pdc_2009_samehanded study
TRANSCRIPT
Patient SafetyPatient Safety
An Empirical Examination of the Safety and Efficiency Implications of y y p
Patient Room Handedness
2009 PDC Conference & ExhibitionLeading the Way to Better Health Care Design
Learning Objectives• Assess the potential impacts of same-handed
patient rooms from the first ever empirical data ll t d th t icollected on the topic.
• Develop an understanding on the natural tt f ipatterns of nursing care.
• Identify how same-handedness of the physical environment might benefit or impede careenvironment might benefit or impede care delivery.
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Presenters• HKS, Inc.
– Tom Harvey, AIA, MPH FACHA
• UTA, School of Nursing
MPH, FACHA– Debajyoti Pati, PhD,
FIIA
– Carolyn Cason, PhD, RN
– Jennie Evans, RN, BS
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Acknowledgments
• Academy of Architecture for Health Foundation Research Grant
• Herman Miller Inc. Research Grant• University of Texas Arlington Smart• University of Texas Arlington, Smart
HospitalTM
• Dr Nancy Rowe Manager Statistical• Dr Nancy Rowe, Manager, Statistical Services, OIT, UTA
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Acknowledgments
• Dr DL Hawkins, Associate Professor & Associate Chair, Dept of Math, UTA
• Mark Ricard, Professor, Department of Kinesiology, UTAgy,
• Andrea Erwin, RN, Kathryn Daniel, PhD, A/GNP-BC and Linda Denke RN SchoolA/GNP-BC, and Linda Denke, RN, School of Nursing, UTA
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Agenda
• Background• Key Conceptsy p• Study Design• Anal tical Methods• Analytical Methods• Key Findings• Conclusions
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Origin of the Issue• IOM reports
highlighting medical errors
• AHRQ reports d iunderscoring
inefficient and unsafe care practicesunsafe care practices
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Architectural Response• Standardization:
– Same-Handed care i tenvironment
– Patient Rooms identical in all de t ca arespects
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Underlying Logic• Experience in aero-
space industry– Flight deck
standardization resulting in safety g yimprovement
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Issue
• Lack of empirical evidence in healthcare psettings to support or refute safety or efficiency impact of handednessy p
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KEY CONCEPTSStandardization : Handedness : Behavior
KEY CONCEPTS
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Levels of Standardization• Level 1: Headwall
– identical array of tiliti i lutilities is always
provided on the corridor side of each room (irrespective of patient side)
Level 1Level 1
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Levels of Standardization• Level 2: Headwall
– consistently placing a t i fcertain array of
utilities on the patient’s left, and another on the right
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Levels of Standardization• Level 3: Caregiver
Zone– design and relative
locations of all elements provided to psupport the care process within the caregiver zone are
Level 3Level 3caregiver zone are standardized across all patient rooms
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Levels of Standardization• Level 4: Patient
Room– patient rooms are
designed identical and all elements in the patient rooms are designed, located and oriented in identicaloriented in identical manner
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Levels of Standardization• Level 5: Unit
– patient rooms and all tsupport spaces are
standardized across all units in a hospital
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Note # 1
• Standardization MAY or MAY NOT involve handednessinvolve handedness
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Handedness TypesHandedness Types
Right handed environment Left handed environmentRight-handed environment Left-handed environment
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Note # 2
• Standardized patient room (level 4) with Right-Handed care environment is currently recommended to address efficiency and safety
• Left-Handed care environment is also being designedg g
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Behavior• Handedness
recommendation is di t d thpredicated on the
belief that care behavior is knownbehavior is known and documented
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Behavior• There exists a
knowledge gap in i lit tnursing literature on
how nurses deliver care (how theycare (how they approach conducting a procedure)p )
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Note # 3
• Without understanding care behavior, it is g ,difficult to assert that a certain physical configuration will optimize care processes g p pand promote efficiency and safety
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THE HANDEDNESS STUDYTHE HANDEDNESS STUDY
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Study Questions
• Are there natural patterns of care behavior?
• Would standardization and/or handedness facilitate or impede care pprocess?
• Are there harmful actions that could beAre there harmful actions that could be linked to the physical environment?
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Study Setting• University of Texas
Arlington, Smart H it lTMHospitalTM
– Team Training Room
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Patient and Subjects• Patient:
– Patient actor• Subject Attributes:
– Age: 21 – 62; median 53• Subjects:
– 20 right handed nurses
53– Education: 1 BSN;
remaining at least a – 20 left handed nurses
e a g at east amaster’s degree in nursingE i 1– Experience: <1yr –30+; median 25
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Physical ConfigurationsIV IV
Scenario 1 Scenario 2 Scenario 3
OBT OBT OBT
S i 4 S i 5 S i 6
O O
IV
O
Scenario 4 Scenario 5 Scenario 6
OBT OBT OBT
IV IV
Scenario 7 Scenario 8 Scenario 9IV
OBT OBTOBT
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Nurse Station• Equipment:
– Dinamap– Suction Kit
C t l ith• Control room with A/V control
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TasksTasks InstructionsTasks Instructions
Vitals Please take your patient’s vital signs and return to the nurse station
Suction Your patient is a new admission who has a tracheotomy and will need to be
i d Pl t d tsuctioned now. Please pretend to suction your patient.
Sitting Please sit your patient on the edgeSitting Please sit your patient on the edge of the bed and return to semi fowler’s position
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Simulation & Sequence• 9 settings x 3 tasks =
27 simulation runs bj tper subject
• Setting sequence and t ktask sequence randomized
• Total 540 simulation• Total 540 simulation runs
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Nursing• Two independent
RNs coded each id t
• Coded behavior:– Approach direction
video segment• A third RN reviewed
d d d t f
– Hesitation in approach– Over bed table use
B d il dj t tcoded data for inconsistencies and mistakes
– Bed rail adjustment– Bed height adjustment– Bed angle adjustmentmistakes Bed angle adjustment
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Nursing• Coded behavior:
– Stretch– Bend– Unstable
Lift– Lift– Twist– RepositionReposition
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Kinesiology• Kinesiology expert
coding of video t t id tif
• Actions:– Stretch
segments to identify harmful/stressful actions
– Bend– Unstable
Liftactions – Lift– Twist– RepositionReposition
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Additional Data
• Subject interviews focused on:– Work flow– Awkward posture or movement– More supportive settingspp g– Factors affecting approach decision
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DATA ANALYSISDATA ANALYSIS
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Analytical Methods
• Logistic regressions for binary response variables
• Poisson regression for frequency counts• Exploratory data analysis• Exploratory data analysis• Content analysis of interview data
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LEFT HANDED NURSESWITHIN GROUP ANALYSIS
LEFT HANDED NURSES
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Behavior Patternh b h iQ: Is there any behavior pattern among left-handed nurses?
se
djus
t
Adj
ust
App
roac
h
Hes
itatio
n
OB
Tab
le U
s
Bed
Rai
l Ad
Bed
Hei
ght
Adj
ust
Bed
Ang
le A
tret
ch
Ben
d
Uns
tabl
e
Lift
Twis
t
Rep
ositi
on
A H O B B A B S B U L T R
Vitals Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Suction Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Sitting NO Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
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Inference # 1
• Within left-handed nurses there appears to be a pattern of predictable behavior across the nine settings
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RIGHT HANDED NURSESWITHIN GROUP ANALYSIS
RIGHT HANDED NURSES
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Behavior Patternh b h iQ: Is there any behavior pattern among right-handed nurses?
e ust
Adj
ust
djus
t
ppro
ach
esita
tion
B T
able
Use
ed R
ail A
dju
ed H
eigh
t A
ed A
ngle
Ad
retc
h
end
nsta
ble
ft
wis
t
epos
ition
Ap
He
OB
Be
Be
Be
Str
Be
Un
Lif
Tw Re
Vitals NO Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
S ti Y Y Y Y Y Y Y Y Y Y Y YSuction Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Sitting Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
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Inference # 2
• Within right-handed nurses there appears to be a pattern of predictable behavior across the nine settings
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LEFT – RIGHT COMPARISONBETWEEN GROUP ANALYSIS
LEFT RIGHT COMPARISON
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Behavior DifferenceQ: Are there differences between left and right handed nurses?Q: Are there differences between left and right-handed nurses?
se
just
Adj
ust
djus
t
ppro
ach
esita
tion
B T
able
Us
ed R
ail A
dj
ed H
eigh
t A
ed A
ngle
Ad
tret
ch
end
nsta
ble
ift
wis
t
epos
ition
Ap
H OB
Be
Be
Be
St Be
Un
Li
Tw Re
Vitals Yes no no Yes no no no no no no no YesSuction Yes no Yes Yes no no Yes no no no no no
Sitting Yes no no no Yes no no Yes no no Yes no
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Inference # 3
• Large number of statistically significant differences between left-handed and right-differences between left-handed and right-handed nurse behavior
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FACTORS AFFECTINGWHERE DO NURSES POSITION VIS-À-VIS THE PATIENT?
FACTORS AFFECTING CAREGIVER POSITION
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Task: VitalsQ: Left-handed nurses’ position vis-à-vis the patient
Position: Left-Handed Nurses
Set ID 1 2 3 4 5 6 7 8 9
%Right
20 100 0 10 50 100 0 100 0
% Left 80 0 100 90 50 0 100 0 100Factor Natural
PreferenceIV IV Dist/
PrefIV IV IV IV
OBT
IV
OBT
IV
OBT OBT OBT
IV
OBT
IV
OBT
IV
OBT
IV
OBT
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Task: VitalsQ: Right-handed nurses’ position vis-à-vis the patient
Position: Right-Handed Nurses
Set ID 1 2 3 4 5 6 7 8 9Set ID 1 2 3 4 5 6 7 8 9
%Ri ht
50 100 10 20 80 100 0 100 20Right% Left 50 0 90 80 20 0 100 0 80Factor Natural
PreferenceIV IV Dist Dist IV IV IV IV
OBT
IV
OBT
IV
OBT OBT OBT
IV
OBT
IV
OBT
IV
OBT
IV
OBT
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Inference # 4• In Task = Vitals
– Location of IV d t i idetermines caregiver location
– In absence of IV, OBTabse ce o V,walking distance determines caregiver locationlocation
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Task: SuctionQ: Left-handed nurses’ position vis-à-vis the patient
Position: Left-Handed Nurses
Set ID 1 2 3 4 5 6 7 8 9
%Right
30 60 0 0 40 50 0 60 10
% Left 70 40 100 100 60 50 100 40 90Factor Natural
PreferenceIV IV Dist/
PrefDist/Pref
IV Dist/Pref/IV
IV/Dist
IV/Pref
IV
OBT
IV
OBT
IV
OBT OBT OBT
IV
OBT
IV
OBT
IV
OBT
IV
OBT
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Task: SuctionQ: Right-handed nurses’ position vis-à-vis the patient
Position: Right-Handed Nurses
Set ID 1 2 3 4 5 6 7 8 9
%Right
80 100 40 60 90 90 40 100 80Right% Left 20 0 60 40 10 10 60 0 20Factor Natural
PreferenceIV/Pref
IV Dist/Pref
Dist/Pref
IV/Pref
IV/Dist
Dist/Pref
PrefPref Pref Pref Pref Dist Pref
OBT
IV
OBT
IV
OBT OBT OBT
IV
OBT
IV
OBT
IV
OBT
IV
OBT
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Inference # 5• In Task = Suction
– One or more of three f t i fl dfactors influenced caregiver’s position:
• Obstructions (IV OBTlocation)
• Walking Distance• Preferred side
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Task: SittingQ: Left-handed nurses’ position vis-à-vis the patient
Position: Left-Handed Nurses
Set ID 1 2 3 4 5 6 7 8 9Set ID 1 2 3 4 5 6 7 8 9
%Right
30 10 60 20 70 20 50 40 80
% Left 70 90 40 80 30 80 50 60 20Factor Natural
PreferenceIV IV Dist/
PrefDist IV IV Dist/
IVIV
OBT
IV
OBT
IV
OBT OBT OBT
IV
OBT
IV
OBT
IV
OBT
IV
OBT
2009 PDC Conference & ExhibitionLeading the Way to Better Health Care Design
Task: SittingQ: Right-handed nurses’ position vis-à-vis the patient
Position: Right-Handed Nurses
Set ID 1 2 3 4 5 6 7 8 9
%Right
60 40 80 30 90 50 50 30 70
% Left 40 60 20 70 10 50 50 70 30Factor Natural
PreferenceIV IV/
PrefDist Dist/
PrefIV IV IV/
Dist/P fPref
OBT
IV
OBT
IV
OBT OBT OBT
IV
OBT
IV
OBT
IV
OBT
IV
OBT
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Inference # 6• In Task = Sitting
– One or more of three f t i fl dfactors influenced caregiver’s position:
• IV location: dangling OBTon same side as IV
• Preferred side• Walking Distanceg
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STRESSFUL/ HARMFULSTRESSFUL/ HARMFUL ACTIONS
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Sitting Task
Stretch Bend Unstable Lift Twist Repos
/ Bed
atio
n
l / Bed
atio
n
l / Bed
atio
n
l / Bed
atio
n
l / Bed
atio
n
l / Bed
atio
n
l
Hea
dwal
l/
Con
figur
a
Tota
l
Hea
dwal
l/
Con
figur
a
Tota
l
Hea
dwal
l/
Con
figur
a
Tota
l
Hea
dwal
l/
Con
figur
a
Tota
l
Hea
dwal
l/
Con
figur
a
Tota
l
Hea
dwal
l/
Con
figur
a
Tota
l
Right 22 10 31 78 10 88 0 1 1 4 1 5 96 8 112 0 0 0Right-Handed
22 10 31 78 10 88 0 1 1 4 1 5 96 8 112 0 0 0
Left-Handed
25 15 25 82 11 90 0 3 3 2 1 2 101 12 108 9 3 9
Total 47 25 160 21 0 4 6 2 197 20 9 3
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Suction Task
Stretch Bend Unstable Lift Twist Repos
/ Bed
atio
n
l / Bed
atio
n
l / Bed
atio
n
l / Bed
atio
n
l / Bed
atio
n
l / Bed
atio
n
l
Hea
dwal
l/
Con
figur
a
Tota
l
Hea
dwal
l/
Con
figur
a
Tota
l
Hea
dwal
l/
Con
figur
a
Tota
l
Hea
dwal
l/
Con
figur
a
Tota
l
Hea
dwal
l/
Con
figur
a
Tota
l
Hea
dwal
l/
Con
figur
a
Tota
l
Right 1 0 1 32 1 32 5 2 7 0 0 0 74 2 74 0 1 1Right-Handed
1 0 1 32 1 32 5 2 7 0 0 0 74 2 74 0 1 1
Left-Handed
0 0 0 14 0 14 1 2 3 0 0 0 41 4 45 0 0 0
Total 1 0 46 1 6 4 0 0 115 6 0 1
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INTERVIEW DATACorroborating Evidence
INTERVIEW DATA
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Subject Interview
• Top factors affecting nurses decision on location vis-à-vis the patient:– Location of IV – Entrance location– Walking Distance– Requirement of hand precisionequ e e o d p ec s o
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Subject Interview
• Best configuration:– Configurations without partitionsg p– Offered immediate visual assessment of the
caregiver zone and equipment location• Positive attribute across all settings:
– Redundant medical gas and utilityRedundant medical gas and utility connections on both sides of the patient
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Handedness
• Right-handed and left-handed nurses behave differently
• Approach and position depends on:– Task typeTask type– Equipment location– Walking DistanceWalking Distance– Nurses’ Preferred side
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Handedness
• Preferred side varies within each group– There is no consistent preference for either p
the left or the right side within left-handed or right-handed nurses
• Handedness of the physical environment may not have any association with care efficiency or safety
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Standardization Types
Level 1 Level 2
Level 3 Level 4
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Standardization
• Level 2 (Headwall) standardization ( )supported:– Standardized headwall with redundant outletsStandardized headwall with redundant outlets
on both sides of the patient across all care settings
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Standardization
• Level 3 (Caregiver Zone) standardization ( g )unexplored:– Advantages of standardization of theAdvantages of standardization of the
caregiver zone across all rooms is implied by the data
– To be examined in future phases
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Standardization
• Level 4 (Patient Room) standardization:– A key room level concept examined: y p
Direction of approach– Evidence suggest that fixed direction of
approach may not be associated with care efficiency
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