A Perioperative Timeline
This timeline outlines the story of a fictional patient who is preparing for a hip replacement operation. The journey of our patient is used to explore how a wearable device could be introduced to monitor the patient's anxiety prior to the operation.
Patient: Carol Greenway
Carol is 58 years old, with a well-established career as a property manager and a portfolio of properties across Sussex and Surrey. Her job is important to her and she travels to properties two days a week by car in addition to her normal daily commute. Carol is an enthusiastic runner and has completed several marathons.
Referral to specialist
8 months ago, Carol started to experience pain and discomfort in her left hip while running and reported this to her doctor. She attended sports physiotherapy sessions and tried swimming as an alternative to running, but found that the pain increased and the movement in her hip became restricted. Her doctor referred her to a hip replacement specialist.
Once Carol's appointment with the specialist is confirmed, she is invited for a follow-up with a nurse at her doctors surgery. The nurse provides an overview of Carol's care plan including the choice to opt-in to the use of a wearable device for monitoring heart rate, breathing and electrodermal activity for use from the appointment through until the conclusion of recovery. Carol decides that she will wear the device as part of her care plan.
Consultation with specialist
Carol is examined by the hip replacement specialist, who determines that she will need the operation. She also meets her perioperative nurse, Brian who will monitor her vitals and anxiety levels through the wearable system. Brian asks how Carol is getting on with the wearable device, has she tried the app yet? Carol and Brian agree on her preferred method of contact as part of her pre-operative care plan.
Pre-operative assessment clinic
Brian asks Carol to complete the State-Trait Anxiety Inventory. Carol is concerned about the operation and how recovery might affect her work and independence. Brian notes that the wearable system has shown that Carol's anxiety has increased. Brian talks through the operative procedure with her and they agree that he will contact if her anxiety levels continue to rise.
Letter for date of operation
Carol receives a letter informing her of the date for her operation; this is both reassuring and worrying. She feels under-prepared for the operation and recovery. Brian notices a spike in her vitals and as previously agreed, sends a text message to check-in with her. After a follow-up call with Brian explaining things to arrange for her hospital visit and after care, she feels a lot better.
Outcome 1: Cancellation
Due to unforeseen circumstances at the hospital Carol's operation has to be cancelled and rescheduled. Unfortunately, the new date occurs when Carol will be abroad and the only other date is several months away. Carol is concerned about the level of pain that she will experience during the longer wait. The specialist and Brian consider pain management for the waiting period.
Outcome 2: As planned
The operation will take place as scheduled.
Day of operation
Carol feels ready for her operation, although a fire drill at the flats next door the night before causes her additional anxiety. Brian is concerned about Carol's levels and decides to move her operation to be first in the day. This will minimise her waiting time and will allow her daughter to pick her up and take her home as soon as she is cleared to leave.
Recovery and device return
Carol's daughter took time off work to support Carol's recovery and Brian continued to monitor her vitals, contacting her when needed. Initially, Carol was starting to move around too soon, but she could tell from the wearable app that this was contributing to increased heart and breathing rates. As a result, she took more time to recover and feels positive about the care that she received.
This site outlines a future service design and user experience project to be undertaken by F. MacNeill. The project is based on, and will contribute to, the ongoing research of Dr. Theofanis Fotis into the use of wearable devices and other technologies in the perioperative environment.
In 2016, Ofcom reported that 71% of UK adults owned a smartphone1. This can be viewed alongside smart watch ownership, which based on Ofcom's sample, are owned by 5% of UK adults2. When we look at these statistics in relation to our patient story above, the demographics do not quite match-up. Our patient is 58 years old and according to Ofcom the highest proportion of Smartphone owners are those under 553. This is intentional as our story is designed to pose a question, what will this adult population of under 55s need and expect in future years?
How will patients' experiences have been shaped by their use of wearable technologies and the mobile applications they use to manage many essential services as part of their lifestyle, such as banking and work?
of UK Adults look up health information online5.
Why Perioperative Care?
The rationale for this investigation into the use of a wearable devices to support pre-operative care, also termed as perioperative care, is supported by the following drivers:
- Perioperative anxiety is experienced by a high proportion of patients 6 7 8 9.
- Perioperative anxiety can pose serious risks, such as causing the patient to need more anaesthetic. It can also result in greater post-operative pain for patients, lengthened recovery and may increase the need for pain management medication. Furthermore, anxiety can contribute to a weakened immune system and therefore lead to a greater incidence of infection10.
- Patients spend less time in hospital than historically12, both in terms of the pre-operative period and upon discharge for recovery. This means that nurse to patient contact time is reduced making it harder to monitor the patient's anxiety and overall physical health; a wearable could help to support an active remote dialogue between patient and nurse and support diagnosis.
- As a use case, the application of a wearable device to monitor perioperative anxiety and overall health offers clear benefits and a tangible path for investigation.
Goal 1 : Explore
To find out if a consumer-level wearable device could be used as part of a perioperative care plan. The device and an accompanying service13 would be used to monitor a patient's vital signs, as a means to identify symptoms of anxiety and monitor overall health from the pre-operative phase through to recovery. What issues might be raised through the introduction of this disruptive technology? What problems could be solved? If this technology is introduced is there potential for improvement to service and care?
Goal 2 : Create
To conceive how a hypothetical wearable device could be used as part of a patient care plan during the lead up to an operative procedure. In the first instance we strive to understand the perspective of nurses; do they believe that consumer-level wearable devices have potential to be used and what are their reservations? Through user-focused co-design with nurses and other medical professionals we hope to define base requirements for such a system from the care provider's perspective.
Goal 3 : Requirements
To define a set of requirements for a wearable device and service designed to monitor perioperative anxiety. The requirements, accompanying research and recommendations will provide a compelling resource as NHS Trusts move towards the "user-centered" goals put forth in the recent National Advisory Group report, Making IT Work...14. It will also provide user-focused insight for device manufacturers and application developers who wish to create solutions for health contexts.
Technology in Health in the UK
This can also be considered alongside the recent influx of funding announced to establish 12 NHS trusts as global centres of digital excellence15. The funding was announced in the wake of an independent review and report by the National Advisory Group, entitled Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England, of the many recommendations outlined in the document the following quote is particularly relevant to this project.16
"...we endorse giving patients full access to their electronic data... We also favour creating easy ways for patients to download such data (in a computable format) for their own use, and to upload patient-generated data (via surveys, sensors, wearables, patient-reported outcome measures, and data from other apps) into their electronic record."
(National Advisory Group, 2016, p. 30)17.
With the adoption of both wearable devices and mobile health applications forecast to increase18, in spite of the significant technical challenges these disruptive technologies present, these trends cannot afford to be ignored.
Introducing the Research Team
Dr. Theo Fotis19 is a Nurse, Futurist and Digital Nursing evangelist. He is currently a Principal Lecturer at the School of Health Sciences, University of Brighton, Visiting Lecturer at the Polytechnic University of Hong Kong and Associate Lecturer at the Open University UK. He is the Editor in Chief of the British Journal of Anaesthetic & Recovery Nursing and Editor of the Brighton Journal of Health Sciences. He has more than 15 years of clinical experience in the perioperative environment. He has published numerous articles and book chapters, and is frequently an invited speaker at national and international events. Currently Theo is leading research projects on digital health focusing on anxiety measurements and implementation and use of digital tools/wearables at the “bedside” for patient’s benefit.
Fiona MacNeill20 is a part-time MSc User Experience Design student and a learning technologist. Her research focuses on the variance between users’ perceptual experience of technology and the operational nature of its use. She received her BA(hons) Fine Art from University of Kent in 2005, moving into creative digital media and then computing in 2009. MacNeill’s professional practice is founded on user-focused, design-grounded theory, coupled with consideration of privacy and trust issues, particularly in IoT, mobile and cloud computing. She has published work on design theory and mobile learning and has undertaken research and presented in the United States and Europe. In 2016, MacNeill was the recipient of a "highly commended" award in the ALT Learning Technologist of the year awards.
As a means to explore future service models we acknowledge, yet temporarily set aside IT infrastructure limitations21 as suitable information derived from wearable devices would ideally contribute to a patient electronic records system which may not yet be available. There is however precedent for independent developers to build applications and services which can have interoperability with existing systems where they are available, for example the echo app22 for repeat prescriptions and medication management, at the primary care level.
This project focuses on two possible use case scenarios for wearable devices as diagnostic and monitoring tools in a perioperative situation:
- Supplied: a wearable device supplied by the hospital, which is worn for the duration of care from the initiation of care plan, prior to the operation through to recovery. This requires that the patient owns a smartphone, tablet or laptop as at this time consumer-level wearables typically have to synchronise via Bluetooth and cannot operate independently.
- B.Y.O.D.: A Bring Your Own Device (B.Y.O.D.) approach23 , which could be facilitated through a bridging mobile application on the patients' smartphone that would allow the information from a variety of devices to be ported to a compatible format. This requires that the patient owns a compatible wearable device and a smartphone or tablet.
These scenarios will also consider the following factors of user experience from a nursing perspective.
Workflow in a clinical environment, such as but not limited to:
- perceived benefits and barriers
- impact on staff workload
- sanitation and device upkeep
- training and learning model for staff for the devices/system
- integration with current practices
- device disposal to be inline with sustainability goals
The nursing perspective of the patient user experience, such as but not limited to:
- benefits and barriers for the patient
- training and learning model for the patient for the device/system
- trust: in the accuracy of information due to device/system limitations or user error
- privacy: complies with the Data Protection Act 199824 and the Caldicott principles25
It will be important to observe how/if the definition of responsibilities differ between the Supplied scenario and the B.Y.O.D. scenario.
In order to consider how consumer-level wearables could be implemented we need to look at what is currently available. Specifically, we need to examine the following factors: device form (how it is worn); sensors contained; the type of information that can be captured by the sensors; data/information output; service restrictions; interoperability; usability; user acceptance; price. These factors will be explored in more depth as part of the project.
|Devices worn on the hand or wrist. Devices worn on the wrist typically make contact with the inside of the wrist in order to take sensor readings. Some devices look similar to digital watches and others are more like pieces of jewellery, so there is an aesthetic aspect with wearables which must be considered.|
|Apple Watch; Fitbit's Charge HR and Surge; Android Wear watches; Samsung Gear S2; Jawbone UP3; WellBe; Embrace Watch; Moodmetric Ring; Garmin Vivoactive.|
|Sensors contained vary per device.
General: Heart rate sensor; accelerometer; gyroscope; ambient light sensor
Mood-specific devices: peripheral temperature sensor; electro dermal activity sensor.
Analytical features: activity, sleep and stress tracking.
|Devices clipped or fastened onto clothing, in some cases touching the skin (e.g. inside trouser waistband). Another variation which falls into this category are necklaces and pin-badge style wearables. Some of the wrist type devices have adaptors to allow them to be worn as clips.|
|Spire, Leaf Nature and Urban, Misfit Shine 2 (due to its versatility as a watch or a clip). Withings Pulse Ox can also be worn as a watch or a clip.|
|Sensors contained vary per device.
Breathing pattern monitor; heart rate monitor; accelerometer; gyroscope; blood-oxygen level.
Analytical features: activity, sleep and stress tracking.