Do mobile computing carts fit well into the workflow of hospital clinicians? And have ergonomic and design flaws limited their usefulness?
Those are questions CIOs, hospital ergonomists and clinical informatics professionals face each time they weigh product options and work with implementation teams.
There's no doubt that the size and maneuverability of carts can impact how nurses - the main day-to-day users of mobile computing carts - perceive their value. After all, nurses walk up to five miles per 10-hour shift, according to a 2008 multisite study by the St. Louis-based Ascension Health and Oakland-based Kaiser Permanente. Pushing, pulling and adjusting the height of a mobile workstation can add to the physical strain of nurses, who already see disabling back injuries as among their top workplace concerns.
“The ergonomics of carts is absolutely an issue that draws complaints from nurses,” says Judy Murphy, R.N., vice president-IS applications at Aurora Health Care in Milwaukee. “There really aren't any great solutions.”
Murphy, who is also a registered nurse, has helped Aurora implement more than 1,300 mobile carts over the past few years. Aurora has more than 25,000 employees at facilities throughout eastern Wisconsin, including a dozen acute care hospitals, a psychiatric hospital, and more than 100 clinics.
Although the health system implemented workstations on wheels (WOWs) several years ago, its nurses had never used them in quite the way hospital planners had anticipated. Because they were bulky and challenging to maneuver in and out of rooms, the nurses tended to leave them in the hallways as they moved from one patient room to the next.
But a 2007 project to introduce bar-coded medication administration forced a re-evaluation of the carts, Murphy recalls. “The cart has to be moved to the patient's bedside so the nurse could scan the patient's wristband,” she explains. That meant no more parking the WOW in the hallway. Nurses soon started to complain about the process change.
Murphy worked with a care transformation team to study options. “We found ergonomic issues about maneuvering them down hallways and into thresholds of rooms,” she notes. “You have some in which the hydraulics start to fail, which becomes an issue for adjusting the height either for one user or between users.”
The team studied many options, including a computer on a fixed arm on a wall of every room, which nurses rejected for ergonomic reasons. As a compromise, the team decided to adopt a smaller cart with a smaller laptop and leave it in the room. “It is more costly to have a computer in every room,” she adds, “but it eliminates the issue of nurses having to go back out in the hallway where they left the cart.”
Murphy stresses that there are no perfect solutions because the cart has to be integrated into the workflow. “Medication administration is the most difficult workflow, because you have the cart, the patient and the medication storage, and it is a process of hunting and gathering. The cart bears the brunt of criticism because it is the biggest thing in the way of cleanly administering medications.”
Russ Branzell, CIO and vice president of information systems at 427-bed Poudre Valley Health System, in Fort Collins, Colo., says his organization, which has 500 mobile computing carts in use, has learned from experience to focus on adjustability of a cart's design - everything from the ability of the carts to move up and down laterally to hand position and screen position.
“We put one cart in our emergency department, where one doc was 4-foot 11 inches and one was 6 foot 10 inches, he recalls. “Not everybody's 5 foot 8 inches and has the same arm length and likes to look at the screen in the same way,” Branzell says. For ergonomic reasons, Poudre Valley also has learned to study how users push the carts and whether any carts had a tendency to tip over. “We didn't know any of that when we bought the carts five years ago,” Branzell says.
He suggests allowing users to experiment with lots of different models and possibly supporting several models depending on the task. “You might want a heavier device where very little movement is involved,” Branzell says. “In cases where they'Re moving from floor to floor, you'll need lighter carts.”
An Ergonomics Checklist
In 2004 Professor Alan Hedge, director of the Human Factors and Ergonomics Laboratory at Cornell University in Ithaca, N.Y., was working with an occupational therapist at two-hospital Finger Lakes Health in upstate New York. He noticed that the size and maneuverability issues related to computing carts were causing some nurses not to use them. “Some of the designs were pretty awful,” he recalls. That experience gave Hedge the idea of creating an ergonomics checklist for mobile computing carts. (http://ergo.human.cornell.edu/Pub/AHquest/CUCompCartEval.pdf.) “Because hospitals are not just ordering one or two of these, but sometimes hundreds,” he says, “we thought it would be useful to develop this checklist to help hospitals make sensible choices.”
After interviewing nursing executives and hospital ergonomists and studying the offerings from the major vendors, Hedge focused the checklist on the major issues that might involve the risk of injury due to poor posture or the need to apply too much force or if the cart is difficult to maneuver. Other issues to consider include whether the computer is located at a comfortable and adjustable height, and how easy it is to use the keypad or mouse.
The pushing and pulling is critical from an injury perspective, but so is what they are doing with the cart, he says. “You have to look at poor positioning of the screen and keyboard and the impact it can have on wrists and necks if they are at inappropriate angles.
One organization that has taken advantage of the Cornell checklist is the Occupational and Environmental Safety Office at Duke University and Health System, Durham, N.C. “We have had a number of issues with mobile carts in our hospitals,” says Tamara James, ergonomics director. The Duke system's three hospitals have several hundred carts in use, she says.
Nurses typically leave the carts out in the hallways when they enter patients’ rooms. “But that requires them to keep information in their heads as they go back and forth, which leaves open the potential for error,” she adds. “There is no great solution.”
Duke has tried some built-in alcoves with fold-down workstations in hallways, and has just started implementing some adjustable wall-mounted computers that are installed in the hallway and actually swing into the room on a long arm. “We like that it is so adjustable and flexible,” she says.
IT leaders grappling with these issues quickly recognize that they are just one part of an informatics team trying to solve a workflow issue. Or as Cornell's Hedge puts it, ergonomics “is not just the technology, it's where you put it.”
Healthcare Informatics 2010 July;27(7):34-35