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Infusion device use in practice: one size does not fit all

Key points
We have

  • identified important differences between the assumptions made during design about how infusion devices will be used and the ways that they are actually used in practice;
  • identified important differences in the ways that infusion devices are used in different contexts, and for different purposes; and
  • developed and shared a set of resources that illustrate the variations in the ways that devices are used.

Background
In 2004 a national recommendation was made to NHS organisations that infusion devices should be standardised as far as possible across each health service trust. This is often interpreted as requiring total standardisation. However, the uses to which infusion devices are put vary significantly across contexts. In a series of studies on how infusion devices are used across different hospital contexts, we have identified important differences in practice.

There are also important differences between the realities of practice and the assumptions that developers are forced to make to conduct risk analysis within the pre-market approval processes.

Planned versus reactive care
This can be seen in the differences in practice between planned and reactive care. In the former, such as therapy for cancer, the administrations of drugs can be planned ahead of time. However, there is often a poor 'fit' between the practices nurses must follow and the device design. For example, common actions, such as checking what doses have been administered in the past hour, often can't be done with a single keystroke. Nursing staff also develop workarounds like using the pump alarm in a way for which it was not designed to alert them when a new administration needs to be set up. In reactive care, such as when anaesthetists react to a patient's condition changing during surgery, the clinician can be characterized as 'programming the patient': using vital signs information from other monitors to adjust drug administrations to stabilize the patient.

Another important difference is the complexity of the programming needed (and the corresponding skill required): some expert clinicians use advanced features of infusion devices for specialist purposes, and need sophisticated programming capabilities. Others may only set up infusions rarely, for routine administration of basic fluids, and need a device that is easy to learn and easy to use.

Manufacturers make assumptions
During the development and approval for market of infusion pumps, manufacturers have to make assumptions about how their devices will be used. These assumptions may be based on discussions with representative members of staff, and manufacturers may have their own set of scenarios of use that guide design, but these are not open to scrutiny by practicing clinicians. Manufacturers also make simplifying assumptions such as that manuals are readily available in busy wards, about how staff will be trained on use of the devices, and about the contexts they will be used in. Our work has highlighted the need to scrutinize these assumptions more closely and to ensure manufacturers have better access to clinical settings. It has also highlighted the many different ways in which devices are used, and the challenges that clinicians face in learning to use a plethora of devices with different interfaces and different ways of interacting with them. As we move more towards the use of devices by patients and carers at home, as in programmes such as UCLH@Home, it becomes even more urgent that devices are easy and safe to use for the purposes intended.

 


"This human factors area is key and we will want to bring it into our work as we go forward." - industry stakeholder


 

We should re-think the designs of infusion devices so that they are consistent, but also fit for purpose. Where variability is required, the differences should be clear to users. Drawing an analogy with car design: most drivers can quickly adapt to driving an unfamiliar hire car because the main controls work in the same way. Specialist heavy goods vehicle drivers have to learn extra skills, but those skills still transfer back to driving an ordinary car. Similarly, the core controls of an infusion pump need to be standard, so anyone can safely do basic infusions without additional training. There will still, however, need to be specialist equipment with differences reserved for specialist circumstances and used only by those trained in those areas.

Achievements
We have produced a set of resources based on the evidence we have collected, that 'make visible' many of the realities of practice, and can help give manufacturers deeper insight in to the design problems to be tackled. This includes a collection of scenarios describing how infusion pumps are used. We have also developed a collection of 'personas' which support design by describing the lives and goals of fictional but realistic people who use infusion pumps. They help designers keep in mind the real people they are designing for. These narratives have been validated by clinicians.

There has been interest in this work from regulators, clinicians and manufacturers. We have presented the evidence to the British Standards Institute and the UK regulator (MHRA), so informing their thinking on future regulation and standards for interactive health technologies. We also gave a keynote talk covering the work at the inaugural event on human factors and device design run by the MHRA, and attended by representatives of other key organisations such as NICE, ABHI, and the EC Medical Devices Task Force. This work has also been presented to manufacturers through meetings both at their offices and at CHI+MED sites. The design lifecycle of new infusion products means that there is likely to be little tangible evidence of changes in practice within the lifetime of the project, but the exchange with key manufacturers and policy makers is ongoing. In addition we were also invited to talk about the work at the Royal Society of Medicine's Patient Safety Symposium in 2014. Follow-up work has been funded by NIHR (the ECLIPSE project) to give a more reliable estimate of the number and kinds of discrepancies between medication prescription and administration and their causes, and to link this to the kinds of devices and the ways they are used in practice. Further work is also needed to more systematically document the detailed uses of infusion device and the range of requirements for future devices.

Publications
Berndt, E., Furniss, D. & Blandford, A. (2014) Learning Contextual Inquiry and Distributed Cognition: a case study on technology use in anaesthesia. Cognition, Technology and Work. 1-19 http://link.springer.com/article/10.1007/s10111-014-0314-y/fulltext.html

Blandford, A., Back, J., Cox, A., Furniss, D., Iacovides, J., & Vincent, C. J. (2014). Closing the Virtuous Circle: Making the Nuances of Infusion Pump Use Visible. Presented at HFES Healthcare Symposium

Blandford, A., Cauchi, A., Curzon, P., Eslambolchilar, P., Furniss, D., Gimblett, A, Huang, H., Lee, P., Li, Y., Masci, P., Oladimeji, P., Rajkomar, A., Ruksenas, R. & Thimbleby, H. (2011) Comparing actual practice and user manuals: a case study based on programmable infusion pumps. Proc. EICS4Med, First International Workshop on Engineering Interactive Computing Systems for Medicine and Health Care.

Blandford, A., Furniss, D. & Vincent, C. (2014) Patient safety and interactive medical devices: Realigning work as imagined and work as done. Journal of Clinical Risk. http://cri.sagepub.com/content/20/5/107

Furniss, D., Blandford, A. & Mayer, A. (2011) Unremarkable errors: Low-level disturbances in infusion pump use. Proc. BCS HCI Conference. 197-204. http://dl.acm.org/citation.cfm?id=2305353

Furniss, D., Blandford, A. & Mayer, A.(2014). The Wrong Trousers: Misattributing medical device issues to the wrong part of the sociotechnical system. In CHI 2014 workshop: HCI Research in Healthcare: Using Theory from Evidence to Practice.

Iacovides, I., Blandford, A., Cox, A., Dean-Franklin, B., Lee, P., & Vincent, C.J. (2014). Infusion device standardisation and the use of dose error reduction software: a UK survey. British Journal of Nursing, 23(14): IV Therapy supplement, S20–S25.

Rajkomar, A. & Blandford, A. (2012) Understanding Infusion Administration in the ICU through Distributed Cognition. Journal of Biomedical Informatics. Vol. 45, No 3. 580-590. DOI http://dx.doi.org/10.1016/j.jbi.2012.02.003

Rajkomar, A., & Blandford, A. (2012, August). A distributed cognition model for analysing interruption resumption during infusion administration. In Proceedings of the 30th European Conference on Cognitive Ergonomics (pp. 108-111). ACM.

Key People
Erik Berndt, Ann Blandford, Anna Cox, Dominic Furniss, Jo Iacovides, Atish Rajkomar, Chris Vincent

Acknowledgements
Franny Gant and Rachel Ganz (MSc students at UCL) completed Masters projects studying infusion device use in practice.