ADL 123 Device

Reducing the risk of bloodstream infections in bone marrow transplant patients

Case Study

At Cincinnati Children’s, infection prevention is a high priority. Patients receiving radiation and chemotherapy for cancer, or when undergoing bone marrow transplantation, are at an increased risk of Bloodstream Infections (BSIs) due to weakened immune systems. Infections lead to prolonged hospitalization, intensive care admission, extensive antibiotic treatment, increased mortality, and increased cost of care. 

Fortunately, research has shown that there are a few simple activities that oncology patients can do to reduce BSI rates. Called Activities of Daily Living (ADL), these include: 1) bathing with chlorhexidine gluconate (CHG) once per day; 2) getting out of bed and being active at least twice per day; and 3) practicing oral care three times per day, as prescribed by a doctor.

An existing educational initiative and adherence program called ADL 1-2-3 aimed to teach cancer patients about the importance of bathing, being active, and practicing oral care to stay healthy and prevent infection.

Inspired by recent reports that use of a token economy motivates patients and improves adherence, a paper-based sticker chart system was developed and managed by clinical staff to track a patient’s weekly completion of ADL 1-2-3 tasks. Based on their adherence to the program, patients were given play money that could be exchanged for prizes. Patient adherence immediately improved, however, managing this system increased the burden on clinical care staff’s already limited time. Clinical staff have many high priority demands in care delivery as a result of the acuity and complexity of these patient populations. Despite the implemented interventions, the results were challenging to sustain.

How can digital technology and automation help reduce workload burdens on the clinical staff, improve adherence and overall quality of care across the continuum by empowering patients and families to manage their own daily infection prevention activities?

LiveWell Team

3 Faculty Advisors
3 Fellows
7 Graduate Students
7 Co-Ops

John Perentesis, MD
Christopher Dandoy, MD
Victoria Hickey, PhD
Melissa Scott, BSN
John Huber, MS

Live Well Collaborative and Cincinnati Children's CBDI Team with final ADL 123 Device PrototypesADL 123 Device mounted on the wall


Encouraging patients and families to team-up with their provider, and empowering them to manage their own daily infection prevention activities while also reducing workload burdens on the clinical staff


Research suggests it’s important for patients to know their actions have an effect on the system. A visual representation of growth and improvement improves motivation, leading to stronger adherence.


Leverage technology to automate burdensome tasks and analyze data.


There is growing awareness patients should be more active and effective managers of their health. Solution should enhance the ability to spread and reliably sustain patient and family engagement and self-management.


Percent Increase in Patient Adherence

The introduction of a token economy lead to a dramatic improvement in individual ADL 1-2-3 adherence from a median of 15% (range 0-20%) prior to the intervention, to 85% (80-95%) during the intervention.

Devices Built

A total of thirty prototypes were produced in-house and implemented into a randomized clinical trial.

Designing the Second Generation of Patient Adherence

The second-generation solution looks to reduce the cost of production, stabilize network compatibility, use gamification to improve the patient experience, and data visualization to improve communication between staff, patients, and families. 

What We Did
User Research
User Testing
Persona Development
UI/UX Design

Product Design
Medical Design
3D Printing
Wearable Technology
RFID Scanning
The LWC team researched and investigated ways to automate the point collection process of the 1-2-3 initiative
Ideation sketches of the physical ADL 123 device
Process and development of physical device being built by the Live Well Team
Building out the internal system of the physical devices
Co-creation activities with stakeholders exploring different types of gamification methods
Co-creation activities with stakeholders exploring different types of gamification methods
General patient journey map outlining adherence and wellness of patients over time
Early stage exploration of different user interface styles for ADL 123 Device 2.0 app


An innovative approach to improving adherence of infection prevention activities, workflow efficiency, and patient satisfaction

The 1-2-3 initiative started at Cincinnati Children’s Hospital with the goal of increasing patient adherence to activities of daily living (ADLs) that are proven to reduce infection rates.

Two generations of solutions have been designed, with the first resulting in a stand-alone device and the second a mobile application that is accessible through a tablet or phone. Investigative research into clinical staff workflows, environmental limitations, and patient conditions and family dynamics suggested that with an automated system, administrative requirements of the ADL 1-2-3 program could be minimized, data could be easily logged and seamlessly archived for future learnings, feedback delays could be shortened, and paper items could be replaced with digital points. These insights lead to the design, development, production, and implementation of a 3D printed, interactive device that allows maximum freedom for all users, while taking into account the constraints of current hospital protocols. An interactive incentivized program enhances patient and family engagement, automates the point collection process, and tracks patient bathing, oral care, and physical activity through an integrated system monitored by hospital staff.

The ADL 1-2-3 Device helped create an environment of co-production with patients and families, while supporting the achievement of unified team goals aimed at fostering infection prevention behaviors to improve patient outcomes. Positive feedback on the Generation 1 device led to the design of our Generation 2 digital application. The ADL 1-2-3 mobile application will improve access to the system, allowing patients and families to download the application to personal or hospital provided mobile devices. Contemporary research in gamification practices resulted in the creation of “Beat the Germ Boss” a goal-oriented game that engages and motivates patients by  providing visual representation of growth, improvement, and real time achievement based on their actions. For family caregivers who cannot be continuously present in the patient's room, a companion mobile phone application allows for progress monitoring. Visual data reports allow staff to view patient progress “at-a-glance” and help facilitate healthcare conversations with patients and families. 

Supplementing the device and application was a series of videos that introduced patients and their families to the importance of infection prevention, the benefits of “activities of daily living”, and how these new tools can help assist in their care management. 

Victoria Hickey RN, MSN
Clinical Director

John Huber
Lead Software Developer
"Development of an automated device to support ADL 1-2-3 adherence, along with the theme of “Infection Prevention is a Team Sport,” has fostered an environment of coproduction with patients and families in an effort to achieve unified team goals aimed fostering infection prevention behaviors to improve patient outcomes."

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