TEJIDO EMPRESARIAL

Phase 3: In-situ simulated pilot testing of IDEAS prescription chart

A total of 29 foundation year doctors working at one hospital completed the evaluation; 14 completed the IDEAS chart and 15 the ICHNT chart. There was no significant difference between the number of medications prescribed on the IDEAS chart compared to ICHT chart (164 of a possible 168 orders, versus 174 of a possible 180 orders; p=0.6).

There were key differences in the degree to which medication orders were completed correctly using the two different charts (Fig 6.8). Medication orders on the IDEAS chart showed a statistically non-significant improvement in legibility (164/164 vs 169/174; p=0.0611). Medication orders on the IDEAS chart were significantly more likely to include correct dose entries (164/164 vs 166/174; p=0.0046) as well as contact information of the prescriber - both printed name (163/164 vs 0/174; p=<0.0001) and contact/bleep number (137/164 vs 55/174; p=<0.0001). Current prescribing guidelines specify that the frequency of medication administration should be charted and this was significantly more likely (120/164 vs 15/174; p=<0.0001) on the IDEAS chart. There was no significant difference for the presence of signatures by prescribers (163/164 vs 171/174;

p=<0.344) or in the documentation of allergy status and reaction.

Figure 6.8: Different completed features of medication orders using the IDEAS and ICHNT charts

We measured key outcomes related specifically to prescribing of two antibiotics as part of the simulated case (see Figure 6.9). The IDEAS chart significantly outperformed the ICHNT chart in prescribers indicating the duration of length of antibiotics (26/28 vs 15/29; p=<0.0001) and also the indication of anti-infective use (28/28 vs 17/29; p=<0.0001) (Table 4).

IDEAS Chart

Yes 164 (100%) 169 (97%) No (0.061) No difference

Was the dose

Yes 163 (99%) 171 (98%) No (0.623) No difference

Was

Figure 6.9: Different completed features of antibiotic prescriptions using the IDEAS and ICHNT charts

Prescribers provided some feedback on perceived ease of navigation through the prescription chart that they had completed as well as their general opinion on the chart’s design (see Figure 6.10). All prescribers completing the IDEAS chart (n=14) agreed or strongly agreed that the chart was easy to navigate and well designed, whilst 4 out of the 15 participants completing the ICHNT chart disagreed with the statements ‘the prescription chart is easy to navigate’ and ‘the prescription chart was well designed’.

Figure 6.10: Prescribers perception on navigation through chart and its design

Endorsements by nursing staff and pharmacists

Four pharmacists were asked to endorse one complete IDEAS chart and one ICHNT chart each with no significant differences seen between the different charts. Ten nurses were asked to sign for medications on one IDEAS chart and one ICHNT chart and again no significant difference was seen in between the charts.

Discussion

Professional organisations in the UK including the General Medical Council and Royal College of Nursing have called for standardised prescription charts to be used across the NHS with a standardised chart already used in hospitals across Wales (303). But standardisation and good design are not the same thing and suboptimal chart design may facilitate medication errors (308) (304). There is a clear case for good design and content of prescription charts and the guidance

about prescription chart design from the increased understanding we have of human judgment and decision making through recent applied research in the behavioural sciences and user-centred design.

Few studies have investigated the context or environment in which prescribing takes place even though it is widely recognised that hectic work environments and time pressures contribute to lapses in judgement and that the design of structured forms in other areas influences completion (310, 311). It is known that different prescription chart designs may be more likely than others to provoke error but little is known about how specific elements of chart design exert their influence (308). This is the first study to explore how behavioural and design insights can be used to improve prescription charts with the aim of reducing medication errors. The IDEAS project has demonstrated, at least in a simulated context, that applying behavioural insights to the design of prescription charts can lead to significant improvements in prescribing behaviour with no apparent problems among prescribers, nursing staff or pharmacists. These benefits were without any prior education or training using the IDEAS chart. It is notable that studies testing standardised charts have previously tended to include some training to support the implementation of the new chart (298). To reflect more usual practice, no such measures were taken in evaluating the IDEAS chart, indicating perhaps that a number of errors, like illegibility and poor prescriber identifiability, are rectifiable without the need for further extraneous interventions by addressing the choice architecture inherent in inpatient prescribing.

There is ongoing debate about the combination of tools that can deliver reduced numbers of prescription errors. Prescribing errors are often multifactorial with several active failures often conspiring together. The design of prescription charts is just one factor contributing to errors and the results of this study demonstrates that simple prescribing errors (legibility, ability to identify prescriber) were significantly reduced by applying behavioural insights and changing the design.

Whilst we have not shown that such errors would have led to actual patient harm, such cognitive lapses in prescribing undoubtedly have an impact in wider clinical practice.

We can use anti-infective prescribing as a lens to what good design of prescription charts can achieve. We know that anti-infectives are often incorrectly prescribed and this can lead to significant consequences such as inappropriate usage and prolonged courses. Inappropriate usage of anti-infectives can contribute to the emergence of antimicrobial resistance and healthcare acquired infections such as Clostridium difficile and the NHS has developed a strategy to ensure better antibiotic stewardship (312). A point prevalence study from 2008 found that 23.9% of antibiotic prescriptions were illegible and 29.9% incomplete (313). A key problem encountered with anti-infectives is that the rationale for usage and proposed course of treatment is often poorly documented. It is recommended by the majority of hospitals that in addition to standard requirements, all anti-infective prescriptions must have an indication and have a stop/review date (312), but current charts often do not encourage this. By having a dedicated anti-infectives section with separate entry boxes for indication and suggested length of treatment, 100% of prescribers completing the IDEAS chart specified the reason for prescribing them. This was a significant improvement when compared to the existing ICHNT chart where only 59% of prescribers specified the indication. No new education or training was required to shift this change in prescribing behaviour; it came about as a consequence of dedicated entry boxes and a separate anti-infectives section.

Despite the inevitable move towards electronic prescribing in the UK, progress has been slow and it is likely to be many years before electronic systems have taken over from paper prescription charts (301). In the meantime, significant improvements in prescribing could be realised by implementing some of the findings of the IDEAS project. Making small changes to the choice environment can be

used as an effective behaviour change mechanism, prompting individuals to change their behaviours in ways that make prescribing safer and more effective

There are several strengths and weaknesses of this study. The Imperial Drug Chart Evaluation and Adoption Study (IDEAS) chart was the result of an intensive exploration of stakeholders’ views and observations of their behaviour in relation to the prescription and administration of medications.

The design of the IDEAS chart incorporated cutting edge behavioural insights using the Mindspace framework. The use of in situ simulation testing enhances the realism of health professionals completing the chart without risking patient safety through the trial of an untested prescription chart. This study is limited by relatively small sample size and the use of simulation rather than a formal clinical evaluation. A number of parts of the IDEAS chart (checklist, separate sections for oxygen and intravenous fluid prescribing) were not tested as part of the evaluation. It was not possible to determine the relative contribution of the different features implemented.

Conclusion

The IDEAS prescription chart - at least in a simulated context - significantly reduced a number of frequent prescribing errors including dosing errors and illegibility. It also served to increase prescriber identifiability and enhance information documentation in relation to antibiotic prescribing. Significant and positive changes in prescribing behaviours took place without the need for extra training and education. A wider clinical evaluation is required but the learning developed through the IDEAS project could contribute to better designed prescription charts that facilitate improved prescribing.


Applying the 6E’s to the IDEAS project

Explore Thorough exploration of the prescribing process and barriers and drivers of safe prescribing was undertaken in the IDEAS project through engagement with end users. Techniques

included a literature review, focus groups and work shadowing.

Enable To facilitate behaviour change the IDEAS chart needed to be designed in such a way that encouraged safe and high quality prescribing. The final chart design enabled users to prescribe effectively whilst fulfilling the requirements set out in the recent AOMRC report.

Engage The IDEAS project engaged front line staff through events that encouraged nurses, physicians and pharmacists to take part in design of the chart and in it’s testing. The project team had input from across the different stakeholder groups that included pharmacists, physicians and nursing staff.

Encourage The two approaches taken to change prescribing behaviour through the IDEAS chart were 1) using the Mindspace framework and 2) principles from user-centred design.

Exemplify Senior clinical and academic staff were brought in to support the project.

Evaluate Because of the obvious risks of introducing an untested chart into a clinical environment, the decision was taken to do simulated pilot testing first.

Chapter 7

7. ‘Priming’ hand hygiene compliance in clinical environments

Summary

Background: Effective hand hygiene compliance (HHC) is one of the most important procedures in preventing hospital-acquired infections. Traditional information/education based interventions have shown only modest and transient benefits to compliance. This study set out to investigate whether psychological priming (through olfactory and visual cues) targeting automatic brain processing could influence hand hygiene compliance

Methods: Randomised controlled trial set in a Surgical Intensive Care Unit (SICU). The primary outcome data involved observations – a mix of health professionals and service users were observed entering the SICU by two trained observers and their hand hygiene compliance was independently verified. Interventions included either an olfactory prime (clean, citrus smell) or visual prime (male or female eyes). The primary outcome measure was hand hygiene compliance measured by the visitor using the hand gel dispenser.

Results: At a 5% level there was significant evidence that a clean, citrus smell significantly improves HHC (46.89% vs 15.00%, p = 0.0001). Compared to the control group, a significant improvement in HHC was seen when a picture of ‘male eyes’ was placed over the hand gel dispenser (33.33% vs 15.0%, p < 0.038). No significant improvement in HHC was seen when a picture of female eyes was placed over the same hand gel dispenser (10.00% vs 15.00%, p = 0.0626).

Conclusions: This is one of the first studies that we are aware of that demonstrates how specific interventions using psychological priming could improve HHC in an actual clinical setting.

Thinking more generally about how priming could influence behaviour change could lead to new and improved interventions across public health.


Introduction

Nosocomial or healthcare associated infections (HAIs) encompass all infections transmitted to patients (and healthcare workers) as a result of consultations and procedures that take place in a healthcare setting. Such infections cause significant morbidity and mortality and are financially costly to patients and the healthcare system (314). The advancements made in treating many diseases over the last two decades has been undermined by infections transmitted during care and as a consequence the detection and prevention of HAIs are now central to many quality improvement programs (315).

Although not all HAIs are avoidable, many are preventable. Using evidenced based measures is a core component of strategies to reduce the burden of such infections. The UK epic2 national evidenced-based guidelines for preventing HAIs in NHS Hospitals were released in 2007 and provided comprehensive recommendations for preventing HAIs in healthcare settings based on best currently available evidence (316). The guidelines provide recommendations divided into four distinct interventions including hand hygiene (see Fig. 7.1);

Hand-washing and healthcare associated infections

Hand-mediated transfer of micro-organisms is a key factor in the development of HAIs as patients, visitors and staff can transmit resident and transient flora from their own hands onto debilitated Figure 7.1: epic2 recommendations on areas for intervention

Interventions 1 Hospital environmental hygiene

2 Hand hygiene

3 The use of personal protective equipment 4 The safe use and disposal of sharps

visitors prevents cross infection in hospital and has been identified as one of the most important procedures in preventing HAI’s. Unfortunately, compliance with recommended instructions on hand washing is often poor with observational and self-reported studies suggesting it rarely exceeds 50%

in either a community setting or amongst health professionals in clinical settings (317-319).

HHC has been shown to be effective strategy in preventing the spread of infections such as influenza and clostridium difficile (320, 321). Numerous studies have shown the benefit to patients of improved HHC. Estimates based on meta-analysis suggest that in a community setting, improved HHC reduced rates of gastrointestinal illness by 31% and respiratory illness by 21% (322). The implementation of a hand-washing programme amongst young military personnel was associated with a 45% reduction in total outpatient visits for respiratory illnesses (323). A hospital wide campaign, with an emphasis on promoting bedside, alcohol-based hand disinfection saw hand washing compliance increase from 48% to 66%, which coincided with a reduction in nosocomial infections and MRSA transmission (317). How improvements in HHC are actually brought about is less clear and there are many examples of interventions that have had little to no sustainable impact on HHC (324). Traditional interventions have tended to rely on ‘changing minds’ and there is significant opportunity to use behavioural insights to enhance existing tools as well as thinking about new interventions to implement.

Behavioural insights and HHC

As has been discussed in earlier chapters, there are two broad terms there are two ways of thinking about changing behaviour. The first is based on influencing what people consciously think about and this is termed the ‘cognitive’ or ‘rational’ model. Most traditional interventions seeking to improve HHC have relied on educating and informing health professionals and service users about the importance of HHC and/or providing feedback on compliance. At best, such interventions have been met with only transient and modest improvements in HHC (325, 326). By encouraging people

to reflect on their behaviours, many interventions have failed to take account of the potential influence of more automatic drivers of behaviour that have recently been identified as being prominent in human judgment and decision making (18) and a key psychological determinant of several behaviours, including hand-washing (327).

The different Mindspace elements could have a potentially significant role in improving HHC.

Social norms have been seen to influence HHC with the presence of other people in restrooms has been shown to increase hand washing (328, 329) and physician compliance with hand washing is influenced by other physicians behaviour (324). Affect has also been used to enhance HHC with a campaign targeting university students being more successful when the material instilled the feeling of ‘grossness’ about dirty hands rather than information related to spread of diseases (330). Whilst there is potential in many types of Mindspace interventions to enhance HHC (ward staff at a hospital in Wales have recently had to sign a commitment contract to improve hand hygiene (331)), herein we focus on how priming - the P in Mindspace - could be used as an intervention strategy to encourage HHC.

Priming - as described in earlier chapters - describes a process in which our behaviour may be automatically altered with little or no awareness if there is prior exposure to certain cues (e.g.

words, sensations, smells or sights) (332). The interest in the potential role of priming in HHC was stimulated by studies demonstrating that people were more likely to keep their surrounding environment clean in the presence of an artificial detergent type smell (103) and that cues of being watched lead to observable changes in behaviour including in reducing littering (101, 102).

Displaying images of eyes has been seen to cause people to act more pro-socially in both laboratory and real world settings and is thought to be related to the perception of being ‘watched’ (333).

In our research team, we had previously demonstrated the impact of a clean disinfectant smell (an olfactory prime) on hand hygiene compliance in a simulated clinical context (334). In this study,

165 novice healthcare providers examined a standardised patient (a professional actor playing the role of a patient). 79 of the participants were exposed to a fresh scent delivered through a commercially available aroma dispenser, whilst 86 participants were exposed to the standard environment. HHC was tracked before patient contact using video surveillance. The HHC was significantly higher in the fresh scent group compared to the control group (80% vs 51%, p<0.001).

These results suggested that hand hygiene could be significantly influenced by olfactory cues. I felt it was important to look at whether this effect carried over to actual clinical environments rather than just simulated ones. I also wanted to investigate how cues of being watched could influence HHC. Two studies are now described. Firstly, the impact on HHC of introducing a clean citrus smell as the intervention prime. Secondly, the impact of an image of a pair of eyes over the hand wash dispenser to introduce a perception of being watched.

Methods

SETTINGS AND PARTICIPANTS

All people entering the Surgical Intensive Care Unit (SICU) at a large urban teaching hospital. This included staff (including clinicians and portering staff) as well as external visitors. The study took place over defined sessions in a three month period over 2012-2013. The primary outcome data involved observations of HHC performed by two observers who were sited at a discrete distance that allowed clear views of the area without being obvious to those entering the ICU. One was outside the unit, the other inside so that they would be able to observe hand hygiene compliance at any time between entrance to the ICU and the actual patient room. The ICU has private (glass walled) rooms. There is a Purell container outside the main entrance and several inside the ICU before reaching the individual rooms. Each instance was coded as ‘washed hands’ / ‘did not wash hands’. Hand hygiene was defined as use of alcohol hand rub at any point between entry to the ICU

and entry to the patient’s room. Ethical approval for the study was obtained (IRB Number 20090104-03).

RECRUITMENT

All entrants (both staff as well as external visitors) to the ICU are expected to comply with hand hygiene recommendations using a hand gel dispenser prominently placed by the entrance door (see Fig. 7.2). A randomized controlled trial was conducted. Twelve different sessions of three hour observations were undertaken with intervention category randomized using a random number generator (www.random.org). Four sessions of observations were undertaken for each of the different intervention arms (control, olfactory prime, visual prime) (See Figure 7.4 for Consort flow diagram) To try and account for different staff/visitor mixes, all observed sessions took place between 9am to 5pm on week-days. A 24-hour break was held between individual sessions.

Figure 7.2: Entrance to the Intensive Care Unit