This presentation covers the planning and development of a pilot Personal Digital Assistant based Clinical Adverse Event reporting system. This was a joint development between University Hospitals Coventry and Warwickshire, Coventry University and Savant Enterprises Limited. It was facilitates by MidTech (part of NHS Innovations) and was part funded by a grant from Advantage West Midlands which helped us purchase £15,000 of hardware to both develop and run the pilot. It started about a year ago and is currently in live running.
Val Ford is the manager of the Clinical Outreach Team who formed the pilot group. There are a total of 8 staff in the Outreach Team and they were chosen as they’re role included a good deal of mobility within the Trust. They’re IT experience was not a consideration in their selection as we needed a representative group of users. I’m Business Development Manager at Savant Enterprises who have 25 years experience in Healthcare Computing raning from small PDA systems to PULSE the systems used by NHSBT to manage all aspects of blood donation in the UK.
Clinical Adverse Events or Clinical Incidents are the record of any untoward event that happens to a person on NHS premises. These can include Slips, trips and falls Staff back injuries Needlstick injuries Deaths etc. Traditionally CAEs are recorded on paper forms, normally A3 in size and 2 or 3 part. Staff members consider them daunting and cumbersome to complete. Because of this not all CAEs are recorded because of the time required. Near misses are left unrecorded because nothing actually happened but Near Misses are seen as very important as no-one was injured (that time) but the same lessons can be learnt. The different parts of the paper form go their separate ways, some locally filed some escalate up to management and one at least makes it to the recording team in clinical governance where the data is transcribed into a incident recording system. Reports produced from this system tend to go upwards to senior management and Trust board but not much trickles downwards to local management and back the individual who initially filled the form in. This can lead to further reductions in the motiviation to complete the forms as nothing is seen to happen as a result.
These problems exist at UHCW (as they do at the vast majority of Trusts). However, at UHCW the form is 4 sides of A4 and is filled in in two stages. This allows initial details to be recorded quickly but slows the process down as subsequent data needs to be added by a manager before the form is deemed complete. Staff still need to return to a desk, request a copy of the form and complete it which normally happens at the end of a shift. The moving around of the paper form with the inevitable miss filling, lost paper etc. means that the journey from source to data entry can take several days.
Though A4 in form the paper form is still 4 sides and an equivalent to a double sided A3 sheet. This form is only a year old with the new version coinciding with the launch of this pilot project. The form is well laid out and colour coded (as long as no photocopies are taken). These pages are normally completed by the individual reporting the CAE.
There are detailed instructions for the form user with these last sections being completed by the manager. These pages are locally known as “Part 2”.
After analysis the workflow and speaking to staff Savant proposed a Pilot system based on the above schematic. The left side represents the pilot system, the right side the current live system. The paper flow is replaced by emails sent from a central database of recorded incidents. The incidents are recorded on any mobile device and get to the central database via docking stations or wireless connections. The new Walsgrave hospital has 320 wireless access points making it ideal for this type of application
These are some of the technical aspects to the project and were the basis for involving hospital IT staff. We recognised that involving in house IT was crucial to the success of the project as they needed to be happy with the architecture we proposed and were able to support it.
One of the crucial areas for the pilot was the choice of PDA. There are many different styles of PDA available and the choice of the right platform would greatly aid the pilot rollout. We involved Coventry University’s TechnoCentre in this process as they receive one of very device available from a range of manufacturers. This gave us an excellent sand pit to play in. The Outreach team were shown a range of devices and after playing with them ended up selecting the iMate JasJar. The two main factors in selecting this device were its screen and the fact that it had a “proper” keyboard. CAE’s still rely on a narrative element and the screen based pop up keyboard was not seen as a viable way of entering a lot of text. The JasJar is effectively a small laptop with a swivel screen. It is quite robust, they are also used by the Police on their POLARIS project.
Involving the end user throughout the life cycle is key to the success of Savant projects. As well as device selection workshops we used Coventry University’s School of Design to produce a user requirements specification which represented the first cut application. Once this was ready Savant hosted a series of application design workshops where that first cut application was refined using user feedback. This was very successful in moulding the application to meet the users way of thinking and working. The final application had some marked differences when compared to the initial version. The screen navigation was seen as important as well as default values in as many fields as possible. As well as application design these workshops gave the users more time to play with the devices and become more comfortable with their use. Papers on the design process have already been published at the Ergonomics Society Conference in December last year and more are in the pipeline.
This slide shows some aspects of the PDA application. The application consisted of 7 screens with screen navigation being possible by using the thumb on the yellow arrow boxes or a finger on the tabs at the bottom. Mandatory fields were indicated with red labels, all button designs were consistent as was their positioning. PDA styluses are easily lost and the application can be used with a finger (or any other pointy object such as a pen). Events can be stored and retrieved later by the user or completed for uploading.
With the incident recorded on the PDA and the PDA docked (or using wireless if available) the completed CAE is sent to the central database where the system automatically emails the team manager to tell them there is an incident awaiting completion. We also used the workshops to design web application that was used by the manager to add the “Part 2” data. This application automatically coded the event using the same rules as were laid out on the paper form. The manager can choose to “reject” a CAE and have it returned to the PDA it came from so that the user can amend the CAE and re-submit it. When the manager completes the form a fully detailed email is sent to the Clinical Governance Team. Data is cut and paste from the email into the input fields which minimises keying errors. The data in the email is laid out in the same sequence as the screen fields to further aid this step.
To summarise; the new process for CAE recording using PDAs is now:
As mentioned before UHCW IT Department was key to this projects role out and with the application complete it was handed over to them for implementation. They support the local users and backup the database etc. Savant have been on site with them in the early days and now support the pilot remotely with their help
Now that CAEs are being recorded we have overcome two major hurdles: Choosing the right technology Training the users in its use With that foundation in place we can extend the application to include focussed feedback to individuals via the PDA. If someone raises an incident involving a patient falling that user can get feedback on best practice and guidelines in that area. We can use thresholds to control that feedback i.e. if someone raises more than 5 of one type of CAE get them some relevant information. This should control the possible information overload. The pilot is due to complete in mid-April and we will publish the results, next steps and further papers after that point. Thank you for your time and for listening.
Savant Limited - Development of a PDA based clinical adverse event recording system
Development of aDevelopment of a
PDA based Clinical Adverse EventPDA based Clinical Adverse Event
Reporting SystemReporting System
University Hospitals of Coventry and WarwickshireUniversity Hospitals of Coventry and Warwickshire
Coventry UniversityCoventry University
Savant LimitedSavant Limited
Key PlayersKey Players
Valerie FordValerie Ford
Clinical Outreach Sister, UHCWClinical Outreach Sister, UHCW
Glyn JonesGlyn Jones
Business Development Manager, SavantBusiness Development Manager, Savant
Background toBackground to
CAE Reporting NationallyCAE Reporting Nationally
It is widely recognised that:It is widely recognised that:
Paper forms unwieldyPaper forms unwieldy
CAEs are under reportedCAEs are under reported
Near-misses even more soNear-misses even more so
Little feedback to managementLittle feedback to management
Less feedback to individual reportersLess feedback to individual reporters
Background at UHCWBackground at UHCW
Paper forms in usePaper forms in use
Two-tier system for form fillingTwo-tier system for form filling
Problems with current systemProblems with current system
Paper logisticsPaper logistics
Manual completion of formsManual completion of forms
At end-of-shiftAt end-of-shift
Near misses not recordedNear misses not recorded
Timeliness of reportingTimeliness of reporting
Evolution of the pilot solutionEvolution of the pilot solution
Highlights of the pilot solutionHighlights of the pilot solution
Data Capture Software on PDAs, Tablets, PCs andData Capture Software on PDAs, Tablets, PCs and
Pocket PC 2003 PDAsPocket PC 2003 PDAs
Windows XP TabletsWindows XP Tablets
SQL Server DatabaseSQL Server Database
Regular email to Datix Data Entry, from database, of newRegular email to Datix Data Entry, from database, of new
forms receivedforms received
Optional wireless connectionOptional wireless connection
Repository would need to know which managers look afterRepository would need to know which managers look after
which areaswhich areas
Emails to Managers would include areas for them toEmails to Managers would include areas for them to
complete before forwardingcomplete before forwarding
Could use PDA to PDA routing or round trippingCould use PDA to PDA routing or round tripping
Choice of PDAsChoice of PDAs
User workshopsUser workshops
Close collaboration with CoventryClose collaboration with Coventry
University TechnoCentreUniversity TechnoCentre
Decided on iMate JasJar becauseDecided on iMate JasJar because
Good screen (VGA)Good screen (VGA)
QWERTY KeyboardQWERTY Keyboard
Full user involvement in system designFull user involvement in system design
3x2hour sessions3x2hour sessions
Coventry University School of DesignCoventry University School of Design
Technology awarenessTechnology awareness
Hands-on testingHands-on testing
New processNew process
User captures initial details on PDAUser captures initial details on PDA
Manager notified of open CAEs via emailManager notified of open CAEs via email
Manager updates CAE detailsManager updates CAE details
Clinical governance team receive emailClinical governance team receive email
with completed CAE form detailswith completed CAE form details
Roll outRoll out
UHCW IT Department fully involvedUHCW IT Department fully involved
Support PDAsSupport PDAs
Host database and web siteHost database and web site
Savant on site forSavant on site for
Roll out supportRoll out support
Working with usersWorking with users
Next stepsNext steps
Complete pilot and revise applicationComplete pilot and revise application
Feedback best practice to the user’sFeedback best practice to the user’s