Download PDF
Appl Clin Inform 2017; 08(02): 632-650
DOI: 10.4338/ACI-2016-12-RA-0209
Research Article
Schattauer GmbH

Developing Mobile Clinical Decision Support for Nursing Home Staff Assessment of Urinary Tract Infection using Goal-Directed Design

Wallace Jones
1   University of Colorado School of Medicine
,
Cynthia Drake
1   University of Colorado School of Medicine
,
David Mack
1   University of Colorado School of Medicine
,
Blaine Reeder
2   University of Colorado College of Nursing
,
Barbara Trautner
4   Section of Infectious Diseases, Departments of Medicine and Surgery, Baylor College of Medicine, Houston, Texas, USA
,
Heidi L Wald
1   University of Colorado School of Medicine
› Author Affiliations Funding This work was supported by the Infectious Diseases Society of America Student Fellowship (WJ) and a grant from the COPIC Foundation.
Further Information

Publication History

received: 07 January 2017

accepted: 02 April 2017

Publication Date:
21 December 2017 (online)

   Permissions and Reprints

Summary

Background: Unique characteristics of nursing homes (NHs) contribute to high rates of inappropriate antibiotic use for asymptomatic bacteriuria (ASB), a benign condition. A mobile clinical decision support system (CDSS) may support NH staff in differentiating urinary tract infections (UTI) from ASB and reducing antibiotic days.

Objectives: We used Goal-Directed Design to: 1) Characterize information needs for UTI identification and management in NHs; 2) Develop UTI Decide, a mobile CDSS prototype informed by personas and scenarios of use constructed from Aim 1 findings; 3) Evaluate the UTI Decide prototype with NH staff.

Methods: Focus groups were conducted with providers and nurses in NHs in Denver, Colorado (n = 24). Qualitative descriptive analysis was applied to focus group transcripts to identify information needs and themes related to mobile clinical decision support for UTI identification and management. Personas representing typical end users were developed; typical clinical context scenarios were constructed using information needs as goals. Usability testing was performed using cognitive walk-throughs and a think-aloud protocol.

Results: Four information needs were identified including guidance regarding resident assessment; communication with providers; care planning; and urine culture interpretation. Design of a web-based application incorporating a published decision support algorithm for evidence-based UTI diagnoses proceeded with a focus on nursing information needs during resident assessment and communication with providers. Certified nursing assistant (CNA) and registered nurse (RN) personas were constructed in 4 context scenarios with associated key path scenarios. After field testing, a high fidelity prototype of UTI Decide was completed and evaluated by potential end users. Design recommendations and content recommendations were elicited.

Conclusions: Goal-Directed Design informed the development of a mobile CDSS supporting participant-identified information needs for UTI assessment and communication in NHs. Future work will include iterative deployment and evaluation of UTI Decide in NHs to decrease inappropriate use of antibiotics for suspected UTI.

Citation: Jones W, Drake C, Mack D, Reeder B, Trautner B, Wald HL. Developing mobile clinical decision support for nursing home staff assessment of urinary tract infection using goal-directed design.Appl Clin Inform 2017; 8: 632–650 https://doi.org/10.4338/ACI-2016-12-RA-0209

Keywords

Antimicrobial stewardship - urinary tract infections - clinical decision support - goal-directed design - nursing home - communications

Clinical Relevance Statement

This study indicates that healthcare providers in the NH context are eager to be engaged in the design, development, and evaluation of information systems that support their work and decision making. Furthermore, results suggest that eCDSS could be successfully adopted in this context and integrated into the existing UTI diagnostic and management workflow in NHs.


Human Subjects Protections

The study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects, and was reviewed by the Colorado Multiple Institutional Review Board.


 

  • References

  • 1 Centers for Medicare & Medicaid Services (CMS), HHS. ,,Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities. Final rule.“ Federal register 2016; 81 (192) 68688.
    PubMedGoogle Scholar
  • 2 Morrill HJ, Caffrey AR, Jump RL, Dosa D, LaPlante KL. Antimicrobial stewardship in long-term care facilities: A call to action. J Am Med Dir Assoc 2016; 17 (02) 183-e1.
    PubMedGoogle Scholar
  • 3 Crnich CJ, Jump R, Trautner B, Sloane PD, Mody L. Optimizing antibiotic stewardship in nursing homes: a narrative review and recommendations for improvement. Drug & Aging 2015; 32 (09) 699-716.
    PubMedGoogle Scholar
  • 4 Dwyer LL, Harris Kojetin LD, Valverde RH, Frazier JM, Simon AE, Stone ND, Thompson ND. Infections in long term care populations in the United States. J Am Geriatr Soc 2013; 61 (03) 341-349.
    CrossrefPubMedGoogle Scholar
  • 5 Nicolle LE. Asymptomatic bacteriuria in the elderly. Infect Dis Clin North Am 1997; 11 (03) 647-662.
    CrossrefPubMedGoogle Scholar
  • 6 Nicolle LE. Urinary tract infections in long-term care facilities. Infect Control Hosp Epidemiol 1993; 14 (04) 220-225.
    CrossrefPubMedGoogle Scholar
  • 7 Nicolle LE, Mayhew WJ, Bryan L. Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria in institutionalized elderly women. Am J Med 1987; 83 (01) 27-33.
    PubMedGoogle Scholar
  • 8 Abrutyn E, Mossey J, Berlin JA, Boscia J, Levison M, Pitsakis P, Kaye D. Does asymptomatic bacteriuria predict mortality and does antimicrobial treatment reduce mortality in elderly ambulatory women?. Ann Intern Med 1994; 120 (10) 827-833.
    CrossrefPubMedGoogle Scholar
  • 9 Courjon J, Pulcini C, Cua E, Risso K, Guillouet F, Bernard E, Roger PM. Antibiotics-related adverse events in the infectious diseases department of a French teaching hospital: a prospective study. Eur J Clin Micro-biol Infect Dis 2013; 32 (12) 1611-1616.
    CrossrefPubMedGoogle Scholar
  • 10 Werner NL, Hecker MT, Sethi AK, Donskey CJ. Unnecessary use of fluoroquinolone antibiotics in hospitalized patients. BMC Infect Dis 2011; 11 (01) 1.
    CrossrefPubMedGoogle Scholar
  • 11 Shlaes DM, Gerding DN, John JF, Craig WA, Bornstein DL, Duncan RA, Eckman MR, Farrer WE, Greene WH, Lorian V, Levy S. Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: Guidelines for the prevention of antimicrobial resistance in hospitals. Clin Infect Dis 1997; 25 (03) 584-599.
    CrossrefPubMedGoogle Scholar
  • 12 Trautner BW, Grigoryan L, Petersen NJ, Hysong S, Cadena J, Patterson JE, Naik AD. Antimicrobial Stewardship Approach for Urinary Catheter-Associated Asymptomatic Bacteriuria. JAMA Intern Med 2015; 175 (07) 1120-1127.
    CrossrefPubMedGoogle Scholar
  • 13 Moja L, Kwag KH, Lytras T, Bertizzolo L, Brandt L, Pecoraro V, Rigon G, Vaona A, Ruggiero F, Mangia M, Iorio A. Effectiveness of computerized decision support systems linked to electronic health records: a systematic review and meta-analysis. Am J Public Health Res 2014; 104 (12) e12-e22.
    PubMedGoogle Scholar
  • 14 Forrest GN, Van Schooneveld TC, Kullar R, Schulz LT, Duong P, Postelnick M. Use of electronic health records and clinical decision support systems for antimicrobial stewardship. Clin Infect Dis 2014; 59 (03) S122-S133.
    CrossrefPubMedGoogle Scholar
  • 15 Abramson EL, McGinnis S, Moore J, Kaushal R. A statewide assessment of electronic health record adoption and health information exchange among nursing homes. Health Serv Res 2014; 49 1pt2 361-372.
    CrossrefPubMedGoogle Scholar
  • 16 Cooper A, Reimann R, Cronin D, Noessel C. About face: the essentials of interaction design. John Wiley & Sons; 2014
    Google Scholar
  • 17 Pruitt J, Grudin J. Personas: practice and theory. Paper presented at: Conference on Designing for user experiences; 2003
    PubMedGoogle Scholar
  • 18 Turner AM, Reeder B, Ramey J. Scenarios, personas and user stories: User-centered evidence-based design representations of communicable disease investigations. J Biomed Inform 2013; 46 (04) 575-584.
    CrossrefPubMedGoogle Scholar
  • 19 Reeder B, Turner AM. Scenario-based design: A method for connecting information system design with public health operations and emergency management. J Biomed Inform 2011; 44 (06) 978-988.
    CrossrefPubMedGoogle Scholar
  • 20 Reeder B, Zaslavksy O, Wilamowska KM, Demiris G, Thompson HJ. Modeling the oldest old: personas to design technology-based solutions for older adults. Paper presented at: AMIA Annual Symposium Proceedings; 2011
    PubMedGoogle Scholar
  • 21 Carroll JM. Making use: scenario-based design of human-computer interactions. MIT press; 2000
    Google Scholar
  • 22 Reeder B, Demiris G. Building the PHARAOH framework using scenario-based design: a set of pandemic decision-making scenarios for continuity of operations in a large municipal public health agency. J Med Syst 2010; 34 (04) 735-739.
    CrossrefPubMedGoogle Scholar
  • 23 Carroll JM, Rosson MB. Getting around the task-artifact cycle: How to make claims and design by Scenario. ACM Trans Inf Syst 1992; 10 (02) 181.
    CrossrefPubMedGoogle Scholar
  • 24 Carroll JM. Scenario-based design: envisioning work and technology in system development. New York: Wiley; 1995
    Google Scholar
  • 25 Cooper A. The inmates are running the asylum. Indianopolis, IN: Sams; 1999
    Google Scholar
  • 26 Reeder B, Hills RA, Turner AM, Demiris G. Participatory design of an integrated information system design to support public health nurses and nurse managers. Public Health Nurs 2014; 31 (02) 183-192.
    CrossrefPubMedGoogle Scholar
  • 27 Filippidou D. Designing with scenarios: a critical review of current research and practice. REQUIR ENG 1998; 3 (01) 1-22.
    CrossrefPubMedGoogle Scholar
  • 28 Flynn KE, Hahn CL, Kramer JM, Check DK, Dombeck CB, Bang S, Perlmutter J, Khin-Maung-Gyi FA, Weinfurt KP. Using central IRBs for multicenter clinical trials in the United States. PLoS One 2013; 8 (01) e54999.
    CrossrefPubMedGoogle Scholar
  • 29 Trautner BW, Bhimani RD, Amspoker AB, Hysong SJ, Garza A, Kelly PA, Payne VL, Naik AD. Development and validation of an algorithm to recalibrate mental models and reduce diagnostic errors associated with catheter-associated bacteriuria. BMC Med Inform Decis Mak 2013; 13: 48.
    CrossrefPubMedGoogle Scholar
  • 30 Davis FD. Perceived usefulness, perceived ease of use, and user acceptance of information technology. MIS Q 1989: 319-340.
    PubMedGoogle Scholar
  • 31 Stone ND, Ashraf MS, Calder J, Crnich CJ, Crossley K, Drinka PJ, Gould CV, Juthani-Mehta M, Lauten-bach E, Loeb M, MacCannell T. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria. Infect Control Hosp Epidemiol 2012; 33 (10) 965-977.
    CrossrefPubMedGoogle Scholar
  • 32 Yen P-Y, Bakken S. Review of health information technology usability study methodologies. J Am Med Inform Assoc 2012; 19 (03) 413-422.
    CrossrefPubMedGoogle Scholar
  • 33 Kaufman DR, Patel VL, Hilliman C, Morin PC, Pevzner J, Weinstock RS, Goland R, Shea S, Starren J. Usability in the real world: assessing medical information technologies in patients’ homes. J Biomed Inform 2003; 36 (01) 45-60.
    CrossrefPubMedGoogle Scholar
  • 34 Jaspers MW, Steen T, van Den Bos C, Geenen M. The think aloud method: a guide to user interface design. Int J Med Inform 2004; 73 (11) 781-795.
    CrossrefPubMedGoogle Scholar
  • 35 Turner AM, Reeder B, Wallace JC. A resource management tool for public health continuity of operations during disasters. Disaster Med Public Health Prep 2013; 7 (02) 146-152.
    CrossrefPubMedGoogle Scholar
  • 36 Turner CW, Lewis JR, Nielsen J. Determining usability test sample size. International encyclopedia of ergonomics and human factors 2006; 3 (02) 3084-3088.
    PubMedGoogle Scholar
  • 37 Virzi RA. Refining the test phase of usability evaluation: How many subjects is enough?. Hum Factors 1992; 34 (04) 457-468.
    CrossrefPubMedGoogle Scholar
  • 38 Lewis JR. Sample sizes for usability studies: Additional considerations. Hum Factors 1994; 36 (02) 368-378.
    CrossrefPubMedGoogle Scholar
  • 39 Nielsen J, Landauer TK. A mathematical model of the finding of usability problems. In: Proceedings of the INTERACT‘93 and CHI‘93 conference on Human factors in computing systems. 1993 May 1 (pp. 206–213). ACM.
    PubMedGoogle Scholar
  • 40 Nielsen J. Estimating the number of subjects needed for a thinking aloud test. International journal of human-computer studies 1994; 41 (03) 385-397.
    PubMedGoogle Scholar
  • 41 Boyatzis RE. Transforming qualitative information: Thematic analysis and code development. Sage; 1998
    Google Scholar
  • 42 Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005: 643-54.
    PubMedGoogle Scholar
  • 43 Gilbert DN, Chambers HF, Eliopoulos GM, Saag MS, Pavia AT, Black D. The Sanford Guide to Antimicrobial Therapy 2016. Sperryville, VA: Antimocribal Therapy; 2016
    Google Scholar
  • 44 Haig KM, Sutton S, Whittington J. SBAR: a shared mental model for improving communication between clinicians. Jt Comm J Qual Saf 2006; 32 (03) 167-175.
    PubMedGoogle Scholar
  • 45 Agency for Healthcare Research and Quality. Communicating a change in a resident‘s condition. Rockville, MD.
    PubMed
  • 46 Tariq A, Gerogiou A, Westbrook J. Enabling seamless information exchange: Lessons from implementation of electronic medication administration records in residential aged care facilities. Proceedings 19th Triennial Congress of the IEA. Melbourne, 9–14 August, 2015
    PubMedGoogle Scholar