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Lessons Learned: The Impact of Smartphone Implementation with Emergency Department Nurses
Event Type
Oral Presentations
TimeFriday, April 1611:00am - 11:20am EDT
LocationDigital Health
DescriptionIntroduction
Inefficiencies within healthcare are common and may cause significant nurse burnout and poor patient outcomes (Koch et al., 2012). Previously at CMH, Ascom phones were used for communication between PICU nurses, physicians, and other departments. These phones have calling and texting capabilities, but no other features. The secondary emergency department (ED), was also utilizing Ascoms, however usage was limited to charge nurses and two resource nurses—no ED bedside nurses had access to Ascoms. Previous work suggests that smartphones have many additional capabilities to enhance forms of communication within healthcare and could potentially streamline patient care (Nagler et al., 2014). While many studies have conducted physician-smartphone usage in the clinical setting, very little nursing-smartphone usage literature exists.

Due to this lack of information, research on smartphone implementation within hospitals became a strongly sought-after initiative. Many hoped that the ability to securely text, send pictures, and call would integrate more smoothly into the clinical workflow than the Ascom devices. As a result, iPhones were implemented into the main hospital’s PICU and secondary ED.

Methods
A preliminary survey, created using the REDCap platform, was sent to all nurses in the PICU and ED. This survey consisted mostly of Likert scale questions and took approximately 15 minutes to complete. The study information, consent, and link for survey completion were sent via each nurses’ work email.

Questions from the initial survey covered a variety of topics, including demographics, personal smartphone usage, satisfaction and perception of integration of the currently used Ascoms (PICU only) and Web On-Call (ED only), and a comment section for smartphone implementation at the hospital.

The original goal of the study was to survey the PICU and ED after 6-12 months of iPhone implementation. However, there were a few unintended occurrences within implementation.

Results
At the time of this submission, the PICU has discontinued use of the iPhones, therefore results will focus primarily on the pre- and post-implementation survey results from the ED.

Two survey questions specifically addressed ease of contact – How easy/difficult is it to contact someone or to be contacted during the shift. There were no statistically significant differences pre and post iPhone implementation.

A one-way analysis of variance (ANOVA) was calculated on participants' satisfaction ratings between the primary communication devices within the ED—Ascoms, Web On-Call for paging, the “What’s next” column within the EMR, and iPhones. The ANOVA was significant, F (3,95) = 4.68, p < .01. Follow up tests revealed that the “What’s Next” column in the EMR outscored all other modalities. An ANOVA was also calculated on participants' workflow integration ratings between the ED’s primary communication devices. The ANOVA was significant, F (3,95) = 4.56, p < .05. Follow up tests revealed that the “What’s Next” column in the EMR outscored all other modalities for integration as well.

Lastly, in the pre-survey participants were asked to rate their agreement on the following statement – “I feel that the use of smartphones will allow me to take better care of my patients” on a Likert scale of 1 = strongly disagree to 5 = strongly agree. The mean score was 3.65, with a standard deviation of 1.20. This was followed up with the same question in the post survey but altered to reflect usage – “The CMH issued iPhone has allowed me to take better care of my patients”. The mean score was 2.60, with a standard deviation of 1.41. An independent sample t test was significant for these differences, t(39) = 2.30, p < .05.

Participants
For the pre-survey, there was a total of 26 nurse responses (48% response rate). Average age was 38 years old (SD = 9.17), 12 years of nursing experience (SD = 8.13), and 8.5 years (SD = 4.96) of experience in the ED. Most nurses rated their smartphone proficiency as expert (18 of 26 people) with most individuals being iPhone users (22 of 26 people).

For the post-survey, there was a total of 21 nurse responses (40% response rate). Average age was 40 years old (SD = 10.84), 14 years of nursing experience (SD = 10.84), and 10 years (SD = 7.73) of experience in the ED. Most nurses rated their smartphone proficiency as expert (18 of 21 people) with most individuals being iPhone users (19 of 21 people).

Discussion/Specific Takeaways
Assumptions regarding dissatisfaction with previous technology (such as Ascoms and Web On-Call) does not mean that implementing new technology (like iPhones) will make clinical workflows better or staff happier. From the results, no changes in ease of communication were indicated after iPhone implementation.

The PICU had a great many “technical” issues with the iPhones at implementation. Three PICU patient rooms were identified as permanent “Dead-Zones” for the iPhones. There were multiple areas of the PICU that were also identified as having poor wi-fi connectivity, which caused the phones to lose connection with the server and be unusable in those locations. As a result, the PICU ceased iPhone usage one month after initial implementation and reverted to Ascom usage. Since this time, they have tried re-implementing the iPhones several times with no success. The ED also experienced some “technical” problems with the iPhones throughout implementation, but their issues were viewed as less severe and they continued using the iPhones for a 6-month period. Even then, as the results indicated – there may have been high expectations for the iPhones which unfortunately, did not pan out.

The post implementation survey also contained an opened-ended comments section. There seemed to be common themes with answers, mostly focusing on the inconvenience of how bulky the iPhones are and the lack of functionality of the phones. Although the primary purpose of the iPhones was to enhance department communication, the phones may have been better received and viewed as more beneficial to the workflow if there were more functionalities, such as more accessibility to apps (like Lexicomp) or the ability to scan barcodes for medication or glucose monitoring.

Although human factors played a large role in the study portion of the research, there was no human factors involvement in the education or deployment aspects of the iPhone implementation. Having human factors involvement during the implementation and planning stages, rather than just for the study might have helped with the process.

Interruption observations were also conducted during the pre-implementation portion of the study in the PICU. These observations measured the number of times a nurse’s Ascom phone rang during 4-hour time blocks, and the nurses’ rating of urgency and importance of each call. Unfortunately, since PICU iPhones were never successfully implemented, this data has no comparison but has been enlightening to staff regarding both Ascom and iPhone usage.
Authors
Human Factors Research Assistant
Human Factors Scientist and Program Director