There are a limited number of formal research studies on mobile healthcare technology and work productivity measures. Mobile healthcare with electronic ordering and charting is emerging technology, and current literature illustrates how carts are increasing functionality by bringing information to the point of care while providing a stand-alone all-in-one device.1-9

Lehigh Valley Hospital and Health Network (LVHHN)-a Magnet-designated, multi-site facility with 750 acute care beds-began using carts as a form of mobile technology in May 2001 and now employs more than 250 carts in 30 units across its three campuses. At LVHHN, the medication administration process hinges on bar coding and electronic medication administration records (eMAR) technology. Each RN is assigned a mobile medication cart that has a wireless laptop and bar-code scanner. Carts were incorporated into nursing workflow to support the implementation of eMAR and computerized provider order entry (CPOE). Two styles of carts were evaluated for this research:

1. Mobile cart with one or no medication drawers (Cart 1). Medications are stored centrally in the unit's 36-drawer locked medication cart in a locked medication room. Nurses collect and prepare medication for each patient in the medication room, go to the patient's room to dispense the drugs, and return to the medication room to prepare for the next patient.

2. Mobile medication cart with locked medication drawers (Cart 2). Medications and supplies are stored in the mobile cart. Nurses can prepare and dispense medications while in the patient's room.

Our study team at LVHHN focused on the two mobile medication cart models described and how each affected the nurses' work process. Specifically, the team set out to gather qualitative input on specific features of each cart as it relates to ergonomics, productivity, patient safety, care quality, and job satisfaction.

Design

This research project consisted of two phases: focus groups of nursing staff and observational workflow analysis of nursing staff and the medication administration process. The study team conducted the workflow analysis for the Cart 2 (or case) portion of the research study in a 30-bed transitional open-heart unit.

* Phase 1: Focus groups: The team conducted focus groups with over 50 nursing staff members from the Float Pool, the Progressive Coronary Care Unit, and the Transitional Open Heart Unit (TOHU). Focus group objectives included identifying the nursing staff's perspective on specific features of the carts, as well as workflow process. Responses were themed by safety; design; functionality; efficiency; direct patient care; and positive/negative subjectivity. Focus group results identified key areas used to develop the data collection tool used in the second phase of the study.

* Phase 2: Quantitative observational workflow research: The survey team developed and tested an observational data collection tool prior to the study to determine whether it captured the needed information to test our hypothesis. Prior to data collection, the tool was reviewed with the designated surveyors on the team to ensure consistent and uniform data collection. Each observer then participated in at least one observational training session and was instructed to only record observations that had an impact on the medication delivery process.

Training results showed a high level of agreement among observers. Observations were conducted in the TOHU, a 30-bed step-down cardiac unit, where both types of mobile medication cart workstations are used. During each of 39 observational periods, two observers selected two staff RNs who were observed performing medication administration using either Cart 1 or Cart 2.

Study team members conducted observations during morning rounds because that time frame routinely had the greatest number of medications administered. The data collection tool identified both demographics and activities in medication administration that could affect the workflow process for RNs. As defined within the tool, brief demographic information was recorded, including the start and end time of the medication process; patient assignment; preparation of the cart before giving medications with supplies (alcohol wipes, syringes, medications from refrigerator, intravenous tubing, medication cups, and juice/applesauce for medication administration); nurse responsibilities as charge nurse or unit leader; and type of cart utilized.

Study team members recorded direct observations of the nurse administering medications. These observations included six categories relating to the workflow process-and how the specific carts influenced the process. These categories were medication preparation, nonmedication supplies, medications, medication administration, documentation, and notes.

Results

We found that the cart used directly impacted the workflow process. Medication carts with multiple patient drawers improved the workflow process in medication administration by decreasing the amount of trips to the medication room, thus increasing the efficiency of the work process. Study team members considered the significant differences between the carts as directly related to locked drawer capacity, in which nurses had individual patient drawers to store medications, as well as separate drawers for locked supplies, such as syringes.

The study revealed a need for decreased trips for supplies when using Cart 2, yet nurses were able to anticipate and stock supplies on either cart prior to medication administration. The mobile cart with no medication drawers had one unlocked drawer in which nurses could stock supplies, such as medication cups, tape, and tubing, which decreased the amount of trips to the central medication room or supply room.

Implications

As technology becomes more integrated to the patient bedside, nurses and nurse leaders need to investigate and provide equipment that leads to an optimal work process. The medication administration delivery process can, at times, become fragmented, in an attempt to meet the needs of patients, visitors, and other healthcare providers.

Based on this study, a mobile medication administration cart with locked drawers improves the nursing workflow process. Research results provided concrete data reflecting improved medication delivery efficiency by significantly decreasing trips to the medication room. LVHHN is committed to providing equipment that will improve efficiency, safety, and workflow process, and will continue to rollout mobile medication carts with locked medication drawers for all inpatient units.

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