How might we get more sickle cell adolescents to consent & adhere to blood clot prevention tactics, thereby reducing clot incidence at UI Medical Center?
Preventable blood clots cause more deaths each year than car crashes, AIDs and breast cancer combined. Certain populations, such as those with Sickle Cell Disease, are more susceptible to clotting because of the makeup of their blood.
In Fall 2018, I worked with Kim Erwin and the University of Illinois (UIC) Institute for Healthcare Delivery Design to develop solutions that encourage education and compliance surrounding blood clot prevention (formally known as VTE prophylaxis) in Sickle Cell adolescents, ages 11-21. Together with our multidisciplinary team of three Institute of Design students, four UIC medical students, and two attending physicians representing the UI Health Quality Improvement team, we developed a systematic approach to standardize patient education, regulate clinician protocols, and drive more at-risk Sickle Cell patients to “yes” using behavioral design strategies.
Phase I: Research
Our research began with a thorough literature review and an assessment of current best practices for VTE prophylaxis education. We primarily focused on studying Sickle Cell Disease and Venous Thromboembolism (VTE) in both children and adults, as well as broader discussions about hospital compliance and adolescent motivation.
Throughout the semester, we conducted approximately 32+ hours of observation on the pediatric inpatient floor (5W) of the UIC Hospital as well as 12 intercept interviews with medical staff, 2 in-depth interviews with Sickle Cell patients, and 2 in-depth interviews with clinical subject matter experts.
Phase 2: provotype testing
In a hectic hospital setting, it is critical to go into the field with designed pieces for interviewees—clinicians, patients, and family members—to easily react to on the spot without too much abstraction. As such, we developed early “provotypes” based on hypotheses generated from our literature review and initial conversations with clinicians and patients. These were then iterated upon over the span of several weeks until we implemented the pilot.
Here are some of the versions we took into the field for testing.
Key Learnings
ONE
Adolescents are a very difficult age group, and Sickle Cell patients are tired of their disease and constantly being in the hospital.
FOUR
Nurses bear the brunt of the burden in promoting VTE prophylaxis with patients. As a result, they become likened to “nagging moms.”
TWO
There are no set metrics/standards for measuring “acceptable” levels of movement and other VTE prophylaxis tactics.
FIVE
Clinicians already have a lot to do, and any interventions need to fit seamlessly into their workflow in order to be implemented properly.
THREE
There is significant practice variation between clinicians in promoting/enforcing VTE prophylaxis within the pediatric ward.
SIX
Patient rooms on 5W are extremely difficult environments to design for because they are dark, dreary, and overcrowded.
Design Principles
Clinician-Focused
WORKFLOW FIT
Build into existing clinician workflowSHARED PRIORITY
Position VTE prophylaxis as a collective priority for everyone on 5W
Patient-Focused
AGENCY & CHOICE
Give patients a sense of control by providing optionsFLEXIBLE & ADAPTIVE
Adapts the experience to each patient’s current emotional and physical needs, choose the appropriate language level for tools, acknowledge surroundings
PHASE 3: Pilot implementation
In late October 2018, we launched our official pilot on the pediatric ward (5W) at UIC Hospital. The pilot ran for a total of 6 weeks, during which we surveyed clinicians about the effectiveness of each element and the system as a whole. Our pilot was designed to work as a system of mutually-reinforcing elements, each developed for a specific purpose and employing a spectrum of behavioral design interventions.
The whole pilot was centered around the idea of being a “preventer,” encouraging patients and staff alike to lean into this identity and be more compliant with VTE prophylaxis.
PILOT ELEMENTS
Poster
Serves as an ever-present behavioral nudge in each hospital room on 5W
Provides reinforcement for nurses
Clearly highlights action items
Door Badges
Incentivizes patient compliance
Encourages social norming by making compliance visible to all on 5W
Mobility Menu
Provides agency and choice for adolescents
Attempts to add structure into the movement measurement question
Allows for nurse “negotiation”
Buttons
Emphasizes that blood clot prevention is everyone’s responsibility
Serves as the basis of a hospital-wide campaign
Patient Education Piece
Makes blood clots more tangible to patients through visualization and modeling
Introduces consequences of non-compliance
Facilitates bedside conversations
Nursing Checklist
Builds on existing nursing workflow
Integrates blood clot prevention discussions into hourly rounding procedures
“Patients are starting to ask the nursing staff when they need to put on their massagers or go for a walk around the ward. The materials—especially the poster—really have made a difference!”
Phase 4: Analyzing Pilot Results
After six weeks, we sent a survey to all clinicians and staff on 5W asking them about the effectiveness of the materials we installed in the ward. We also solicited qualitative feedback and personal anecdotes from several nurses and residents, and the Quality Improvement team pulled data showing how our pilot affected a variety of key metrics pertaining to blood clot incidence and compliance rates.
Special thanks to our multidisciplinary TEAM
UIC Institute for Healthcare Delivery Design: Kim Erwin, Sarah Norell
IIT Institute of Design Students: Moire Corcoran, Divya Jain
UI Health Clinical Staff: Lewis Hsu, Andrew Kreppel, Jamie Ghafari, Jocelyn Sales
UIC College of Medicine Students: Alex Kenefake, Jessie Klugman, Carlos Montero, Soobin Kim