A GRAPHICAL ICU WORKSTATION Stanley B. Higgins, PhD, Keyuan Jiang, PhD Bridget B. Swindell, RN, Gordon R. Bernard, MD The Division of Biomedical Engineering and Computing and the Division of Pulmonary Medicine Vanderbilt University, Nashville, Tennessee 37232 ABSTRACT A workstation designed to facilitate electronic charting in the intensive care unit is described. The system design incorporates a graphical, windows-based user interface. The system captures all data formerly recorded on the paper flowsheet including direct patient measurements, nursing assessment, patient care procedures, and nursing notes. It has the ability to represent charted data in a variety of graphical formats, thereby providing additional insights to facilitate the management of the critically ill patient. Initial nursing evaluation is described. INTRODUCTION AND BACKGROUND Computers have been successfully employed in the care of critically ill patients for many years [1,2]. Uses have ranged from intelligent real-time monitors [1,2], electronic charting [3,4], expert advisors [5,6], to management of patients [7], and even closed loop control of infusion pumps [8]. Indeed, the ability to automate many of the routine data collection activities, such as the automated clinical laboraory, and non-invasive monitoring such as the electrocardiogram (EKG has led to a significant data PATF
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management problem in the Intensive Care Unit (ICU). Further compounding the situation is the stereo-typic nature of the data generation process. This explosion of data has created its own set of problems. It is not always obvious that "computerization" makes staff more efficient or improves the quality of patient care. Beyond the problems of managing the automatically generated data, other data handling problems include repetitive entry of data on multiple forms, large numbers of secondary calculations required from primary data, (for example cardiac shunt and intake and output (I&O)), absence of alarms on many vital statistics, lack of integration of clinical laboratory data with other bedside data, and tedious quality assurance procedures. The ICU flowsheet has become the vehicle for recording most vital information about the patient. It is used by the nursing staff in most intensive care units in the United States. Typical data recorded includes cardiovascular vital signs, neurological status, I&O, patient care procedures, and even safety items. Also included are nursing notes and nursing care assessments. In addition, some vital signs are trended. A completed ICU flowsheet, used at Vanderbilt University Hospital, is shown in Figure 1. Although the ICU flowsheet is an efficient manual instrument for recording data it has deficiencies including variable charting styles. For example, one nurse may record "yes", while another nurse may record this as "+". Another problem is the inherent inaccessibility of the flowsheet, both geographically and temporally. The paper flowsheet must be viewed at the bedside, while flowsheet data from prior days or from discharged patients is all but lost, buried in the patient's hospital chart. Finally, data on this flowsheet is not easily manipulated, nor is it easy to assess older patient data (>24 hours). What is needed is an efficient mechanism for managing, presenting, and interpreting this data. Most recent attempts to solve this problem have focused on the problem of gathering data from the patient, mostly through real time monitors, incorporating that data into the electronic record. We have taken a different approach to our solution which we describe later. We describe a workstation-based system that reproduces the functionality of the paper ICU flowsheet, and adds the capability to manipulate and represent the data contained in the flowsheet in an efficient manner. We describe our early experiences with
783
this system, including the results of a nursing evaluation of the system. METHODS Our goal is to replicate the functions of the ICU flowsheet in use at Vanderbilt Hospital. The paper flowsheet is designed to be a complete patient record containing data on cardiopulmonary vital signs, neurological status, I&O, nurse acuity, and nursing documentation. The sheet is organized as a rectangular matrix with rows representing variables to be measured and columns representing time (usually one hour). There is also space for graphing some variables such as temperature and respiratory rate. Data is gathered from the multitude of data sources in the ICU including direct patient measurements, observations, monitors, clinical laboratories, and calculations. Each flowsheet represents one patient-day in the ICU. As time passes, the sheets are built up to represent the complete ICU history for the patient.
Project Goals: The new electronic chart had to: be natural and take no more nursing time than the manually kept flowsheet; eliminate all manual transcription of data within and between flowsheets; produce a hard copy record, equivalent to the paper record, for the patient chart; perform all secondary calculations, such as fluid balance, automatically; provide security to prevent unauthorized tampering with patient data; provide a mechanism for making nursing documentation more uniform; provide graphs of any variable on demand; provide the capability to efficiently incorporate older data in the presentation; interface, where possible, to existing ancillary systems, such as the clinical laboratory. It is worthwhile to list some goals that we were specifically avoiding: namely, we were not attempting to create a real-time monitoring system connected directly to bedside monitors, nor were we attempting to create an ICU informnation system incorporating Admission-Discharge-Transfer functions or doctor's orders. The value of graphics in the interpretation of ICU data has been recognized for some time [9,10]. The sheer volume of data in the ICU make it difficult to assimilate and hinders clinical judgement. The format of tabular data makes it difficult to spot trends that may require intervention. Beyond this some variables, such as blood pressure (BP) and heart rate(HR), are most useful when considered together. Thus, the integral use of graphics was a major design consideration. Our original thinking was to create an exact bit-mapped image of the paper flowsheet with itpoint and shoot" data entry. That is, to enter temperature at 14:00 hours, the nurse simply points to the area on the screen representing that item-time and enters the correct reading. This capability would remove one of the maj'or hurdles to data entry found in many current systems,
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amounts, etc. Other flowsheet items are calculated from the entered data. Calculations are performed using embedded formulas that fire automatically and invisibly whenever data is entered to a cell that provides input to calculated variables. Examples of calculated items include Mean Arterial Pressure, and cumulative total I&O. Some items, such as cardiac rhythm have standardized responses that the nurse can select from a pop up menu. A checkoff procedure for documenting nursing care, use (or changing) of dressings, and equipment is incorporated. To document one of the above procedures, the nurse simply checks the appropriate action for the appropriate time. Nursing assessments are performed through the use of dialogue boxes. Assessments can be recorded with free text or by selecting pre-defined responses for each item. Interaction with the system is through a mouse, cursor keys, or the keyboard. A cell is selected by moving the cursor to the desired cell and entering the appropriate data. If the entry changes an existing value in the cell, an audit trail is created that documents the former value as well as the time and the name of the nurse making the change. This documentation is repeated whenever the item is altered. These values can be viewed and ultimately become part of the printed documentation for the chart. If other calculated variables depend on the entered value, they are updated immediately. A virtual window into the actual chart is displayed. Navigation within the flowsheet is performed by "dragging" the mouse to the desired cell, using the cursor keys, or by selecting the "move" option from the menu bar at the top of the screen. With this last option the virtual window moves immediately to a specific area of the sheet, or to a specific shift (7-3, 3-11, 11-7). : _
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The central station system. A central station system capabilities as the bedside system but in a read-only format. Any patient's chart can be displayed here. The data at the central station is updated every two minutes to reflect changes entered into a bedside system. One of the main uses of the central system is to provide attending physicians an efficient way to review any patient's chart on the unit without conflicting with the nurse's use of a bedside system. Flowsheets can also be reviewed from remote workstations connected to the ICU network.
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Figure 3. Typical screen display showing two hours of charted data and four sets of graphs including HR. BP, temperature, and fluid balance trended for 24 hours. The user interface provides other functions to the user. A nurse's note can be attached to each cell. This note is hidden from view but the cell contents are displayed in red to indicate the presence of a cell note. These notes are 785
The System Environment. A description of the system
prototyping can be found in [111. The ICU charting system is written entirely within Microsoft Excel running under Microsoft Windows. The workstations are high performance, personal computers with 8514/A style graphics displays. All workstations are connected to a file server running Novell Netware. The file server provides storage, print, and back-up services for all patient data. The bedside units can operate stand-alone and are designed to do so in case of a network failure. Nursing Evaluation. In order to determine utility of the ICU workstation concept and to evaluate nursing acceptance of it we performed an evaluation in the Medical Intensive Care Unit at Vanderbilt University Hospital. The Evaluation was conducted as follows: twelve nurses who volunteered to evaluate the system were given an inservice on the system to provide basic familiarity with the ICU workstation capabilities. Each of the participating nurses completed a pre- and post-evaluation questionnaire. The purpose of the questionnaire was to determine if preconceived ideas about computerization influenced the nurse's acceptance of the system, to document problems encountered with the workstation during the evaluation, and to measure nursing reaction to the utility of the system. RESULTS Bedside System. We have accomplished our stated working goals with this initial version of the ICU workstation. We have created a natural user interface to the electronic flowsheet through the use of interactive, bitmapped graphics. Each patient's daily flow sheet is connected logically to previous daily flowsheets. Thus it is a simple task to automatically transcribe data from previous day's flowsheets, eliminating manual transcription, and satisfying another system goal. Since the printed copy of the electronic flowsheet is essentially identical to the former manually kept flowsheet, the Medical Records Committee at our institution approved the use of this instrument as a completely acceptable replacement for the current form. The printed copy produced becomes the legal medical ICU record. Calculations are automatic, achieving another design goal. The security system causes only minimal hinderance to system operation although it can cause some frustration if passwords are forgotten. Nursing documentation using this system is more uniform for several reasons. Through use of canned responses the choice of terms used for some data items is limited. Because the system is electronic it does not possess all the flexibility of paper records, namely, it does not allow notation in margins of the flowsheet or squeezing in multiple items in a single cell. Thus, the user is forced to conform to a more uniform method of charting. This ultimately creates a more consistent and readable chart. The system can provide graphs of any charted variable on
786
demand and can trend variables for days or weeks. Central Station. MTe main benefit of the centrl station is that it allows simultaneous access to a bedside chart. Bedside nursing is undisturbed by chart review occurring elsewhere. Attending physicians may review several charts quickly from one location. We have not yet evaluated the use of the central station by non-nursing
personnel.
Nursing Evaluation. During the evaluation the system was used an average of 28.8 hours by each of the participating nurses, with actual time of use ranging from 3.5 hours to 60 hours. The nurses previous computer experience ranged from complete novice to skilled. Even so, ten nurses (83%) felt their computer skills had improved during the trial. Ten of the twelve nurses felt that using
the ICU worksheet more enjoyable than using the traditional paper record. When asked if they found data entry easier than manual paper entry using this system the responses varied. We found a strong correlation (r=0.83) with the length of time they were able to use the system and the ease of data entry. Our evaluation study indicates that charting with this system is no more difficult than a manual method, especially as usage of the system increased. Many small problems with use of the system were documented, including the use of passwords, printing, moving from screen to screen and so forth. The most frequently cited problem was the use of the nursing note feature. Finally, nine of the twelve nurses said they definitely wanted this type of technology in their work environment. The system is currently being installed in the ten bed medical intensive care unit at Vanderbilt
University Hospital. DISCUSSION The automatic creation of graphs is currently the single greatest benefit of the ICU workstation. The ability to convert rows of numbers into temporal graphs provides the user with an instant assessment tool not contained in the paper chart. With graphical data, abnormal values are easily spotted, as are more subtle trends not apparent from inspection of the raw numbers. In many intensive care units fluid balance is calculated once at shift change. The ICU workstation displays fluid balance dynamically, immediately showing any imbalance problems. The ability to condense and display data from many days of charting provides an important tool that is simply unavailable in a manual charting environment. Combining multiple variables onto one chart is another device that the electronic flowsheet provides which can give a better picture of the clinical situation. Interactions between variables may become apparent using this device. The graphical ICU workstation provides a powerful platform to test new types of data representation.
One unfulfilled goal for our ICU workstation is electronic connection to existing ancillary hospital systems such as the clinical laboratory. Our clinical laboratory system does not currently support network access. In order to receive data from the clinical lab we are forced to capture data from the "push" printer located in the ICU or create a terminal link. Eventually we hope to achieve network access to all ancillary patient data systems or through a newly installed Patient Care System that will incorporate the clinical laboratory data. It is also relevant to discuss our non-goals as well. We have not yet created an automatic interface to our bedside monitors because our local experience has been that data from bedside monitors in the ICU are only a small part of the clinical picture used to care for patients. This experience is apparently echoed by other institutions who have found that bedside monitors provided less than 20% of the data used in the care of critically ill patients [14]. Considering the amount of effort required to effectively retrieve data from the bedside monitors in real time we decided to focus our limited resources elsewhere. Compounding this is the unreliability of some data acquired continuously. Monitors have not yet acquired sufficient intelligence to separate true data from anomalous data. We have avoided creating an ICU information system. In our institution the traditional information system functions such as ADT will be managed by a centralized PCS. Our goal is to create a network interface to the PCS, accessing relevant patient information and passing information such as billing and orders to it. Our system can be optimized to provide the essential elements of the electronic charting process. This is a crucial point. Some recent commercial ICU systems are marketed as workstation systems, but become unwieldy as they attempt to provide trditional PCS services. These added services may add significantly to their costs without providing much added functionality, especially if such functions already exist in an installed PCS. We have tried to keep the development of our system focused on providing the greatest benefits for the users, namely an efficient mechanism for charting that provides meaningful insight into the data produced in the intensive care unit. The system provides the traditional benefits of computerization, namely, improved and more accurate nursing documentation, potential for decreased nurse charting time, the ability to manipulate data in the electronic flowsheet for reporting and QA management pwposes, as well as the enhanced potential to conduct clinical research. Beyond these is the insight provided by the utilization of sophisticated graphical data presentations. The ability to retrieve and view data from several flowsheets is a significant advantage over the former manual manipulation of data. Another more subjective advantage is the creation of a more sophisticated work place for ICU nurses. Our nurses
787
want to work with this technology, hence it becomes an important tool for retention and recruitment of nursing staff. Finally, a benefit is the relatively low cost of providing this technology for our environment. This system can operate from a variety of low cost personal computers utilizing commercially available software. Because of the use of a standard software and network environment the system can be easily integrated into other information systems as they are developed. CONCLUSIONS We have created an ICU workstation environment that has a natual, easy to use, user interface. Results of our evaluation of this system indicate that after some small period of orientation, charting with this system is as rapid as charting with the conventional paper-based flowsheet. Data contained in the electronic flowsheet can be manipulated through secondary calculations using the primary data or through the use of graphic displays that condense the temporal data thus allowing for better interpretation and identification of physiological trends. REFERENCES 1. Sheppard, LC, Kouchoukos, NT, Computers as monitors,
Anesthesiology, 1976, 45(2):250-259. 2. Harrison, DC, Sanders, Wj, Tecklenberg, PL, Alderman, EL, State of the art of automated arrhythmia detectors - commercial systems, Computers in Cardiology, 1974, pp 11-14. 3. Ramsey, M, III, Vitalnet: a bedside workstation for medical surgical nursing, 12th Annual Symposium on Computer Applications in Health Care, 1988, pp 773-778. 4. Pryor, TA, Computerized nurse charting, International J. of Clinical Monitoring and Computing, 1989, 6:173-179. 5. Roth, K, DiStefano, JJ, IIL Chang, BL, CANDI: development of the automated nursing assessment tool, Computers in Nursing, 1989, 7(5):222-227. 6. Bloom, KC, Leitner, JE, Solano, 1L, Development of an expert system prototype to generate nursing care plans based on nursing diagnosis, Computers in Nursing, 1987, 5(4):
140-145. 7. Sittig, DF, Gardner, RM, Pace, NL, Morris, AH, Beck, E, Computerized management of patient care in a complex controlled clinical trial in the intensive care unit, Computer Methods and Programs in Biomedicine, 1989, 30:77-84. 8. Sheppard, LC, Kouchoukos, NT, Shotts, JF, Wallace, FD, Regulation of mean arterial pressure by computer control of vasoactive agents in postoperative patients, Computers in Cardiology, 1975, pp 91-94. 9. Shabot, MM, Carlton, PD, Sadoff, S, Nolan-Avila, L, Graphical reports and displays for complex ICU data: a new, flexible and configurable method, Computer Programs and Methods in Biomedicine, 1986, 22:111-116. 10. Andrews, RD, Flexible reporting of clinical data, 11th Annual Symposium on Computer Applications in Health Care, 1987, pp 374-378. 11. Higgins, SB, Jiang, K, Swindell, BB, Bernard, GR, Prototyping a workstation-based ICU charting system, 12th Annual Intemational Conference of the IEEE on Engineering in Medicine and Biology, 1990, pp 1217-1218.
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management problem in the Intensive Care Unit (ICU). Further compounding the situation is the stereo-typic nature of the data generation process. This explosion of data has created its own set of problems. It is not always obvious that "computerization" makes staff more efficient or improves the quality of patient care. Beyond the problems of managing the automatically generated data, other data handling problems include repetitive entry of data on multiple forms, large numbers of secondary calculations required from primary data, (for example cardiac shunt and intake and output (I&O)), absence of alarms on many vital statistics, lack of integration of clinical laboratory data with other bedside data, and tedious quality assurance procedures. The ICU flowsheet has become the vehicle for recording most vital information about the patient. It is used by the nursing staff in most intensive care units in the United States. Typical data recorded includes cardiovascular vital signs, neurological status, I&O, patient care procedures, and even safety items. Also included are nursing notes and nursing care assessments. In addition, some vital signs are trended. A completed ICU flowsheet, used at Vanderbilt University Hospital, is shown in Figure 1. Although the ICU flowsheet is an efficient manual instrument for recording data it has deficiencies including variable charting styles. For example, one nurse may record "yes", while another nurse may record this as "+". Another problem is the inherent inaccessibility of the flowsheet, both geographically and temporally. The paper flowsheet must be viewed at the bedside, while flowsheet data from prior days or from discharged patients is all but lost, buried in the patient's hospital chart. Finally, data on this flowsheet is not easily manipulated, nor is it easy to assess older patient data (>24 hours). What is needed is an efficient mechanism for managing, presenting, and interpreting this data. Most recent attempts to solve this problem have focused on the problem of gathering data from the patient, mostly through real time monitors, incorporating that data into the electronic record. We have taken a different approach to our solution which we describe later. We describe a workstation-based system that reproduces the functionality of the paper ICU flowsheet, and adds the capability to manipulate and represent the data contained in the flowsheet in an efficient manner. We describe our early experiences with
783
this system, including the results of a nursing evaluation of the system. METHODS Our goal is to replicate the functions of the ICU flowsheet in use at Vanderbilt Hospital. The paper flowsheet is designed to be a complete patient record containing data on cardiopulmonary vital signs, neurological status, I&O, nurse acuity, and nursing documentation. The sheet is organized as a rectangular matrix with rows representing variables to be measured and columns representing time (usually one hour). There is also space for graphing some variables such as temperature and respiratory rate. Data is gathered from the multitude of data sources in the ICU including direct patient measurements, observations, monitors, clinical laboratories, and calculations. Each flowsheet represents one patient-day in the ICU. As time passes, the sheets are built up to represent the complete ICU history for the patient.
Project Goals: The new electronic chart had to: be natural and take no more nursing time than the manually kept flowsheet; eliminate all manual transcription of data within and between flowsheets; produce a hard copy record, equivalent to the paper record, for the patient chart; perform all secondary calculations, such as fluid balance, automatically; provide security to prevent unauthorized tampering with patient data; provide a mechanism for making nursing documentation more uniform; provide graphs of any variable on demand; provide the capability to efficiently incorporate older data in the presentation; interface, where possible, to existing ancillary systems, such as the clinical laboratory. It is worthwhile to list some goals that we were specifically avoiding: namely, we were not attempting to create a real-time monitoring system connected directly to bedside monitors, nor were we attempting to create an ICU informnation system incorporating Admission-Discharge-Transfer functions or doctor's orders. The value of graphics in the interpretation of ICU data has been recognized for some time [9,10]. The sheer volume of data in the ICU make it difficult to assimilate and hinders clinical judgement. The format of tabular data makes it difficult to spot trends that may require intervention. Beyond this some variables, such as blood pressure (BP) and heart rate(HR), are most useful when considered together. Thus, the integral use of graphics was a major design consideration. Our original thinking was to create an exact bit-mapped image of the paper flowsheet with itpoint and shoot" data entry. That is, to enter temperature at 14:00 hours, the nurse simply points to the area on the screen representing that item-time and enters the correct reading. This capability would remove one of the maj'or hurdles to data entry found in many current systems,
784
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Figure 2. Computer generated flowsheet. The bed-side system. A partially filled-in electronic flowsheet is displayed in Figure 2. An area in the upper left is provided for nursing personnel to sign into the flowsheet. We have included a multiple password system to enforce system security. The objective was to protect the integrity of the patient record, but also to document any changes made to the record after initial data entry. A user password must be entered to gain access to the system. In our environment, each nurse uses a unique password. Each nurse "signs off" her shift of the flowsheet. Once the shift is over, the attending nurse is the only individual allowed to change a value entered in that shift, and only after giving the proper password identification. The change is recorded along with the time and name of the nurse in the nursing notes section of the flowsheet. Some patient demographic data is displayed to uniquely identify the patient. This data is automatically carried forward onto successive sheets. The electronic sheet closely mimics the former paper flowsheet, with items listed as rows, and time represented as columns. The sheet is divided into areas listing hemodynamics, respiratory, neurological findings,. and intake and output. Some of the items are entered directly by the nurse from other data sources, monitors, blood pressure cuffs, IV
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amounts, etc. Other flowsheet items are calculated from the entered data. Calculations are performed using embedded formulas that fire automatically and invisibly whenever data is entered to a cell that provides input to calculated variables. Examples of calculated items include Mean Arterial Pressure, and cumulative total I&O. Some items, such as cardiac rhythm have standardized responses that the nurse can select from a pop up menu. A checkoff procedure for documenting nursing care, use (or changing) of dressings, and equipment is incorporated. To document one of the above procedures, the nurse simply checks the appropriate action for the appropriate time. Nursing assessments are performed through the use of dialogue boxes. Assessments can be recorded with free text or by selecting pre-defined responses for each item. Interaction with the system is through a mouse, cursor keys, or the keyboard. A cell is selected by moving the cursor to the desired cell and entering the appropriate data. If the entry changes an existing value in the cell, an audit trail is created that documents the former value as well as the time and the name of the nurse making the change. This documentation is repeated whenever the item is altered. These values can be viewed and ultimately become part of the printed documentation for the chart. If other calculated variables depend on the entered value, they are updated immediately. A virtual window into the actual chart is displayed. Navigation within the flowsheet is performed by "dragging" the mouse to the desired cell, using the cursor keys, or by selecting the "move" option from the menu bar at the top of the screen. With this last option the virtual window moves immediately to a specific area of the sheet, or to a specific shift (7-3, 3-11, 11-7). : _
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flowsheet is automatically saved at preset intervals as a data protection device. Any variable can be trended on screen by selecting that variable with the cursor. Predefined and preformatted graphs are also available and are selected with the graph option. The user can select graphs that incorporate BP and HR, or one that displays fluid balance, where fluid balance is the net difference between cumulative intake and output. Multiple graphs can be displayed simultaneously. The graphs are dynamically updated; when a value is entered or changed on the flowsheet the graphs immediately reflect that change. A typical display incorporating the last two hours of the chart and four graphs are shown in Figure 3. Hidden charts can be brought to the front by clicking on them with the mouse. Data from prior charts can be incorporat-
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ed with current data to form a longer trend chart. A graph depicting six days of I&O measurements is given in Figure 4. The entire flowsheet including the nurse's notes section is printed each day.
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Figure 4. Fluid balance trended for six days. Bars extending above abscissa represent intake, bars below represent output, continuous line representsfluid balance.
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automatically affixed with the time of the note as well as the name of the documenting nurse. The nurse's notes are ultimately printed as part of the permanent record. The
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The central station system. A central station system capabilities as the bedside system but in a read-only format. Any patient's chart can be displayed here. The data at the central station is updated every two minutes to reflect changes entered into a bedside system. One of the main uses of the central system is to provide attending physicians an efficient way to review any patient's chart on the unit without conflicting with the nurse's use of a bedside system. Flowsheets can also be reviewed from remote workstations connected to the ICU network.
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Figure 3. Typical screen display showing two hours of charted data and four sets of graphs including HR. BP, temperature, and fluid balance trended for 24 hours. The user interface provides other functions to the user. A nurse's note can be attached to each cell. This note is hidden from view but the cell contents are displayed in red to indicate the presence of a cell note. These notes are 785
The System Environment. A description of the system
prototyping can be found in [111. The ICU charting system is written entirely within Microsoft Excel running under Microsoft Windows. The workstations are high performance, personal computers with 8514/A style graphics displays. All workstations are connected to a file server running Novell Netware. The file server provides storage, print, and back-up services for all patient data. The bedside units can operate stand-alone and are designed to do so in case of a network failure. Nursing Evaluation. In order to determine utility of the ICU workstation concept and to evaluate nursing acceptance of it we performed an evaluation in the Medical Intensive Care Unit at Vanderbilt University Hospital. The Evaluation was conducted as follows: twelve nurses who volunteered to evaluate the system were given an inservice on the system to provide basic familiarity with the ICU workstation capabilities. Each of the participating nurses completed a pre- and post-evaluation questionnaire. The purpose of the questionnaire was to determine if preconceived ideas about computerization influenced the nurse's acceptance of the system, to document problems encountered with the workstation during the evaluation, and to measure nursing reaction to the utility of the system. RESULTS Bedside System. We have accomplished our stated working goals with this initial version of the ICU workstation. We have created a natural user interface to the electronic flowsheet through the use of interactive, bitmapped graphics. Each patient's daily flow sheet is connected logically to previous daily flowsheets. Thus it is a simple task to automatically transcribe data from previous day's flowsheets, eliminating manual transcription, and satisfying another system goal. Since the printed copy of the electronic flowsheet is essentially identical to the former manually kept flowsheet, the Medical Records Committee at our institution approved the use of this instrument as a completely acceptable replacement for the current form. The printed copy produced becomes the legal medical ICU record. Calculations are automatic, achieving another design goal. The security system causes only minimal hinderance to system operation although it can cause some frustration if passwords are forgotten. Nursing documentation using this system is more uniform for several reasons. Through use of canned responses the choice of terms used for some data items is limited. Because the system is electronic it does not possess all the flexibility of paper records, namely, it does not allow notation in margins of the flowsheet or squeezing in multiple items in a single cell. Thus, the user is forced to conform to a more uniform method of charting. This ultimately creates a more consistent and readable chart. The system can provide graphs of any charted variable on
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demand and can trend variables for days or weeks. Central Station. MTe main benefit of the centrl station is that it allows simultaneous access to a bedside chart. Bedside nursing is undisturbed by chart review occurring elsewhere. Attending physicians may review several charts quickly from one location. We have not yet evaluated the use of the central station by non-nursing
personnel.
Nursing Evaluation. During the evaluation the system was used an average of 28.8 hours by each of the participating nurses, with actual time of use ranging from 3.5 hours to 60 hours. The nurses previous computer experience ranged from complete novice to skilled. Even so, ten nurses (83%) felt their computer skills had improved during the trial. Ten of the twelve nurses felt that using
the ICU worksheet more enjoyable than using the traditional paper record. When asked if they found data entry easier than manual paper entry using this system the responses varied. We found a strong correlation (r=0.83) with the length of time they were able to use the system and the ease of data entry. Our evaluation study indicates that charting with this system is no more difficult than a manual method, especially as usage of the system increased. Many small problems with use of the system were documented, including the use of passwords, printing, moving from screen to screen and so forth. The most frequently cited problem was the use of the nursing note feature. Finally, nine of the twelve nurses said they definitely wanted this type of technology in their work environment. The system is currently being installed in the ten bed medical intensive care unit at Vanderbilt
University Hospital. DISCUSSION The automatic creation of graphs is currently the single greatest benefit of the ICU workstation. The ability to convert rows of numbers into temporal graphs provides the user with an instant assessment tool not contained in the paper chart. With graphical data, abnormal values are easily spotted, as are more subtle trends not apparent from inspection of the raw numbers. In many intensive care units fluid balance is calculated once at shift change. The ICU workstation displays fluid balance dynamically, immediately showing any imbalance problems. The ability to condense and display data from many days of charting provides an important tool that is simply unavailable in a manual charting environment. Combining multiple variables onto one chart is another device that the electronic flowsheet provides which can give a better picture of the clinical situation. Interactions between variables may become apparent using this device. The graphical ICU workstation provides a powerful platform to test new types of data representation.
One unfulfilled goal for our ICU workstation is electronic connection to existing ancillary hospital systems such as the clinical laboratory. Our clinical laboratory system does not currently support network access. In order to receive data from the clinical lab we are forced to capture data from the "push" printer located in the ICU or create a terminal link. Eventually we hope to achieve network access to all ancillary patient data systems or through a newly installed Patient Care System that will incorporate the clinical laboratory data. It is also relevant to discuss our non-goals as well. We have not yet created an automatic interface to our bedside monitors because our local experience has been that data from bedside monitors in the ICU are only a small part of the clinical picture used to care for patients. This experience is apparently echoed by other institutions who have found that bedside monitors provided less than 20% of the data used in the care of critically ill patients [14]. Considering the amount of effort required to effectively retrieve data from the bedside monitors in real time we decided to focus our limited resources elsewhere. Compounding this is the unreliability of some data acquired continuously. Monitors have not yet acquired sufficient intelligence to separate true data from anomalous data. We have avoided creating an ICU information system. In our institution the traditional information system functions such as ADT will be managed by a centralized PCS. Our goal is to create a network interface to the PCS, accessing relevant patient information and passing information such as billing and orders to it. Our system can be optimized to provide the essential elements of the electronic charting process. This is a crucial point. Some recent commercial ICU systems are marketed as workstation systems, but become unwieldy as they attempt to provide trditional PCS services. These added services may add significantly to their costs without providing much added functionality, especially if such functions already exist in an installed PCS. We have tried to keep the development of our system focused on providing the greatest benefits for the users, namely an efficient mechanism for charting that provides meaningful insight into the data produced in the intensive care unit. The system provides the traditional benefits of computerization, namely, improved and more accurate nursing documentation, potential for decreased nurse charting time, the ability to manipulate data in the electronic flowsheet for reporting and QA management pwposes, as well as the enhanced potential to conduct clinical research. Beyond these is the insight provided by the utilization of sophisticated graphical data presentations. The ability to retrieve and view data from several flowsheets is a significant advantage over the former manual manipulation of data. Another more subjective advantage is the creation of a more sophisticated work place for ICU nurses. Our nurses
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want to work with this technology, hence it becomes an important tool for retention and recruitment of nursing staff. Finally, a benefit is the relatively low cost of providing this technology for our environment. This system can operate from a variety of low cost personal computers utilizing commercially available software. Because of the use of a standard software and network environment the system can be easily integrated into other information systems as they are developed. CONCLUSIONS We have created an ICU workstation environment that has a natual, easy to use, user interface. Results of our evaluation of this system indicate that after some small period of orientation, charting with this system is as rapid as charting with the conventional paper-based flowsheet. Data contained in the electronic flowsheet can be manipulated through secondary calculations using the primary data or through the use of graphic displays that condense the temporal data thus allowing for better interpretation and identification of physiological trends. REFERENCES 1. Sheppard, LC, Kouchoukos, NT, Computers as monitors,
Anesthesiology, 1976, 45(2):250-259. 2. Harrison, DC, Sanders, Wj, Tecklenberg, PL, Alderman, EL, State of the art of automated arrhythmia detectors - commercial systems, Computers in Cardiology, 1974, pp 11-14. 3. Ramsey, M, III, Vitalnet: a bedside workstation for medical surgical nursing, 12th Annual Symposium on Computer Applications in Health Care, 1988, pp 773-778. 4. Pryor, TA, Computerized nurse charting, International J. of Clinical Monitoring and Computing, 1989, 6:173-179. 5. Roth, K, DiStefano, JJ, IIL Chang, BL, CANDI: development of the automated nursing assessment tool, Computers in Nursing, 1989, 7(5):222-227. 6. Bloom, KC, Leitner, JE, Solano, 1L, Development of an expert system prototype to generate nursing care plans based on nursing diagnosis, Computers in Nursing, 1987, 5(4):
140-145. 7. Sittig, DF, Gardner, RM, Pace, NL, Morris, AH, Beck, E, Computerized management of patient care in a complex controlled clinical trial in the intensive care unit, Computer Methods and Programs in Biomedicine, 1989, 30:77-84. 8. Sheppard, LC, Kouchoukos, NT, Shotts, JF, Wallace, FD, Regulation of mean arterial pressure by computer control of vasoactive agents in postoperative patients, Computers in Cardiology, 1975, pp 91-94. 9. Shabot, MM, Carlton, PD, Sadoff, S, Nolan-Avila, L, Graphical reports and displays for complex ICU data: a new, flexible and configurable method, Computer Programs and Methods in Biomedicine, 1986, 22:111-116. 10. Andrews, RD, Flexible reporting of clinical data, 11th Annual Symposium on Computer Applications in Health Care, 1987, pp 374-378. 11. Higgins, SB, Jiang, K, Swindell, BB, Bernard, GR, Prototyping a workstation-based ICU charting system, 12th Annual Intemational Conference of the IEEE on Engineering in Medicine and Biology, 1990, pp 1217-1218.
