Samuel Cheng
UX Designer & Engineer
Summary

This project focused on understanding the communication and interactions between the major parties involved in an Intensive Care Unit (ICU): patient, physicians, nurses, various specialists (e.g. respiratory therapist, nutritionist, case manager) and family members. We looked into the processes behind how a patient is admitted into the ICU from the emergency room or hospital, how transfer is handled between departments and worker shift changes, and how various ICU tasks, such as rounds, are performed. In this project, we decided to focus our attention on the interactions within the patient room itself by using augmented reality (AR) to present a layer of information to help family members understand the bewildering array of equipment, staff, and sepsis care processes as they navigate the ICU room.

Details:

  • August - December 2015
  • Team of 4
  • User research, observations, literature review, Unity3D (Vuforia SDK), C#
Problem

In the United States alone, there are about 750,000 diagnosed cases of sepsis each year, 30% of which result in death (Marik, 2011). As sepsis progresses into severe sepsis and septic shock, the ICU mortality rate rises to 50% and 80% respectively (Jawad et al., 2012). According to a study done by the Healthcare Cost and Utilization Project in 2011, sepsis was the most expensive condition treated in U.S. hospitals, costing the healthcare system almost $20.3 billion, a figure that represents about 5.2% of the total aggregate cost for all hospitalizations (Torio et al., 2011).
Motivation and Goal

Stepping into an unfamiliar room with your loved one hooked up to a lot of unfamiliar machines is a daunting and stressful experience for families. However, family members, given proper guidance, can overcome their fear, confusion, and anxiety and become powerful advocates for their loved ones resulting in positive outcomes. We seek to empower the family in the patient room by adding a layer of technology to the surrounding environment via AR thereby making the invisible visible. Our goal is to demystify the sepsis care process and environment for the family by educating and encouraging them to be effective participants in sepsis care.


"[Families] want to be involved but they are put off by all the high tech and all the equipment so that they are reluctant to even come near the patient." -Nurse (interview)
Value

We establish that no one cares more about the patient than the family. However, the family is often crippled with fear, anxiety, and uncertainty (Hupcey, 1999). The first task is to inform them of the benefits and the powerful role that a patient advocate can bring (Lindahl et al., 1998; Newell et al., 2006). Our solution takes this one step further by educating the family on the sepsis care process, the roles of clinicians, the patient room, and hospital policies. With empowered families acting as patient advocates, they will take a more active and effective role in the care process, thereby ultimately reducing the mortality rate of sepsis.
Research Evidence

Research shows that the family is crucial in the care process by playing several roles such as that of protector, facilitator, coach, and historian. The work they do is important but are often times neglected because it is not immediately apparent. Furthermore, evidence shows that the family is more than capable of learning about and participating in the care process which brings results similar to that of nurse care.

Our research shows that nurses often play the role of being patient advocates. The ICU nurse is in a unique position to meet, support, and protect the patient and family. However, there are often gaps between how nurses view a family’s role in the care process and how family’s view their role in the care process. We’d like to bridge these gaps and enhance nurse-family communication by centering it around the well-being of the patient.

We found that the main emotion facing families in the ICU is fear and the main need they have is hope. The question becomes: how does the family overcome this stressful situation and be integrated into the ICU as supporters/caregivers in order to ensure best outcome? We believe the best way to do so is to show the family the benefits of having a patient advocate and to empower them to be one via education.


Decision Making

Our team went through several phases of coming up with both divergent and convergent ideas which ultimately resulted in this AR project. We first began studying rounding and interactions in the patient rooms and breaking down various areas of that system.

After several team discussions into problems facing the sepsis care process in regards to rounding and interactions in the patient room, we decided to take a slight twist on the system and focus on solving a problem that the family would face in this scenario. We were all interested in researching more into the family aspect of care and it seemed like a natural step to take in our brainstorming. This would prove especially important as we would be entering into the realm of family-clinician communication.


Next, we decided upon four divergent ideas regarding supporting the family in the care process. The first was a smart interpretation and instant signaling application which would allow the family to take a picture of the bedside monitor, analyze its values and note any problems, alert the nurse of discrepancies, and be assured that the nurse was taking care of it. The second was a similar idea to the first but instead incorporated a sensor attached the nurse’s station that would inform and reassure the family that the nurse was viewing their loved one’s vitals and reports. The third was a sepsis and ICU education application which would use QR codes to explain the sepsis care process to the family and educate them about certain vital signs and important values. The fourth was a family/nurse chat messaging system which would allow both parties to instantly contact the other with questions and answers thereby facilitating communication and easing anxiety.

We consulted with several local ICU clinicians who believe that the sepsis and ICU education application held the most promise. The other ideas, though valuable, seemed to encroach on nurse autonomy or had glaring privacy concerns.

As a team we converged on the education application idea and agreed to incorporate an augmented reality component because it provided a level of novelty for family members. The decision was made to focus solely within the patient room, leaving out what would be happening in the nurse’s station and various doors and entryways.

After that decision was made, work began on the application prototype. Other conference calls were made to clinicians to continue gathering information about the family’s needs and behaviors in the patient room.
Design Descripton

The prototype consisted of two parts: an AR part and a mockup of how different screens of the mobile application would look.

Augmented Reality

The AR portion was built in the Unity 5 game engine using Qualcomm’s Vuforia Augmented Reality Software Development Kit (SDK). Vuforia’s SDK uses various computer vision algorithms to locate and track planar images. The code was written in C# and XCode 7 was used to compile, load, and build the app to an Apple iPad Mini.

Upon opening the app, the user could use the iPad’s camera to scan several AR markers. A blue cube would hover and spin around indicating that the marker has been recognized by the camera. As a prototype, a simple blue cube was chosen though in reality, any other object could also suffice (pictures, text, 3D models). The user would tap on the blue cube bringing up a dialog box with details about the marker selected. The idea is that these AR markers would be deployed around the patient room. The patient’s family could then locate these markers with the app to learn more about the device, policy, clinician, or process associated with the marker.

Application Screen

The mockup of the application was built in Pixate and Sketch. In an effort to fit a health and clinical environment while conveying a sense of novelty and technology, the color palette below was chosen. We expected to incorporate the AR component into the "Devices" screen. In the "Clinicians" screen, there is a description of every job description and a brief introduction of every clinician involved in the sepsis car process. In the "Q&A" screen, there are frequently asked questions by family members and their subsequent answers. These questions are divided into three categories: how to best care for your loved one, how to communicate with clinicians, and how to take care of themselves. In the "Symptoms and Treatment" screen, family members can learn about the symptoms of their loved ones and about the whole sepsis treatment process and what signs to watch out for.

Story

We feel it best to walk people through a user journey (told from the perspective of a family member) to explain how we envision this system playing a role in the healthcare process.

First, you enter the patient ICU room. Your loved one is hooked up to all sorts of scary-looking and daunting equipment. The room is filled with beeps, chirps, and blinking lights. You are clueless as to what is going on. You are scared and have no idea whether your loved one is going to wake up.

Then, you pick up the tablet in the ICU and use the education application to start to learning about what sepsis is, its symptoms, and the treatment process. You can begin to grasp what is happening around you and try to help in a way you can. You walk around and look closely at the various devices around the room. Viewing them through the application, you notice a colorful, bouncing indicator on the screen. You click on it and read about what that device is called, what it is used for and what the appropriate readings should be. You begin to monitor your loved ones condition accordingly and learn about what questions should be addressed to which person, e.g. asking the nurse about the medication, and asking the doctor about current conditions. Finally, with the help of the application, your active participation and the care team’s efforts, the patient recovers quickly.

Discussion

After demoing our prototype to several ICU clinicians and other professionals in the health IT field, we received several pieces of feedback and advice. First, many agreed that educating and empowering the family is a wise move since family members are invaluable resources for clinicians and patients to have by their side. However, there are several concerns that this may lead to over-aggressive family members constantly interrupting nurses who are performing other duties over issues that are benign or normal. However, one nurse we had talked to said that she would rather err on the side of more questions and feedback from family members than fewer because there is the possibility for valuable information to be gleaned.

It is also important to mention that patient security and privacy must be fully respected even in the case of incorporating new technologies. One possible concern would be if patient vitals and readings would be accessed by individuals (including friends and other visitors). This means that this application can only be accessed from hospital-provided tablet devices, not personally-owned devices. A possible solution is if the tablet in each ICU room does not have access to the Internet but perhaps an internal-facing hospital WiFi. In addition, no data is stored on the tablet itself so that subsequent patients cannot discover previous data. The tablet must also be equpped with forms of tracking or alarms such that it cannot be stolen from the room.
References

Jawad, I., Lukšić, I., & Rafnsson, S. B. (2012). Assessing available information on the burden of sepsis: global estimates of incidence, prevalence and mortality. Journal of global health, 2(1). doi: 10.7189/jogh.02.010404.

Marik, P. (2011). Surviving sepsis: going beyond the guidelines. Annals of Intensive Care, 1(1), 17. Retrieved from http://www.annalsofintensivecare.com/content/1/1/17.

Torio, C.M. (AHRQ), Andrews, R.M. (AHRQ). National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2011. HCUP Statistical Brief #160. August 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcupus.ahrq.gov/reports/statbriefs/sb160.pdf.

Hupcey, J. E. (1999). Looking out for the patient and ourselves–the process of family integration into the ICU. Journal of Clinical Nursing, 8(3), 253-262.

McAdam, J. L., Arai, S., & Puntillo, K. A. (2008). Unrecognized contributions of families in the intensive care unit. Intensive care medicine, 34(6), 1097-1101.

Davidson, J. E., Powers, K., Hedayat, K. M., Tieszen, M., Kon, A. A., Shepard, E., ... & Armstrong, D. (2007). Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004–2005. Critical care medicine, 35(2), 605-622.

Lindahl, B., & Sandman, P. O. (1998). The role of advocacy in critical care nursing: a caring response to another. Intensive and Critical Care Nursing, 14(4), 179-186.

Newell, J. N., Baral, S. C., Pande, S. B., Bam, D. S., & Malla, P. (2006). Family-member DOTS and community DOTS for tuberculosis control in Nepal: cluster-randomised controlled trial. The Lancet, 367(9514), 903-909.

Martire, L. M., Lustig, A. P., Schulz, R., Miller, G. E., & Helgeson, V. S. (2004). Is it beneficial to involve a family member? A meta-analysis of psychosocial interventions for chronic illness. Health psychology, 23(6), 599.