pdc_2009_samehanded study

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.


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


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


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


Agenda

• Background• Key Conceptsy p• Study Design• Anal tical Methods• Analytical Methods• Key Findings• Conclusions


Origin of the Issue• IOM reports

highlighting medical errors

• AHRQ reports d iunderscoring

inefficient and unsafe care practicesunsafe care practices


Architectural Response• Standardization:

– Same-Handed care i tenvironment

– Patient Rooms identical in all de t ca arespects


Underlying Logic• Experience in aero-

space industry– Flight deck

standardization resulting in safety g yimprovement


Issue

• Lack of empirical evidence in healthcare psettings to support or refute safety or efficiency impact of handednessy p


KEY CONCEPTSStandardization : Handedness : Behavior

KEY CONCEPTS


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


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


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


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


Levels of Standardization• Level 5: Unit

– patient rooms and all tsupport spaces are

standardized across all units in a hospital


Note # 1

• Standardization MAY or MAY NOT involve handednessinvolve handedness


Handedness TypesHandedness Types

Right handed environment Left handed environmentRight-handed environment Left-handed environment


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


Behavior• Handedness

recommendation is di t d thpredicated on the

belief that care behavior is knownbehavior is known and documented


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 )


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


THE HANDEDNESS STUDYTHE HANDEDNESS STUDY


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?


Study Setting• University of Texas

Arlington, Smart H it lTMHospitalTM

– Team Training Room


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


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


Nurse Station• Equipment:

– Dinamap– Suction Kit

C t l ith• Control room with A/V control


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


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


DATA CODINGDATA CODING


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


Nursing• Coded behavior:

– Stretch– Bend– Unstable

Lift– Lift– Twist– RepositionReposition


Kinesiology• Kinesiology expert

coding of video t t id tif

• Actions:– Stretch

segments to identify harmful/stressful actions

– Bend– Unstable

Liftactions – Lift– Twist– RepositionReposition


Additional Data

• Subject interviews focused on:– Work flow– Awkward posture or movement– More supportive settingspp g– Factors affecting approach decision


DATA ANALYSISDATA ANALYSIS


Analytical Methods

• Logistic regressions for binary response variables

• Poisson regression for frequency counts• Exploratory data analysis• Exploratory data analysis• Content analysis of interview data


LEFT HANDED NURSESWITHIN GROUP ANALYSIS

LEFT HANDED NURSES


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


Inference # 1

• Within left-handed nurses there appears to be a pattern of predictable behavior across the nine settings


RIGHT HANDED NURSESWITHIN GROUP ANALYSIS

RIGHT HANDED NURSES


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


Inference # 2

• Within right-handed nurses there appears to be a pattern of predictable behavior across the nine settings


LEFT – RIGHT COMPARISONBETWEEN GROUP ANALYSIS

LEFT RIGHT COMPARISON


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


Inference # 3

• Large number of statistically significant differences between left-handed and right-differences between left-handed and right-handed nurse behavior


FACTORS AFFECTINGWHERE DO NURSES POSITION VIS-À-VIS THE PATIENT?

FACTORS AFFECTING CAREGIVER POSITION


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


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


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


Task: SuctionQ: Left-handed nurses’ position vis-à-vis the patient


Set ID 1 2 3 4 5 6 7 8 9

%Right

30 60 0 0 40 50 0 60 10



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


Task: SuctionQ: Right-handed nurses’ position vis-à-vis the patient


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


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


Task: SittingQ: Left-handed nurses’ position vis-à-vis the patient


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



PrefDist IV IV Dist/

IVIV

OBT

IV

OBT

IV

OBT OBT OBT

IV

OBT

IV

OBT

IV

OBT

IV

OBT


Task: SittingQ: Right-handed nurses’ position vis-à-vis the patient


Set ID 1 2 3 4 5 6 7 8 9

%Right

60 40 80 30 90 50 50 30 70


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


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


STRESSFUL/ HARMFULSTRESSFUL/ HARMFUL ACTIONS


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


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


INTERVIEW DATACorroborating Evidence

INTERVIEW DATA


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


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


CONCLUSIONSCONCLUSIONS


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


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


Standardization Types

Level 1 Level 2

Level 3 Level 4


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


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


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


QuestionsQuestions


pdc_2009_samehanded study

Design

better health care design

pdc conference exhibition

care delivery

key concepts standardization

y p patient room handedness

patient safetypatient

mph facha uta

acknowledgments dr