Nepal Field Study
Infant Incubator Project
Jan 21-27, 2007
Field Team:
Timothy Prestero, DtM
Matt Eckelman, YaleUniv.
Field Study Protocol
Process, Schedule and To-Do Lists
Guiding Principles
Direct all questions toward the idea that the final result will be a low-tech isolette.
Product Brief
Target Functions
Infant Warming: must include monitoring and control
Isolation: not a key product feature in the US, what about Nepal?
Oxygen: dangerous without monitoring, is this in or out?
Additional functions/requirements
Easy access or pass-through
Infant monitoring (instrumentation)
Life-support (assisted respiration, intravenous and oral feeding)
Infant handling (examination, repositioning, changing)
Sterility and cleaning
During use (baby bio messes)
Between infants (clean-out and storage prep)
Monitoring
Infant visibility
Alarms: no signal vs. bad signal
Power supply
Maintenance and repair
Identification and security
Potential “easy wins”
Tilting bed for acid reflux
Integrated scale for infant weight without removal
Ports and gates to prevent baby from rolling off table
Infant skin temp as control input (“servo” mode) via stick-on transducer
Pulse oximeter (low-cost Chinese mfg using 1985-era IP?)
Built in wires for crucial monitoring functions
Research Questions FOLLOW-UP (post-Nepal email, US research, March trip)
Product Priorities
What is the “number one” feature you would want in an isolette (nurse, doctor, parent)? Any "easy wins"?
How common are problems related to excess O2?
What do you think about an integrated pulse oxymeter?
Kanti NICU (close to US resources) vs rural clinic (no resources)
Where is our target market on this continuum?
What environments will the isolette be designed for? Only city hospital?
Users and Interations
Baby access
ASK: Describe the moment-to-moment care in Nepal
What kinds of procedures will they perform?
What kinds of access do they want/need?
What are their routines: rounds, hand-off, on-call
OBSERVE: Access to baby
What happens in real procedures?
Demonstrate putting the baby in the incubator and hooking them up
How often do they move/remove the baby?
How easy/awkward is it?
How many people does it take?
What roles do the parents play?
Do you ever use Kangaroo care?
How might this affect the incubator design?
Air quality inside the incubator
How often are babies changed in the ICU?
How long will they sit in a dirty diaper (average, worst case)?
Is ammonia build-up a problem? Are there any other problematic gasses or contaminants generated inside the incubator?
For the standard incubator, how many air changes per hour? What is desirable?
Incubator functions and allowances (monitoring and life support)
Incubator vs warming table
Relative advantages and disadvantages
Uses, relationship, existence
Order of use in baby care (warming table for critical, “graduate” to incubator?)
Tell us more about alarms and measurements
From what range do you need to be able to see/hear them?
What control do you need over settings?
How reliable? Any false alarms?
Incubator design
What are we seeing about the design?
Allowances inside the incubator for wires, gadgets
Allowances in the housing for access (ports, respirator inlet, bed lift)
Research Questions CLOSED or VALIDATE
Product Priorities
What babies are you trying to help?
What weight ranges (percentages)?
What are the most common additional health issues:
Jaundice
Acid Reflux
Cholera, Typhoid, other infections
Malnutrition
What percent of infants need help with:
Temperature regulation
Nourishment
Breathing
What is important in Nepal to keep a baby alive?
How do they treat these babies now?
Temperature
Isolation and infection control
Oxygen and respiration
Product Environment
Describe the NICU
What is the total capacity of infants in the environment?
What are staff levels? What are the staff-patient ratios?
How much space do they have for storage?
How long do infants stay in the NICU?
Are certain times of year busier than others?
What is the range of environmental conditions in the hospital/environment?
Temperature
Humidity
Light
Noise
What is the basic structure of the infant-related portion of the hospital? What assumptions can we make about the NICU environment?
Will the incubator environment ever exceed 37 degC?
Are mosquitos a problem in summer?
Do contagious staff/parents stay home?
What kind of power is available in all of these environments?
Is surge protection needed?
Is emergency power needed? How long must it last?
What kinds of germ barriers are employed?
What chemicals/methods would be used to sterilize the isolettes?
Do they use any anti-bacterial hand creams?
Do they wear gloves?
Do they wear gowns?
Is the ambient environment filtered in any way?
Are sick people prevented from entering the immediate environment?
Is the environment near the infant well-lit? Is additional lighting required?
Users and Interations
Who are the stakeholders?
Shadow some relevant people; doctor, nurse, parent, maintenance
Who does the moment-to-moment care in Nepal?
What kinds of procedures will they perform?
What kinds of access do they need?
What roles do the doctors play?
What kinds of procedures will they perform? What kinds of access do they want/need?
Who do they interact with?
What is their routine; rounds, hand-off, on-call
What roles do any other staff members play?
What roles do the parents play?
Do you ever use Kangaroo care? How would this affect the incubator design?
Incubator functions and allowances (monitoring and life support)
If naked babies are so much easier to monitor/observe, why are all of the babies in the Kanti NICU covered with clothes and blankets?
What about the infants and their environment do you monitor either through equipment or human observation?
What are the most important indicators?
The qualities
Weight
Body temperature vs skin temperature (difference?)
Baby crying (change me!): can you hear this?
Blood sugar
Bowel movements and urination
Blood oxygen level
Pulse
Respiratory rate
Blood tests
Urine tests
Humidity
Airborn germ levels
Other?
Specific qualities:
SKIN TEMP vs CORE TEMP: Is there a difference or some conversion protocol for determining infant core temperature from measured skin temperature?
Respiration: how is this measured/monitored?
Blood pressure: how is this measured/monitored?
About the measurement
Methods
Instrumentation (gadgets attached to or around baby)
Observation (visual checks of skin color, respiration)
Handling (feeling stomach, organs; checking pulse)
Frequency
Continuously (pulse, temp)
Periodically (diaper weight, baby weight, bloodwork)?
What are the target ranges?
What qualities can you control directly (temp, oxygen sat) vs indirectly (heart rate, blood pressure)?
Instrumentation
Do they ever use a urethral catheter?
Time lag between control settings and system response?
How long does it take an incubator to warm up? And how fast does this need to be in emergency use?
Fact-checking
Double-check vital signs (measured constantly) and high-priority measurements/observations
Validate common and emergency interventions
What kinds of information do they record about the infant, and where/howdo they store that data?
Do the infants have a "chart"?
Where is it located?
Electronic data. other systems
What kinds of equipment are currently used in Nepal? What kinds of equipment will need access to the incubator interior and what does it look like?
Bubble CPAP
Heart monitor
IV for fluids
Feeding tube
Oxygen with nose tube
High-freq respirator with stiff tubing and humidification
Blood Oxygen monitor
Storage requirements?
Diapers, clothes
Gadgets that “belong” to each baby, like nasal suction, transducers
How does Nepal deal with baby waste products; diapers?
Does this isolette need to serve as a high-access isolette as well for procedures?
What kinds of materials are local?
General Questions
Are there any places to get better care in case the baby needs more intensive care?
What kinds of liability issues exist?
Desired observations/assets
Day-in-the-life of a Nepal NICU
Fly on the wall: Shadow one “round” of one patient care (St. Elizabeth’s suggests it’s a four-hour cycle for infant monitoring, changing, feeding, etc). This includes opportunities to observe doctors, nurses, staff and parents interacting with infants and equipment.
Shadow the Kanti NICU doc on his/her rounds (watch for modes of access, monitoring)
Nepal NICU in their own words
Interviews: detailed Q&A with key staff, videotaped for later reference
Roleplaying with Narration: ask nurse/doctor/staff to pantomime the ways that they do or would interact with an incubator
Guided tour: ask nurse/doctor/staff/parent to show us around the NICU while describing what they do (watch for interview creep, interesting but irrelevant stuff)
Nepal NICU context: photos and diagrams
NICU floorplan and work areas, indicate uses of space
Equipment around each baby
Baby roadmap (from delivery room to NICU to going home, with connecting hallways, door, etc)
Synthesis Frameworks and Categories: THINK LIKE A DESIGNER
Patient qualities chart
Measurement
What is monitored
How is it measured (what it means in terms of access)
Methods
Instrumentation (gadgets attached to or around baby)
Observation (visual checks of skin color, respiration)
Handling (feeling stomach, organs; checking pulse)
Frequency
Continuously (pulse, temp)
Periodically (diaper weight, baby weight, bloodwork)?
How critical is the quality
What does it indicate in terms of overall health
Response
Alarm: bad signal vs no signal
Automatic response
Intervention: “controllability” and response time
Baby Journey:
US: womb to warming table to incubator to home
Nepal?
Incubator Journey: use, clean, store
Incubator dependencies: what does this device rely on in order to be successful
Infrastructure and environment
Gadgets and supporting equipment
Doctor/nurse/staff
Parents
Incubator product spec sheet
Research Protocol
Prepare 1-2 page questionnaires (cheat sheets) for each user/subject/setting
Heading: interview categories as a reminder
Page 1: must have questions
Page 2: nice-to-have questions
In general, these cheat sheets are “cross-sections” of the huge question list above
Establish field team assignment list for each day/activity
Who takes notes
Who takes pictures/video
Interview rules of thumb
Keep quiet during the interviewee’s response
Eliminate interviewer input during interviewee response, especially on recordings
don’t guide the answer through “er” and “um”
think about “clean” recordings for later use (ie just the interviewee talking, no chatter or leading comments from interviewer)
Request simultaneous translation rather than synopsis
Synch wristwatch with camera clock, time-stamp key notes for later review
Finish strong
Pay attention to what interviewee says in the last five minutes, when you shut off the camera and start packing up your stuff.
Parting comments tend to be great summaries.
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