friedman, B.  (2009, September/October).  Connected care reducing errors through automated vital signs data upload.  CIN: Computers, Informatics, Nursing, 27(5), 318-323.