WATCH ME GROW

Improving patient and family engagement throughout recovery from a stay in the intensive care unit

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The Problem

A stay in an intensive care or biocontainment unit (ICU and BCU respectively) is a traumatic experience that has short- and long-term effects on patients and their family members. 

Patients experience severe physical deconditioning, their cognitive abilities are impaired, and they are at risk for developing anxiety, depression, and post-traumatic stress disorders. Patients are also typically unable to remember factual events from their stay and thus develop unrealistic ambitions for their recovery.

Families are deeply affected by the traumatic memories of their loved ones in these conditions, which is worsened by the lack of communication and comprehension of the situation. In biocontainment units, families are not allowed to enter the room, which removes them further. Without adequate information, family members develop an overprotective fear of relapse, showing a high risk of anxiety for months after the event. 

There is a need for better patient and family engagement throughout the recovery process in such units. 

 

The Process

This project followed an evidence-based design process where input from healthcare providers was sought out every step of the way. 

 

Research

Understanding healthcare delivery requires a systems thinking approach as it is a large and complex socio-technical system. Changing one element of the system is bound to have ripple effects on a number of other elements from all the linkages and interactions at play. 

First, we partnered with clinicians to map out the typical journey of a patient and their family from intake to an intensive care unit through to discharge. In doing so, we identified all stakeholders, their movements and interactions, as well as all tools and technologies used and moved around the medical floors. 

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We then went to visit the (empty) biocontainment unit at Emory Hospital and a cardiac intensive care unit at Piedmont Hospital. This enabled us to get a more practical understanding of the environment, how fast-paced it was, the noise, the number of machines, the presence and absence of family members.

At Piedmont, we were also able to carry out three contextual inquiries, two with nurses and one with the wife of a patient. Those proved extremely invaluable as they provided meaningful insights about how family and healthcare providers interact in those emotionally-charged environments, and we started identifying opportunities for improvements. 

Notes from site visits

Notes from site visits

Putting it all together

Putting it all together

For a more visual interpretation of our freshly acquired knowledge, we used the System Engineering Initiative for Patient Safety (SEIPS) 2.0 model, a human factors framework for studying and improving the work of healthcare professionals and patients. 

SEIPS Model for healthcare delivery in intensive care units, with a focus on patient and family engagement

SEIPS Model for healthcare delivery in intensive care units, with a focus on patient and family engagement

At this point, we identified the phase of recovery as one where a lot could be done to improve support for patients and their families. We decided to look deeper at this issue and performed an extensive literature review on the subject. Again, to see the bigger picture, we visualized the problem space as shown below. In doing so, we identified a combination of barriers to short- and long-term recovery, and we set out to create something that would overcome said barriers. 

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Before moving on to the design phase, we looked at the competitive market. This revealed there are currently no products, tools, or support systems in place providing adequate patient and family engagement throughout recovery in intensive care units. 

 

Solution Ideation 

We approached the ideation process by doing quick individual brainstorm sessions followed by group debriefings of ideas we had come up with. Those sessions were extended design sprints in a way, except that we were trying to think in terms of a system solution rather than purely a tool or device. The debriefings allowed us to knit together a meaningful solution, using the best parts of different ideas.

We converged on the idea of using nature as a growth metaphor in a recovery incentive program that would encourage a holistic approach to recovery - physical, cognitive, and emotional. Once that was settled, with the help of healthcare providers, we went through a series of iterations. 

A major point where expert feedback changed our solution for the better was in going from a physical tree on a wall in the room to a digitalized version. This was suggested as a way to automate the process as much as possible for a more seamless integration in the hospital staff's workflow to ensure a higher adoption rate. 

Prototype of the Physical Tree version

Prototype of the Physical Tree version

Digital version of the tree

Digital version of the tree

 

Final Concept Specifications & High-Fidelity Prototype: Watch Me Grow 

Watch Me Grow builds onto the existing system of setting daily goals for the patient's recovery, tracking and visualizing patient achievements through the metaphor of a growing tree. Currently, during rounds, the care team establishes the daily goals and records them on a whiteboard, like the one shown in the image below. However, with the whiteboard, goals are erased at the end of the day and there is no cumulative tracking of the recovery progress. 

 
Typical whiteboard in an intensive care unit room

Typical whiteboard in an intensive care unit room

 

This is where the tree visualization comes in. Whenever a goal is added to the list, the tree grows a new bud. Once the goal is completed, the bud blossoms into a leaf. At any point in time, the tree embodies and documents the full progress of the patient's recovery. The tree imagery was chosen based upon research linking nature-related images with a reduction in stress, improvements in emotional functioning, and increased recovery rates — all welcome benefits in our problem space!

Due to a growing trend of incorporating smart projectors and smart boards in hospital room designs, we decided to use this technology for the Watch Me Grow system. A virtual design streamlined the entire care process, reducing unnecessary work that the staff might have otherwise experienced and providing more options for communication. 

Three types of goals can be added — physical, cognitive, or emotional — to encourage a holistic approach to recovery. By encoding each goal type with a different color and leaf shape, the aim is to be able to tell at a glance where the patient is in the recovery overall. 

Once the goal is completed, it can be checked off. The smart projector picks up the check mark and turns the corresponding bud into a leaf. 

Finally, Watch Me Grow offers a privacy mode, which enables the patient or family to temporarily hide sensitive medical information that is normally displayed on the tree. This can be useful when the patient receives visits from friends for example. 

Watch Me Grow demo on the smart projector

Watch Me Grow demo on the smart projector

An accompanying mobile application allows the family to remotely track the patient’s recovery progress by displaying the achieved recovery goals on the tree. The mobile application offers the default tree view and an alternative list view that can be sorted by date or category. In the tree view, clicking on a leaf shows detailed information of the corresponding achieved goal and allows family members to interact with the patient and provide social appraisal by adding comments, photos, or videos as attachments. Notifications of newly achieved goals or comments can be toggled on and off.

Mobile application wireframes and flows

Mobile application wireframes and flows

The following storyboard highlights the main points of interaction with the Watch Me Grow system on both media on a typical day of recovery in an intensive care unit.

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Value Analysis

True to the evidence-based design process, based on feedback from experts and existing research, we looked at the value Watch Me Grow could add to intensive care and biocontainment units. 

On a high-level, the system offers value in two key areas: the visualization of the recovery process and the communication of the recovery process. 

Visualization enables the patient and family to track achievements and progress over time. The application motivates the patient by providing instant, augmented feedback in the form of visual incentive and social appraisal. It also mitigates the feelings of helplessness a patient experiences by providing them with a sense of control over their rehabilitation. Finally, the tree tracks incremental improvements which reduces staff burnout and encourages them to fully invest in the patient’s recovery.

Communication consists of the goal-tracking feature and the messaging feature. Through the goal-tracking feature, Watch Me Grow fills in patient memory gaps by serving as an “Intensive Care Unit diary” and reducing the long-lasting effects of delirium and unconsciousness. Goal-tracking also manages the patient’s unrealistic recovery expectations and the family’s overprotective concerns. The messaging feature enables family members to track the patient’s progress remotely as well, which is essential in the biocontainment unit.

The visualization below provides our value statement in a more digestible format. 

 

Future Developments

The way we see it, this is just the beginning. We have a few ideas for improving the product in the future.

One idea is to offer customizable themes for the recovery process such as a city solar system, painting, etc. Another is to integrate the system with the interdisciplinary plan of care by recording daily progress in the electronic medical record. Finally, we want to add additional communication functionalities to make information exchange between family members easier

We presented our concept to the healthcare community of Atlanta during a showcase at the SimTigrate Design Lab in December 2016 where Watch Me Grow received an enthusiastic response. Regarding application functionality, the audience proposed creating more flexible filtering options, adding administration controls, and providing improved accessibility options. 

We are currently looking at taking Watch Me Grow to the next stage, with potentially launching and testing it full-scale in a local hospital.