30 seconds on this page. The point: + Looking at nursing with a programmer ’s eyes
Again, 30 seconds. The point is not to go into detail but to convey at a glance that nursing is complex work. The reference is for people who are actually interested in the details.
We are not solving the whole problem of the complexity of nursing – that can ’t be solved; it is by its nature complex – but we can build a tool that eases one part of the burden, the cognitive load (next slide).
Nurses have traditionally solved it for themselves with “brains”. Stone age! But the solution proves that the problem is real. So let’s examine a brain: What do nurses need help remembering? + This RN works in a telemetry unit (higher acuity than med-surg, lower than ICU). The patient:nurse staffing ratio is 3:1. + This brain is made by printing from the EMR that subset of the Patient Census that is this nurse's responsibility (her patients) on this shift. In this high-acuity unit (these patients have demanding diseases and many co-morbidities) + The right-hand column is from the back of the sheet; the nurse folded the page over and lined up the rows for notating vital signs for later transcription to the EMR. Note the consistent sequence: temp, HR, BP, RR, SpO2. + Notations in red remind the nurse to chart them. Crossed out means they have been charted. + Lab values of concern (e.g. K+) are hand-notated. The low K+ could indicate excessive use of non-K+ sparing diuretics. + Relevant medical history (Hx) is hand-notated. + Though the hospital has an electronic MAR system, some medications to be administered (observe that they are checked-off) are hand-notated. + I&O data is collected. + Braden Scale: risk for pressure ulcers.
What does an electronic brain look like? Here ’s ours. Both software and business.
Our solution is basically a checklist (with a nice GUI). Checklists in healthcare are suddenly sexy.
Login ahead of time. Make sure Airplay is working. Now our demo. One minute: start a shift, pick some patients and protocols, look at SAG.
NurseMind.com-Health 2.0 01.15.2013
Nurse Tech, Inc.NurseMind January 15, 2013 SVHealth Dan Keller firstname.lastname@example.org (415) 861-4500http://www.nursemind.com
The Problem• By WW2, airplanes had become very complex.• “This bomber is too complicated for even the smartest pilot.”• Forget something crash. The Solution• Checklists increased people’s capacity to handle complexity.• Now crashes are rare. Nursing has the same problem. Our product is a checklist for nurses.
About Me• MS 1983 UCSF Medical Information Science• 22 years in tech – DKTS: programming, consulting, training• 2010 completed nursing school, RN.• Patient care is rewarding work. – Surprise! People are even more interesting than machines.• But there is a problem to solve…
What Do Nurses Do? “Domains of Nursing Practice” (Benner, 1984)The Helping Role Effective Management of Rapidly Changing SituationsThe Healing Relationship: Creating a climate for and Establishing a Commitment to Healing. Skilled Performance in Extreme Life-Threatening Emergencies:Providing Comfort Measures and Preserving Personhood in the Face of Pain and Extreme Rapid Grasp of a Problem Breakdown Contingency Management: Rapid Matching of Demands andPresencing: Being with a Patient Maximizing the Patient’s Participation and Control in His or Resources in Emergency Situations Her Own Recovery. Identifying and Managing a Patient Crisis Until PhysicianInterpreting Kinds of Pain and Selecting Appropriate Strategies for Pain Management and Assistance Is Available ControlProviding Comfort and Communication Through Touch Administering and Monitoring Therapeutic Interventions andProviding Emotional and Informational Support to Patients’ Families RegimensGuiding Patients Through Emotional and Development Change Starting and Maintaining Intravenous Therapy with Minimal Risk and ComplicationsThe Teaching – Coaching Function Administering Medications Accurately and SafelyTiming: Capturing a Patient’s Readiness to Learn Combating the Hazards of ImmobilityAssisting patients to Integrate the Implications of Illness and Recovery into Their Lifestyles Creating a Wound-Management Strategy that Fosters Healing, Comfort, and Appropriate DrainageEliciting and Understanding the Patient’s Interpretation of His Illness Monitoring and Ensuring the Quality of Health Care PracticesProviding and Interpretation of the Patient’s Condition and Giving a Rationale for Procedures Providing a Backup System to Ensure Safe Medical and NursingThe Coaching Function: Making Culturally Avoided Aspects of an Illness Approachable and Care Understandable. Assessing What Can Be Safely Omitted from or Added to Medical OrdersThe Diagnostic and Monitoring Function Getting Appropriate and Timely Responses from PhysiciansDetection and Documentation of Significant Changes in a Patient’s ConditionProviding an Early Warning Signal: Anticipating Breakdown and Deterioration Prior to Organizational and Work-role Competencies Explicit Confirming Diagnostic Signs Coordinating, Ordering, and Meeting Multiple Patient Needs andAnticipating Problems: Future Think Understanding the Particular Requests: Setting PrioritiesDemands and Experiences of an Illness: Anticipating Patient Care Needs Building and Maintaining a Therapeutic Team to Provide OptimumAssessing the Patient’s Potential for Wellness and for Responding to Various Treatment Therapy Coping with Staff Shortages and High Turnover SOURCE: Benner, P. (1984). From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison Wesley.
What’s Hard about Nursing?• Technical skills – Starting IVs, sterile procedures, dealing with difficult/frightened people, etc., etc.• Rapidly-evolving patient situation – New orders, patient/family demands, changes in patient status• Clinical judgment – Must not blindly do; always think: is this med right? Does this order make sense?• Rapidly-evolving work situation – Teamwork, turnover, staffing shortages• Risky work – Needlesticks, hurting your back (esp. w today’s heavier patients, etc.)• Remembering everything!
Cognitive Burden• Multiple patients, each with distinct needs• Interruptions• “Simple” stuff like fetching all supplies in a single trip• Nurse “brains” – Guild/folk culture, constantly reinvented
Our Solution: A To-Do List with Timings• Serious software on a mobile platform (iPhone) – 50K lines of Objective C. – Deep nursing data (shifts, protocols). Growing. – Server backend w/ DB. Maintenance. Support. – Subscription – 2-tier marketing strategy 1. Individual RNs’ professional tools 2. Hospital best practices – A kind of social networking: build and share shifts and protocols• A unique GUI – RoT
Why It Works• Recognition is easier than recall.• Checklists are gaining acceptance in health care. – Aviation has used them for generations. – Atul Gawande’s great articles in the New Yorker• Even for veteran nurses, lists help.
Demo via Airplay• Backup plan – Screenshots at http://www.nursemind.com/book/iphone-app• Observe – Choose my shift – Enter my patients and their protocols – View my to-do list (Shift-at-a-Glance) – Enter some vital signs – Mark some tasks completed
Project Status• Two years in development• Dozens of shifts and protocols, hundreds of tasks• Currently out in betas• Patent pending• Add-ons planned, e.g. for multi-nurse environments• Soft launch: App store release soon• Big launch: Nursing school trade show in March• Soon, revenue
Thanks for Listening!• Tell your nurse friends!• Visit our web site!• Stay in touch -- Dan Keller email@example.com (415) 861-4500 http://www.nursemind.com