Sociotechnical Analysis of a Neonatal ICU in the Context of CPOE Barbara Sheehan, RN CPNP, Peter Stetson, MD MA, Adam Wilcox, PhD, Philip L. Graham III, MD MSc, Leanne Currie, RN DNSc School of Nursing, Dept. of Biomedical Informatics, Dept .of Medicine, Dept. of Pediatrics Columbia University; and New York-Presbyterian Hospital, New York, New York. • NICU babies are vulnerable to prescribing error due to: • complex calculations required for dosing • urgency of treatment • lack of clear diagnostic indicators of disease • Information technologies have been shown to prevent errors when carefully planned and implemented. • Lack of attention to sociotechnical factors has been attributed to system failures and possible increases in errors. Background Methods • Ethnographic observations, key informant interviews and focus groups were conducted in 2 metropolitan NICUs between January and June 2008. • Attending neonatologists, neonatal fellows, pediatric residents, nurses, nurse practitioners, and pharmacists were included for a total of 33 clinicians. • A total of 48 hours of ethnographic observations were carried out at various time points during the day. • Content analysis was performed looking for themes related to organizational core task and organizational culture. • A model developed by Reiman and Odewald was used to categorize the themes. Acknowledgements: The Electronic Communication for Antimicrobial Management (ECAM) project is supported by NINR R21 NR010823-01 and is part of the Center for Interdisciplinary Research for Antimicrobial Resistance (CIRAR) Results Objective • The aim of this study was to examine the sociotechnical environment of the Neonatal intensive care unit (NICU) prior to the development of decision support for antibiotic prescribing. Implications for Further Research • The organizational core task identified was to “save the baby”. This is the driver for all protocols and plans of care. • Activities are focused around the core task and are carried out in the face of vague symptoms, complex problems, multi-tasking and with multiple technologies. • Information communication technologies (ICT) are part of organizational culture and have a significant impact on the core task. • Characteristics of organizational culture included mentoring, and adapting based on higher level decision-makers. • Decisions are made by the attending, but the orders are written by the NP or Resident – this poses a challenge for computerized clinical decision support within CPOE. • In-depth investigations into social processes involved in decision-making may help to better understand how technology can best support these processes. • The best methods for providing decision support in the NICU setting need to be identified. Conclusions Structure of Work: Multidisciplinary rounds, Team shift report, Multiple interruptions, Highly technical tools, Hierarchical decisions Organizational Climate: Mentoring and education, Collaboration Organizational inefficiencies Conceptions about Work Demands: Pride in practice Team integrity Organizational Culture Organizational Core Task Objective of Work: Save the baby Prevent morbidity Feed and grow Characteristics of Work: Complex, Variable, Vague External Influences: Parents/Families Corporate organization Regulatory requirements Media Culture-Task Continuum in the Neonatal ICU Themes and Related Quotes Organizational Core Task Organizational Culture Characteristics of Work : Vague signs & symptoms “If you’ve ever seen a pre-term infant die of gram negative sepsis where in 2 hrs…… it’s really horrendous…anytime these kids do anything…they don’t give you a clear sense that they’re septic. Whatever they’re doing it all presents the same way.” Organizational Climate : Mentoring and education “ The continuing education piece here is big.” “We have a pretty good way of doing it. We have a very understood way of doing it. I know that we all have it in our brains.” Objective of Work : Save the baby “It always goes back to how sick is this baby at this time and then navigate from there.” Conception about Work Demands : Pride in practice & Team integrity “We have a good continuity of care…those are our babies, those are yellow (Nurse Practitioner) team babies.” External Influences : Regulatory requirements & corporate organization “ID (infectious disease) and epidemiology [have an] issue with us treating culture- negative infections. One of the hospital initiatives is to reduce our rate of blood stream infections that’s…....a QI project with JCAHO.” Structure of Work : Hierarchical decisions “If there’s an issue, it’s between us, the fellows and the attending.” Way of Responding to Tasks: Multitasking and collaborative information gathering Collective Sense Making: Creation of NICU policies (formal & informal) References 1. Berg, M. Patient care information systems and healthcare work: a sociotechnical approach. International Journal of Medical Informatics. 1999:55(2):87-101. 2. Reiman, T. Oedewald, P. Assessment of complex sociotechnical systems. Theoretical issues concerning the use of organizational culture and organizational core task concepts. Safety Science. 2007:45(7): 745-768.