4-DIRECTT
Designing ‘For the Direct Transfer’ of Patients with an Acute Type A Aortic Dissection
My Role -
Researcher, Strategist, Designer and Electronics/ Code Developer
Client -
Royal London Hospital (Barts Trust), THINK AORTA
Brief
Type A Acute Aortic Dissection (TAAD) is a national patient safety issue. It is a life-threatening, time-critical disease that carries a high mortality rate and can be challenging to diagnose due to its diverse presentation.
After diagnosis, patients must be transferred to specialist centres for surgery. 50% of patients with a TAAD die before reaching any hospital and a further 50% die before reaching a specialist centre.
As there is no standardised referral pathway, delays in the transfer of patients are frequent, leading to cardiac arrest before reaching specialist centres. In the UK, the number of diagnosed cases is forecast to double by 2050 due to a growing ageing population, advanced imaging, and a raising of awareness.
Solution
4-DIRECTT is a wearable for TAAD patients. The flexible screen communicates clearly to clinicians where the patient should be on the inter-hospital transfer pathway, based on how long has passed since diagnosis.
It helps enforce the four-hour guideline for transfer of patients to a specialist centre, aiding clinicians to make informed decisions about the patient care based on the time since diagnosis.
Key Skills - Communication, Complex Problem Solving and Openness
Research
Owens just before his surgery at Barts
The problem statement took a year to develop, through extensive research in the Emergency Department (ED) of Royal London Hospital (RLH).
While researching The Memory Project, I learnt about the nation-wide misdiagnosis of TAADs.
Over the next two years, I developed a strong research relationship with Dr Samy Sadek, a consultant in Pre-Hospital Care and Emergency Medicine at RLH and Gareth Owens, chair of Aortic Dissection Awareness UK and Ireland, THINK AORTA and a survivor of a TAAD after treatment at RLH and Barts.
I conducted countless interviews to understand why TAADs were being missed on such a wide scale.
Design Workshop
I began by asking the question,
"Why are TAADs difficult to diagnose?"
Taking an ethnographically-inspired approach, I designed a workshop with six clinicians to understand the process of diagnosing a patient from the clinicians' point of view.
Using a patient case, we developed two storyboards (blue and orange) which walked through the steps they would take to diagnosis.
We added tensions (yellow) surrounding the steps in the storyboard and used pink stickers to highlight the main tensions they each perceived.
Insights
1. Intoxication, language barriers and intense pain all create barriers to communication of symptoms
2. A "trauma mindset" needs to be applied to TAAD patients as they are often not prioritised
3. CT scans are a distinct point of tension as they require the approval from a radiologist who do not handle the cases
Pivoting the Brief
After a year of researching I hit a block:
A key symptom that separates TAADs from other differential diagnoses is that the (chest) pain moves over time but there is no way to track this
With 30% of ED patients presenting with chest pain, I would need to track roughly 240 people a day
So, the solution needed to be cheap and well-integrated into pre-existing practices
But, my access to the ED was restricted and observing patient questioning was out-of-bounds
Owens helped widen the scope by explaining,
The delay to diagnosis was only half the story.
Transfer of patients to specialist centres for surgery takes just as long.
"What we really need is a huge, ticking-time-bomb on [TAAD] patients so that every clinician knows how long they've been sat there... But you can't do that to a patient..." - Gareth Owens
My brief pivoted to observing why such delays accrue during the transfer of TAAD patients.
I found that patients are passed through multiple teams and often verbal handovers are not followed with the digital notes. This makes it hard for teams to know how long a patient has been in the pathway.
Visualising Time
How do you visualise time passing to create a sense of urgency for the clinician but not the patient?
The Visualisation Requirements were:
1. Clearly visible from ten metres (half an ED corridor)
2. Create a sense of urgency for the clinician but not for the patient
3. Provide the patient with reassurance / the feeling of being seen
The design reinforces the timing guidelines set by the NHS. It progresses through each stage of the pathway, showing clinicians which step the patient should be at.
It does this by:
1. Using embedded context to communicate information. The letters R, C and T refer to the transfer guideline steps laid out by the NHS. The steps have timing guidelines and so, can be used to tell the time implicitly by clinicians.
2. The visualisation is designed to become clearer as time passes. Yellow is the second-easiest colour to see at distance followed by blue.
3. The state change from blue to yellow creates urgency for the clinicians while helping the patient feel seen and be seen.
The Form
The form took inspiration from blood pressure monitor cuffs and tree wraps that stop young saplings being eaten by deer.
4-DIRECTT is designed to be worm on the upper arm. The form naturally curls round meaning it will adjust to fit onto an arm, bed frame or leg.
Prototypes
Works-like prototype with Arduino coded visuals
Half-size looks-like prototype with TPU 3D printing
Context sketch