This case study details the redesign of a resuscitation trolley for in-hospital cardiac arrests by a multidisciplinary team involving industrial designers, clinicians and clinical psychologists.
The complex system of resuscitation and the demands placed by a resuscitation team on the trolley were investigated through interviews and workshops with experienced users and continued input from the clinical side of the collaborative team. Using a modified ‘Failure Mode and Effects Analysis’ tool, the resuscitation process was mapped, the problems identified and design opportunities developed.
Using co-design methods and critical clinical refinement of a breadth of ideas, a first stage prototype was produced. Subsequent rigorous testing in a simulated environment provided a large amount of user feedback. This led to further improvements in the design, and five second stage prototypes were produced for a more formal hospital trial, the results of which are published in clinical journals.
This project was initiated by the initial research partner, the National Patient Safety Agency (NPSA) after figures showing that poorly stocked resuscitation (or ‘crash’) trolleys led directly to patient safety errors.
Crash trolleys are used to store all commonly used equipment for resuscitation attempts. They are wheeled to the scene of a cardiac arrest, and members of the team performing the resuscitation attempt access their equipment from the trolley.
Closed cardiac chest compressions were first described ten years after the first crash trolley. While the arrest protocol has evolved and technology such as the defibrillator has progressed immeasurably, the crash trolley has stagnated since their introduction to the hospital ward in the 1940s.
The brief was to research the resuscitation process and restocking procedure, and to design, construct and test a prototype that improved both the resuscitation and restocking processes. A multidisciplinary team of designers, clinicians and psychologists was assembled to tackle this brief.
The resuscitation procedure was initially researched through an extensive literature search, which was expanded upon through input from practising resuscitation personnel. The clinicians in the collaborative team were important at this stage, as relevant knowledgeable input was being given from people who fully understood the intent of the project and eventual design work. An Advanced Life Support (ALS) course was attended and documented through video to observe how clinicians learn resuscitation, and videos of actual arrests were also observed. Animations of resuscitations were produced from close observation of real life arrests.
Following the initial research it became clear that a tool was needed to focus design attention on specific areas. A hybrid form of task analysis and a more detailed Failure Mode and Effect Analysis (FMEA) proved to be useful. The tool involved breaking down the resuscitation process into smaller discrete tasks, each of which has potential errors, causes and effects. This focused input from the clinical side of the team to ensure the task list and errors were comprehensive, and helped to map the process as a cycle rather than a linear progression.
Each of the errors outlined using this tool provided a trigger for design work and concept generation. The clinicians were then involved in creative techniques to provide further design prompts.
The resulting breadth of initial concepts underwent successive revisions through an iterative critical process. The preferred design and features were detailed and made into a full size, fully functioning prototype (Figure 14) which was tested in numerous simulated resuscitation scenarios in different hospitals.
This design has an open layout to make access easier and identification of equipment clearer, as well as facilitating the restocking process. The trolley splits into three sub-sections, allowing the team to clearly identify individual roles, and configure the equipment around the patient as necessary.
Following the simulation testing of the phase one prototype, the project benefited from a Medical Futures Innovation Award, and a Wellcome Technology Transfer grant to fund further testing and development. A manufacturer partnered this further development, and design modifications were made (improved layout, materials and splitting mechanism) before five phase two prototypes (Figure 15) were produced for further trials. A number of simulation scenarios were run, and the trolleys were also used in real life cardiac arrests, with positive user feedback. The results were published in peer reviewed clinical journals.
Discussion & Conclusion
The main challenges of the project lay in gathering a consensus of opinion from such a broad user base. In addition to the collaborative clinical team members, Resuscitation Officers at other hospitals were also consulted (through bodies such as the Council for Professionals as Resuscitation Officers), and through attending and presenting at the International Congress of the European Resuscitation Council (see resources). Technological and manufacturing constraints were identified from various trade technology shows, and from the manufacturing partner.
Finding a design to satisfy all of these needs is difficult but not impossible when the correct expertise is sought at each relevant stage. This process has been done iteratively to refine the ideas, and to ensure that the design remains relevant to the initial brief.
The testing, increasing in its rigour, has done much to persuade the clinical team and colleagues about the benefits of the inclusive design process. Simulation and real life testing performed
in isolation from any of the design team and collaborative clinicians meant that the feedback was free from bias.
In parallel with the more extensive trials, the project progressed through the commercialisation process, which included a competitor analysis, IP protection and the negotiation of a licensing agreement with a commercial partner. Many additional skills were called into play. An assessment of the size of the UK market for resuscitation trolleys was reliant upon company data, and was best performed by the manufacturing partner.
Despite being optimistic about sales, the market has since shown itself to be small for the R&D investment. The positive feedback from the front line, and the positive dissemination via the clinical journal papers, has led to a steady demand for the new design, though not enough for the UK manufacturers to continue manufacture. The project has attracted international interest, and the development team are pursuing active manufacturing interest in other countries.
Walker, S., McKay, A., Deelchand, V., Gautama, S., Sevdalis, N. and Vincent C. (2011). ‘Assessment of a newly designed resuscitation trolley in a simulated environment’. Circulation, 124: A234.
Walker, S., McKay, A., Deelchand, V., Gautama, S., Vincent, C. and Sevdalis, N. (2011). ‘Evaluation of the effect of a newly designed resuscitation trolley on the efficiency of the cardiac arrest team in a simulated environment’. Anaesthesia, 66(10): 958–960
Resus-station (2007). [online]. Last accessed 19th June 2015 at: http://www.rca.ac.uk/researchinnovation/helen-hamlyn-centre/research-projects/2007-projects/resus-station/