Off the Charts
High-tech documentation and monitoring systems help reduce errors and free nurses to devote more time to direct patient care

By Heather World
August 16, 2004

Dominique Anderson, RN, BSN, has worked in intensive care long enough to know that when one thing goes wrong, everything goes wrong. At those times, an ICU nurse must be in many places at once to save the life of her charge.

“If your patient isn’t doing well, the last thing you’re thinking of is charting,” said Anderson, who works in the 20-bed ICU at the Mayo Clinic Hospital in Phoenix. “You’re thinking, ‘What can I do to get my patient through this crisis?’”

In a different ICU, Anderson would have to follow patient stabilization by poring over printouts of vital signs, comparing them, marking dots, and writing notes to graphically display the crisis she had just handled. But because Mayo has a modern electronic information system called Picis, she can instead tell the computer which vital signs to compare, and generate an assessment in minutes.

High-tech solutions like ICU information systems can give nurses more time to spend on direct patient care. According to a study conducted by David Wong, MD, PharmD, chief of anesthesiology at the VA Long Beach (Calif.) Healthcare System, a nurse can save an average of more than an hour per 12-hour shift in documentation time, freeing up more time for direct patient care and assessments. Furthermore, the nurses studied did not have to interrupt other tasks to document care as often as their paperwork-bound counterparts.

National mandates to reduce human error in hospitals, as well as a move toward remote medicine, both herald a shift toward automated documentation, said Carol Bickford, RN, PhD, of the department of nursing practice and policy at the American Nurses Association. In remote medicine, critical care physicians might be able to treat their patients virtually from afar.

“We’re trying to streamline the data collection process,” Bickford said. “People like that.”

ICU information systems are nothing new, nor are the studies about them, Wong said. But 20 years ago, when such systems first started, nurses had fewer requirements for recording information.

“As medicine and nursing care have advanced, we’ve developed new drugs and new treatments, which are usually additive,” Wong said. That usually means more documentation, he said. Fortunately, computer technology has advanced with the times, too.

For Wong’s study, an observer watched nurses use the latest version of the technology, the GE Marquette Quantitative Sentinel system, and noted their tasks in real time.

“We actually recorded down to the second when a nurse stopped doing one thing and started doing something else,” Wong said.

In the newest systems, like that used at the Mayo Clinic Hospital, the computer is a relational database, which allows an ordinary user to retrieve and compare data like breathing rate, heart rate, blood pressure, or any combination of such vital signs. Previous incarnations required network administrators for data manipulation.

System buy-in

But Wong cautions that the system’s advantages are not automatic.

“Buying it and installing it is not even the half of it,” he said. Nurses, administrators, and information technology specialists who customize the program must all be enthusiastic about the system.

“The more you can customize the system to match the ICU culture, the better,” Wong explained.

Michael Roberts, RN, MA in organization management, service line manager of Cedars-Sinai Medical Center surgical ICU in Los Angeles, said customizations to their 10-year-old system come from nurses themselves. The staff nurses meet the system’s programmers every month to suggest any changes.

“I think that’s what makes it so successful,” he said.

Roberts ticked off a list of changes suggested by nurses: creating a nonverbal pain scale for comatose patients that correlates with the verbal scale, access to quality improvement data, and a medication safety alert.

Some elements of the system, like the medication safety alert, can protect against human error. Information from intravenous pumps feeds directly into the computer, which measures the medication rate every two minutes for high-risk medications, Roberts said. If the rate goes over hospital policy, he said, an alert is sounded.

“We don’t just rely on the pump alarm,” he said. “We have something measuring actual rates.”

Roberts estimated the system doesn’t save time as much as it increases accuracy.

“It works great in times of crisis: When the nurse is actually doing things for the patient, the computer is keeping track of the data so the nurse doesn’t have to remember or find the paper towel she wrote that information on,” he said.

Even when things go smoothly, the system gives a patient’s health care providers more detail, he said. Nurses’ notes alone run 44 pages long. Each patient has an interdisciplinary plan of care online, which is upgraded each shift.

“It’s really in-depth,” he said.

Nurses at the Mayo Clinic Hospital say electronic notes allow them to document more details more quickly, said Judy Whitman, RN, MSN, CCRN, clinical director of critical care and cardiac monitoring.

“I have not done any studies to determine if we save any money,” Whitman said. “However, I can tell you the nurses would not go back to paper.”

Furthermore, the entire Mayo Clinic Hospital uses paperless documentation and has since it opened in 1998. “It is easy to navigate the system if a nurse is floated into another unit,” Whitman said.

Techno time-saver

Fresno (Calif.) Heart Hospital has not yet installed an interface between the computer and the monitors — nurses still must type in a patient’s information — yet even this advance has administrators and nurses praising the system, said Pilar de la Cruz-Reyes, RN, MSN, the chief nurse executive.

“From an administrative viewpoint, it’s a wonderful tool when you have to review a chart and you don’t have to try to decipher things,” said de la Cruz-Reyes, a self-described “old- time nurse” who, like the 103 nurses in her employ, quickly adapted to the new system. “This is the wave of the future.”

For example, she said, nurses are notorious for not completing individualized nursing care plans for each patient, a time-consuming process. But the $2.2 million Medi-Tech system provides templates for all conditions, problems, and associated outcomes.

“You don’t have to start writing from scratch,” de la Cruz-Reyes said.

Instant results

Not only does the system compensate for messy, hurried, varied, or incomplete handwritten notes, it offers instant results. In keeping with the fast pace of the information age, X-rays are available on screen as soon as they are done, with no smudged fingerprints obscuring the results. A nurse can look at a patient’s lab work the minute the results are in.

And everyone with security access — from physician to nurse to administrator — can look at the chart at the same time, de la Cruz-Reyes said.

Bonnie Brock, RN, BSN, is the informatics nurse at Fresno Heart Hospital who helps nurses make the transition to computerized charting.

“The ease of information retrieval is really key on this,” she said. “I can see the picture of what took place with the patient so much faster than looking through a paper chart.”

When Fresno Heart Hospital opened its doors Oct. 15, Brock had been training her nurses for six weeks. She gave them four four-hour sessions, plus four hours on the system outside the classroom using fake patients. Now that she has nurses on the floor who know how to use the system, she has reduced the number of four-hour sessions for new nurses to three.

“It’s very scary that first day,” Brock said, remembering some comments she heard from new users. “The first day you take patients and use the system you will probably say, ‘I can’t do this.’”

Yet not even one year later, Brock has discovered some of the nurses she worried would have the hardest time with new technology have been the best users.

Getting up and running on the computerized ICUs is perhaps the smallest drawback to the system. System upgrades or changes can cause serious or hard-to-find errors, said Bickford of the ANA.

“Software coding is a complex process, and if you’re not paying attention, things go wacko,” she said.

Errors have happened in the past, she said, and no governing body tracks these errors.

While computer errors are the nightmare of programmers, other more seemingly mundane problems must be discussed as the country’s health care facilities move toward computerization, Bickford said.

If software becomes obsolete or a software maker goes out of business, how is the stored data retrieved for use? Then there is cost — wires, monitors, disposal, updated software, electricity. How do facilities absorb the cost? Finally, a move to standardize terminology and practice is just getting under way, Bickford said.

And, of course, sometimes systems go down. Roberts of Cedars-Sinai said the hospital has a paper backup system in case of technical trouble.

Weena Gorospe, RN, BSN, an overnight nurse on the Cedars-Sinai surgical ICU, loves the system for making her job easier, but agrees that things become much more difficult when the system goes down.

“You’re helpless,” Gorospe said. “All your data is in the computer, so there’s no way you can access it. You have to go back and forth, grab vital signs from the bedside, and copy all medications onto the trifold.”

Yet such breakdowns are rare, and Gorospe said she loves the system.

“It makes it easier for us, and it’s really more accurate,” she said. “To me, it gives more time for direct patient care.”