Online Journal of Nursing Informatics (OJNI) Spring 2008 Volume 12, Number 1
ISSN # 1089-9758 Indexed in CINAHL © 1996 - 2014
O'Connell, M. & Craig, J. (February, 2008). Computerised equipment usage in intensive care units:
An inventory of computerized systems used in Sydney Metropolitan General ICUs.
Online Journal of Nursing Informatics (OJNI), 12, (1) [Online].
By Mary O'Connell, RN, BHlthSc (Nursing), MHIM and
Janelle Craig, BAppSc(MRA) Cumb, MComm UNSW
Objective: This informatics project was undertaken to give background information for upcoming research into the training needs of Intensive Care Unit (ICU) nurses in the use of computerised equipment. Staff in the ICUs were asked their views on the utility and user friendliness of their equipment.
Methods: An inspection of 14 Sydney metropolitan general ICUs was carried out by one of the investigators to determine the current range of computerised equipment used by ICU nurses. Computerised equipment was classified according to installation before or after the year 2000 to give an indication of innovation.
Results: Across the ICUs studied, 14 individual computerised equipment systems were being used. Varying frequencies were found for individual computerised equipment systems.
Conclusions: Computerised equipment tends to be current with technologies implemented since 2000. A very positive approach is being taken in ICUs with regard to the introduction of new technologies.
Key Words: Computerised equipment; Intensive Care Units; Nursing practice.
Computerised equipment is increasingly used in fast-paced healthcare environments such as Intensive Care Units (ICU) where core decisions must be made quickly. These computerised technologies contribute to improving patient care (ZytKowski, 2003; Marin, 2005; Munir & Kay, 2005). The range of computerised equipment used in the daily work of an ICU nurse is extensive, with the manner in which ICU nurses practise and the methods employed in documenting patient care directly related to these computerised technological advances (Rivers et al, 2003). However previous research (Brewer, 1981; Fitter, 1986; McConnell & Murphy, 1990) has identified a problematic relationship between nursing practice and the use of advancing computerised technologies.
Senior management usually makes decisions about computerised hardware and software selections in healthcare facilities, including ICUs (Coghlan, 1986). As a result, computerised equipment can vary from department to department and between hospitals. Biomedical Engineering Departments attempt to maintain asset registers detailing the type and amount of equipment utilised in a healthcare facility. However these registers provide little information on the complexities of each piece of equipment.
Computerised technology in healthcare is constantly evolving and being updated in the workplace hence it is relevant and timely to "take stock". This study was undertaken to determine the range and contemporaneity of computerised equipment currently used by nurses in ICUs and to ascertain the degree of uniformity of hospital monitoring systems in acute care areas. This data will provide preliminary information for future research investigating the training needs of ICU nurses in the use of computerised equipment. Contemporaneity and user friendliness of the equipment was of particular interest as these are known to strongly impact on clinical nursing practice affecting education, time management, confidence and knowledge.
Intensive Care Units were established in the 1960s, and computer technology was introduced to manage the large volumes of patient data that were being generated (East, 1992). Since then, there has been a plethora of computerised equipment employed in ICUs that has been instrumental in decreasing the length of hospital stay despite increased condition acuity and increased complexity of care. Technological proficiency is essential with rapid patient turnover being the norm in complex "hi tech" environments (Pelletier et al, 1998).
Computerised technologies have changed ICU nursing practice, necessitating further education and training. ICU nurses' rely on computerised equipment to allow them to focus on patient care rather than on capacious data analysis. Whilst nursing practice and education in the use of computerised equipment have been researched, the published literature does not contain a comprehensive overview of current technological trends and equipment usage patterns.
An initial list of 22 general ICUs in public and private hospitals in the Sydney metropolitan area was generated using data contained in the Hospital and Health Services Yearbook (2004). This list was further refined by limiting the sample to ICUs in tertiary referral public hospitals capable of providing complex, multisystem life support for an indefinite period, which correlates to role level 3 of the Australian and New Zealand Intensive Care Society (ANZICS) classification (ACHS, 2003). Also ICUs in larger private hospitals (ANZICS role level 2-3) were capable of providing the same support for a period of at least several days. This culling process was considered necessary to create a more homogenous sample. The Sydney metropolitan area has only three fully computerised ICUs and all of these were included in the sample, although it should be noted that one of these is classified as ANZICS level 2.
Fifteen hospitals were approached to participate in the study. A letter of introduction was sent to each Nurse Unit Manager (NUM) explaining the project and requesting the participation of their facility. Responses to the participation letter were received and appointments made for on-site visits. One private hospital declined to participate in the study.
Prior to undertaking the on-site visits, a list of commonly used computerised equipment in general ICUs was composed. This list formed the basis of the inventory that was reviewed at each facility. The inventory recorded type of computerised equipment, brand and date of installation.
14 ICUs were visited between 16 March and 9 May 2005. At the site visit, the researcher met with the NUM or ICU Clinical Nurse Educator (CNE) and together they reviewed the computerised equipment in use and completed the inventory.
The study was descriptive in design and results are shown by frequencies with percentages in order to identify the full range of computerised equipment. 14 individual Sydney metropolitan general ICUs were inspected, 11 in public hospitals and three in private hospitals.
Computerised equipment was defined as that which produced patient data. This covered all the monitoring systems and individual stand-alone computerised equipment externally attached to or inserted into the patient. In fully computerised ICUs the data readout is communicated electronically to the Clinical Information System (CIS) and paper charting is unnecessary. In partially computerised ICUs, the data readout is communicated electronically only to the Central Monitoring System (CMS) with paper charting being necessary. Computerised equipment did not include internet applications and/or information derived from this source.
General ICUs, in public hospitals were the focus of the study, however a number of larger private hospitals were included to determine if there was any variation in computerised equipment usage between the public and private health sectors.
It was agreed that the number of brands and models of computerised equipment would be identified as this reflects contemporary nursing practice in ICU. Computerised equipment is often characterised by the manufacturer's stylised features and 'signature' functionality, and as such, nurses, like other users, identify computerised equipment by brand name and model. Computer software information was not collected as it was beyond the scope of this project.
The date of implementation of the computerised equipment was sought because uptake and usage of computerised equipment may be affected by perceived qualities such as innovativeness, age and user friendliness. The year 2000 was chosen because the threat of technical failure brought about by 'Y2K' non-compliance required all organisations, including healthcare facilities, to assess potential risks with computerised systems (Connell, 2002). Consequently, many hospitals reviewed and updated equipment just prior to the year 2000.
Data was analysed using descriptive statistics.
Fourteen computerised equipment systems that produced a significant amount of patient data were identified. No difference was found in equipment usage between the private and public hospitals reviewed. The advantages of using more contemporary and user friendly computerised equipment was acknowledged by NUMs and CNEs in the time saving to ICU nurses with complicated component and tubing set-ups not being required on newer models capable of self testing and calibrating. Also user-face capabilities and presentation were more sophisticated with touch screen navigation. Some of the computerised equipment offered a better range of functions than their predecessors that ultimately decreased the nursing workload with reduced patient observations.
Table 1 indicates the types of computerised systems used by individual hospitals and year of installation.
Clinical Information Systems
Three (21%) ICUs had fully computerised clinical information systems (CIS). The CIS had been implemented before 2000 in two ICUs and in 2001 in the third ICU.
Computerized Monitoring System
Computerised monitoring systems (CMS) were used in all 14 participating ICUs. However, 13 of the ICUs had CMS's that were different from those used in other hospitals departments. Only one hospital used the same CMS throughout the entire hospital. Only four (29%) ICUs had installed a new CMS post 2000.
Intra Aortic Balloon Pump (IABP)
11 (79%) ICUs had ready access to an IABP. The three remaining ICUs did not possess an IABP, but borrowed one if required from their Coronary Care Unit, Cardiothoracic Unit or Operating Room. There were only two brands of IABP identified, with each brand having two models of this equipment in the ICUs. Two of the four models of IABPs in use were implemented after 2000. Three (27%) ICUs used IABP implemented after 2000.
Continuous Veno Venous Haemodialysis (CVVHD)
All ICUs used CVVHD. There were four different brands of CVVHD equipment in the ICUs, with one manufacturing two models. Some hospitals used two different brands of CVVHD machines. Six (42%) ICUs used CVVHD machines implemented after 2000.
Ventilators were available in all ICUs. Six different brands of ventilators were identified, with three manufacturers producing two/three models. Some hospitals used two or three different brands of ventilators. Nine (64%) ICUs had ventilators that were implemented after 2000.
Bilevel Positive Airway Pressure (BIPAP)
All but one ICU either had BIPAP machines; the other used the continuous positive airway pressure (CPAP) function on their ventilators to perform non-invasive breathing assistance. Only one brand of BIPAP machine was used. Some ICUs used both types of non-invasive breathing assistance. Thirteen ICUs (93%) used BIPAP machines; all were implemented from 2000 onwards.
Continuous Cardiac Output (CCO)
12 (86%) ICUs used both the stand-alone CCO monitor and percutaneous insertion CCO (PICCO) system, while two (14%) used the CCO module function attached to their central monitoring system. Two brands of CCO monitors were identified, with one manufacturer producing two models. Some ICUs used two different brands of CCO monitor. Ten (83%) ICUs used CCO implemented after 2000.
All ICUs had defibrillators, ranging from monophasic models, which require escalating energy levels for terminating ventricular fibrillation, to biphasic models. Four (28%) ICUs used monophasic defibrillators, eight (57%) used biphasic defibrillators and two (15%) used both types of defibrillator. Ten (71%) ICUs used defibrillators that were implemented after 2000.
All ICUs had some form of transport monitor even if they only used the cardiac monitor screen on the defibrillator. 13 ICUs had specific transport monitors and one ICU had all patient computerised systems incorporated on an individual large portable stand and used this for transport monitoring and ventilation. Six brands of transport monitors were identified, with three ICUs using two different brands of transport monitor. Five (36%) ICUs used transport monitors that were implemented after the year 2000.
13 ICUs visited used transport ventilators; one ICU used a large portable stand with all patient computerised systems including a ventilator. Four brands of transport ventilator were identified, with one manufacturer producing two different models of this machine. Two ICUs used more than one brand of transport ventilator. Six (43%) ICUs used transport ventilators that were implemented after 2000.
Blood Gas Machines
Ten (71%) of ICUs had their own blood gas machines. The remaining four (29%) sent specimens to pathology for blood gases testing. Three different brands of blood gas machine were identified with one brand being the most commonly used. All blood gas machines were installed prior to 2000.
All ICUs had intranet access to a hospital pathology service for results, either via a desktop monitor or through intranet facilities on their computers.
There were two systems available for the viewing of x-rays. Nine (64%) ICUs used the traditional method for viewing X rays ie via an x-ray board, while five (36%) ICUs used a Picture Archiving and Communications System (PACS). The latter method could be by a designated computer screen for PACS usage or on individual computer monitor screens at the patient's bedside. The implementation of both types of technology predated 2000.
All ICUs had electrocardiography machinery. Nine (64%) ICUs used individual machines, five (29%) used their CMS (the ECG function required the changing of monitoring leads) and one ICU (7%) used their CIS for this functionality. Three brands of ECG machines were identified. Five (35%) ICUs used ECG machines and three (21%) ICUs used their CIS or CMS functionality, all implemented after 2000.
The results show that in the study ICUs there was a great diversity of complex computerised equipment in use. Most pieces of equipment were current in terms of their installation/implementation, however there is some lack of uniformity in hospital monitoring systems in acute care areas. No difference was found in equipment usage between the private and public hospitals reviewed. While the sample is quite defined, we suggest it is representative, in that ICUs in a substantial majority of tertiary referral public hospitals and larger private hospital took part. As the inventory was conducted in metropolitan Sydney, the issues addressed and discussed relate to NSW; thus any inferences drawn may not necessarily apply in other Australian states/territories. However replication of this study is an area for further research, which could serve to provide a more comprehensive overview of the computerised equipment used in Australian ICUs. The obvious limitation of any such inventory will be the changing nature of the computerisation. This again endorses ongoing research in this area.
Technological advances in the computerised equipment used in ICUs indicates what the future holds. The sophistication of the computerised equipment is exemplified by clinical information systems that record and save all manner of data, be it patient observations, medications, treatments, doctors orders or patient progress notes. Fully computerised ICUs offered the best time saving opportunities to clinical nursing practice with their fully automated data capture from physiological bedside monitors and documentation saving at the click of a mouse. The monitoring systems illustrate their flexibility with their measurement modules of multiparameter data acquisition devices that can include ECG, invasive blood pressure (IBP), non-invasive blood pressure (NIBP), temperature, oxygen saturation (SaO2), cardiac output, heart rate, carbon dioxide (CO2) monitoring, respiration rate, electroencephalography (EEG), transcutaneous gas, mixed venous oxygen saturation and bispectral index. More modules are being added to this list as the need arises. The changing face of medicine is being reflected in the advancing technological management of patient care.
The results showed most of the computerised equipment in current daily usage has been implemented after the year 2000. The only pieces of computerised equipment implemented before these were x-ray, pathology and the blood gas machines. Pathology and x-ray services are a part of the hospital infrastructure and have intranet services for viewing the results. In ICUs that did not have their own blood gas machine, the specimen was sent to pathology for testing. However, the cost of individual pieces of computerised equipment such as IABPs and blood gas machines must be taken into consideration when looking at purchase or replacement. Individual items can cost upwards of $60,000 and constrained hospital budgets cannot afford to purchase new computerised equipment unless the models are sufficiently out dated or require high maintenance levels. This is another reason for not restricting use of IABPs to one unit but allowing access to them from a central area such as the Operating Room or Cardiothoracic ICU.
In all but one of the study ICU's, the non-standardization of computerised monitoring systems was apparent, as only one hospital had the same system throughout its acute specialty areas. Different monitoring systems in acute specialty areas of the hospital make significant demands on the time ICU nursing staff spent interchanging monitoring leads and probes if a patient is transferred to another speciality area. However, the more serious problem was of the patient's status being compromised by time consuming technological changeovers. Agency nursing staff are regularly employed on a casual basis and expected to be proficient with a diverse range of complex computerised equipment. This warrants further research, as the broad based skills and knowledge expected of agency nursing staff to manage complex computerised equipment has its own inherent problems (McConnell & Fletcher, 1995; Douglas et al, 2001).
ICU nurses are expected to be both knowledgeable and competent in dealing with computerised equipment that is a large part of their clinical nursing practice. In larger public hospitals and fully computerised hospitals there are data managers or equipment coordinators to help nursing staff with the overseeing of computerised equipment. However, in the majority of ICUs studied, nursing staff were expected to manage the computerised equipment, report malfunctions and maintain a competent standard of practice in their dealings with the equipment (Haghenbeck, 2005). They require knowledge and training as to how it functions, what it measures and the interpretation of this data for optimum patient management and outcomes. ICU nurses are responsible for the supervision of computerised equipment with regard to troubleshooting, alarms, assembly/dismantling and cleaning requirements (Coghlan, 1986). With such a variety of computerised technology, how ICU nurses manage to learn the functionality and interoperability of this equipment is indicative of the highly specialised training that is required for this sophisticated area. The extensive and broad range of computerised equipment and inherent responsibilities typifies the educational requirements for ICU nurses. The dynamic nature of computerised equipment and the consequentially changing face of nursing education will continue to maintain grounds for future research.
The overall impression after conducting this study was highly encouraging. Much of the computerised equipment is current and utilising technologies implemented after the year 2000.
The opportunity to be able to speak with NUMs, CNEs, equipment coordinators and data managers about their computerised equipment reassured the investigator that a very positive approach is being taken in ICUs with regard to the introduction of new technologies. The majority of ICUs were interested in further research being undertaken and were very supportive. Further research using this inventory will be commenced in the coming year.
Mary O'Connell, RN, BHlthSc (Nursing) Southern Cross, MHIM Sydney
At the time of writing, Candidate, Health Science Doctorate, Faculty of Health Sciences, The University of Sydney
Mary O'Connell is a registered nurse currently working in Cardiothoracic ICU at the Prince of Wales Hospital Sydney. She has had extensive experience in many areas of nursing in Australia and overseas in the Middle East and Britain. She also holds a masters degree in health information management with her area of interest involving nursing and health informatics. Currently she is writing her doctoral thesis investigating the training needs of ICU nurses to use computerised equipment.
Janelle Craig , BAppSc(MRA) Cumb, MComm UNSW
Janelle Craig is a Lecturer and Postgraduate Coordinator in the Discipline of Health Information Management, The University of Sydney, Australia. Her areas of expertise are health informatics, health care information systems and health care systems and she lectures at both undergraduate and postgraduate level. Her current research involves the investigation of electronic communication patterns between patients and general practitioners, and electronic discharge referral systems.
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