Detailed analysis of ‘work as imagined’ in the use of intravenous insulin infusions in a hospital: a hierarchical task analysis

Abstract

ObjectiveVariable rate intravenous insulin infusions (VRIII) is a high-risk medication that has a potential to cause significant patient harm if used in error. Complex preparation of VRIII in clinical areas and the need for frequent monitoring and adjustment increase the complexity of using VRIII. An emerging approach, called Resilient Healthcare, proposes understanding complexity of work by exploring how work is assumed to be done and compare it with everyday work. This study aimed to explore how VRIII is perceived to be used by healthcare practitioners, focusing on one aspect of Resilient Healthcare: understanding how work is assumed to be done, using a method called hierarchical task analysis (HTA).DesignA qualitative study using document analysis and focus groups.SettingA vascular surgery unit in an acute National Health Service teaching hospital in the UK.ParticipantsStakeholders/users in different professional roles involved in the process of using VRIII.ResultsThe HTA showed the complexity of using VRIII and highlighted more than 115 steps required to treat elevated blood glucose. The process of producing hospital-specific guidelines was iterative. Careful consideration was taken to coordinate the development and implementation of guidelines. Documents provided detailed clinical instructions related to the use of VRIII but practitioners selectively used them, often in deference to senior colleagues. Intentional adaptations, for example, proactively asking for a VRIII prescription occurred and were acknowledged as part of providing individualised patient care.ConclusionUsing VRIII to treat elevated blood glucose is a complex but necessary process mediated by a range of factors such as organisational influences. Adaptive strategies to mitigate errors were common and future research can build on insights from this study to develop a broader understanding of how VRIII is used and to understand how adaptations are made in relation to the use of VRIII.

Modelling the use of variable rate intravenous insulin infusions in hospitals by comparing Work as Done with Work as Imagined

“…Some of the tasks performed by healthcare practitioners in situ and illustrated in the WAD HTA, were aligned with the tasks presented in the WAI HTA. This could be due to VRIII guideline developers in the study hospital using a variety of resources in addition to the national guidelines and audits, for example by consulting the Think Glucose Group (a multidisciplinary group of healthcare professionals at the study hospital concerned with inpatient diabetes), an inpatient specialist nursing team who have extensive hands-on experience, and junior doctors (22). They also followed up the implementation of the guidelines through the ward managers and link nurses, who informed the guidelines developer team about the problems and queries faced in frontline care, which were then addressed by the team and shared in question and answer form with all healthcare practitioners.…”

“…A separate study that produced a HTA of WAI (see Supplementary file 2) was used to conduct a comparison of WAI and WAD. The WAI HTA was developed using two sources of data: VRIII guidelines and related documents and focus groups with guideline developers, managers and healthcare practitioners (22). The observed tasks, sub-tasks and plans presented in the WAD HTA were compared with the related tasks and plans in the WAI HTA to identify alignments and misalignments.…”

“…However, systems use various strategies to imagine how everyday clinical work is accomplished, in order to strengthen work and narrow the gap between WAI and WAD. WAI has been previously addressed in the context of using VRIIIs in the hospital unit (22). The hospital used various resources to produce its own hospital-specific guidelines, such as the relevant Joint British Diabetes Societies for Inpatient Care guidelines, (4) (4) (4) (4) the National Diabetes Inpatient Audit , local incident reports, feedback, clinical audits and quality improvement projects.…”

“…The hospital guaranteed the delivery of patient care by ensuring the use of the hospital-specific guidelines. Any identified deviation was approached by having conversations and asking questions designed to identify the reasons behind the deviation, giving feedback, finding a compromise, providing immediate informal education, and finally changing the wording of guidelines or modifying the content of mandatory training materials if required (22).…”

“…The model depicts a feedback loop, illustrating review work. The hospital site employed various means to continuously review the delivery of patient care, such as quality improvement projects; audits; comments and feedback from healthcare practitioners; and incident reports using the local incident reporting system (22). In CASs, reviewing clinical work should include monitoring and investigating everyday work and the resultant outcomes by engaging different stakeholders to discuss practical solutions in an attempt to counter the misalignment between WAI and WAD and to enhance patient safety (28).…”