I. INTRODUCCIÓN
1.3 Teorías relacionadas al tema
Data from the handover observation of the ambulance crew to ED staff revealed that (42/74) 56.7%, preferred the electronic handover of patients information on the paper one, in other words, preferred using the ePRF on the PRF, for more detail see Section 9.2. Yet still ambulance crew had mixed views about the benefits from using the ePRF. In particular:
1. All participants think it is time consuming and it takes a long time to complete.
Five participants stated that it is comprehensive and covers everything.
2. Some consider the ePRF as a detailed legal medical document, and some view it as a sophisticated system that is too detailed, which can then lead to information overload.
3. The ePRF has more fields than the paper PRF, however, some of these require information that is beyond the crews’ training and ability to assess.
4. The format of the PRF ensures the included data is concise and that the most important information needed is highlighted, whereas the volume of informa-tion requested by the ePRF on multiplicity of ‘pages’ on the screen can cause important information to be lost in the details.
Four themes emerged from the thematic analysis of the combined interviews and observations of the ambulance crew regarding communication and information transfer of the ePRF system. The thematic analysis of the data revealed:
1. Connection Availability: If connectivity is not available, the ambulance crew face the challenge of finding a way to connect their Toughbook (that holds the ePRF) to the system to download a patient’s incident initial information and/or upload the finalised ePRF. Finding workarounds to overcome those
obstacles adds more time and stress to the job. For instance, after completing a handover in ED, paramedics sometimes need to connect the Toughbook to the Docking Station in order to download the patient’s incident initial information, where this has failed to download previously due to connection failure. They will also try to reboot the system if the screen freezes or the system does not respond. They will even go outside the ED in order to make a connection. All that might happen more than once in a 12-hour shift. The need to reboot the system, attach the Toughbook to the Docking Station at the ED, and enter the patient’s information manually increase the delay in making the ambulance crew available for the next job. A interviewee paramedic stated that one of the problems they face is:
“Connectivity sometimes with the Toughbook, because if you are in a bad communication area, or for whatever reason it’s not down-loading the information, sometimes we end up having to manually put all the information in, which is time consuming... Sometimes if you’ve got either connectivity issues, where the Toughbook got more than 500 packets a day waiting to be sent or received, and you’ve get two little red balls on it, and it’s got no internet, no connectiv-ity, you’ve either got to wait till you get to the hospital, they have a database station (Docking Station) where you can log it in, and hopefully it should download the information, but if the system is down totally, which frequently happens, then the only way to do it is manually.”
Another interviewee paramedic stated that she downloads information from the Docking Stations installed in EDs if connectivity was lost:
“....and we just put it (Toughbook) in there (Docking Station) and it downloads all the information.”
2. Job Type: The two job categories are red jobs, which are life threatening incidents requiring an eight minute response rate, or green jobs, which are not
deemed to be life threatening, and for which the response rate can be between 20 minutes to 60 minutes depending on the patient’s condition. Table 5.1 displays the type of response for each category which have been prioritized into nationally agreed categories according to the situation. The job category also affects the crews’ availability to be assigned to another incident and a call-out, and hence can reduce the numbers of ambulance crews available for other incidents. It seems more reasonable to have two different ePRF formats compatible with the incident category, complex for red jobs, and simple for green jobs. In an interview, the paramedic’s reply to the question ‘how long do you typically spend entering all the information about the patient into the ePRF?’ was:
“It totally depends on the sort of incidence it is, if it is a straight forward incident and depending on the individual paramedic, .... If it’s a major job i.e. uses a resuscitation, or a major trauma in-cident, or a major medical emergency if we take them in through resuscitation they will may probably take a lot longer ”
3. Ease of Data Entry: Entering the data in the ePRF while travelling to ED might also distract a paramedic from observing the patient or providing care. This is due to the fact that doing such a job requires attention and focus because different tabs and boxes may have to be filled or chosen, involving scrolling up and down and clicking on other tabs with different information requirements.
Two factors that affect patient data entry time were identified. The first is the type of format being used whether electronic (ePRF) or paper (PRF).
According to the interviewees the ePRF takes at least 20 minutes to complete on average; one paramedic reported that in complex ‘outlier’ cases completion can take up to three hours. In contrast, the PRF takes on average five to ten minutes to complete, depending on how complicated the job is. As a consequence, the PRF has sometimes been used by paramedics to buy time by claiming that the ePRF is not working. However, although the time spent
completing the PRF is less than that needed for the electronic one, it might not ensure legibility as the ePRF does.
The second factor that affect patent data entry is the job category. If the job is a green incident (not life threatening), then the paramedic can complete entering the data en-route, but if it is a trauma or a complicated red job (life threatening), where time is needed to provide care to the patient, then entering the data may not be possible until the patient is handed over to ED care. A paramedic in an interview stated that entering data in the ePRF is not as easy compared to the paper format:
“In the sense of inputting data in the ePRF, that is time consum-ing compared to a soft format (PRF) where you just write it yourself.
(The PRF) is free flow you could just write it.... but most of us finds it time consuming to complete it...compared to the paper ”
4. Technical Issues: Ambulance crews also have identified other technical is-sues related to hardware, software, and/or malfunctions. The problems en-countered while using the Toughbook may be either technical, physical, and/or personal. Technical and/or physical problems include: running out of bat-tery charge, Toughbook damage, software updates, data insertion to ePRF, navigation issues and rigidity with the ePRF system, dropping it, facing a technical glitch, unresponsive system and out of date devices that are more than four years old. The personal issues are reflected thorough the threat to data accuracy when spelling errors occur. Data accuracy can be a problem when spelling errors mislead readers and potentially contribute to treatment error (though this is not unique to the ePRF). Medication error may lead to disability, death, and unnecessary health processes (Courtenay and Griffiths, 2009). One paramedic interviewee stated that she once broke her Toughbook unintentionally, she said:
“In an ambulance they (Toughbook) are stored in the back, on a secure house and then in a car, this is stored on the floor on the passenger seat, so that they do not move around. Because I forgot
last week and left it on the seat and went, weeeeee, straight to the floor when I hit the brakes”
Another paramedic stated the technical difficulties he faces with the Tough-book:
“We are only supposed to use the PRF if the ePRF is not work-ing, but then it’s only if it’s (Toughbook) actually physically broken.
Frequently what happens is they don’t charge up enough on the vehi-cles and we don’t have the cables to do it when we are back on base during a break to give it a boost, so eventually if you’re on it too long the batteries die.”
8.3 Summary
The final phenomenological approach was focused on the ambulance crew. Elic-iting their requirements were in two sets. The first set was regarding an existing information transfer system of the ePRF. The second was their requirements from the IB interface. Ambulance crew wanted the IB interface to be simple, easy to nav-igate, view, and use. They also required specific patient information to be displayed to support their decision-making while on scene. Other information they required were patients’ previous encounters with external healthcare providers and/or the the ambulance service. Findings from the ambulance crew from the ePRF study were issues related to connection, job type, easy of data entry, and technology.
Findings from this chapter and the previous three, Chapters5,6, and7, were to answer the second research question, which is investigating issues of the sociotechni-cal aspects surrounding the information transfer system. The three approaches were triangulated in order to form background basis for the study of the IB prototype, and therefore assisted in answering the first research question.