Team Cognition in Handoffs: Relating System Factors, Team Cognition Functions and Outcomes in Two Handoff Processes.

OBJECTIVE: This study investigates how team cognition occurs in care transitions from operating room (OR) to intensive care unit (ICU). We then seek to understand how the sociotechnical system and team cognition are related. BACKGROUND: Effective handoffs are critical to ensuring patient safety and have been the subject of many improvement efforts. However, the types of team-level cognitive processing during handoffs have not been explored, nor is it clear how the sociotechnical system shapes team cognition. METHOD: We conducted this study in an academic, Level 1 trauma center in the Midwestern United States. Twenty-eight physicians (surgery, anesthesia, pediatric critical care) and nurses (OR, ICU) participated in semi-structured interviews. We performed qualitative content analysis and epistemic network analysis to understand the relationships between system factors, team cognition in handoffs and outcomes. RESULTS: Participants described three team cognition functions in handoffs-(1) information exchange, (2) assessment, and (3) planning and decision making; information exchange was mentioned most. Work system factors influenced team cognition. Inter-professional handoffs facilitated information exchange but included large teams with diverse backgrounds communicating, which can be inefficient. Intra-professional handoffs decreased team size and role diversity, which may simplify communication but increase information loss. Participants in inter-professional handoffs reflected on outcomes significantly more in relation to system factors and team cognition (p < 0.001), while participants in intra-professional handoffs discussed handoffs as a task. CONCLUSION: Handoffs include team cognition, which was influenced by work system design. Opportunities for handoff improvement include a flexibly standardized process and supportive tools/technologies. We recommend incorporating perspectives of the patient and family in future work.

Scenario-Based Evaluation of Team Health Information Technology to Support Pediatric Trauma Care Transitions.

BACKGROUND: Clinicians need health information technology (IT) that better supports their work. Currently, most health IT is designed to support individuals; however, more and more often, clinicians work in cross-functional teams. Trauma is one of the leading preventable causes of children's death. Trauma care by its very nature is team based but due to the emergent nature of trauma, critical clinical information is often missed in the transition of these patients from one service or unit to another. Teamwork transition technology can help support these transitions and minimize information loss while enhancing information gathering and storage. In this study, we created a large screen technology to support shared situational awareness across multiple clinical roles and departments. OBJECTIVES: This study aimed to examine if the Teamwork Transition Technology (T3) supports teams and team cognition. METHODS: We used a scenario-based mock-up methodology with 36 clinicians and staff from the different units and departments who are involved in pediatric trauma to examine T3. RESULTS: Results of the evaluation show that most participants agreed that the technology helps achieve the goals set out in the design phase. Respondents thought that T3 organizes and presents information in a different way that was helpful to them. CONCLUSION: In this study, we examined a health IT (T3) that was designed to support teams and team cognition. The results of our evaluation show that participants agreed that T3 does support them in their work and increases their situation awareness.

Human-centered design of team health IT for pediatric trauma care transitions.

BACKGROUND: As problems of acceptance, usability and workflow integration continue to emerge with health information technologies (IT), it is critical to incorporate human factors and ergonomics (HFE) methods and design principles. Human-centered design (HCD) provides an approach to integrate HFE and produce usable technologies. However, HCD has been rarely used for designing team health IT, even though team-based care is expanding. OBJECTIVE: To describe the HCD process used to develop a usable team health IT (T3 or Teamwork Transition Technology) that provides cognitive support to pediatric trauma care teams during transitions from the emergency department to the operating room and the pediatric intensive care unit. METHODS: The HCD process included seven steps in three phases of analysis, design activities and feedback. RESULTS: The HCD process involved multiple perspectives and clinical roles that were engaged in inter-related activities, leading to design requirements, i.e., goals for the technology, a set of 47 information elements, and a list of HFE design principles applied to T3. Results of the evaluation showed a high usability score for T3. CONCLUSIONS: HFE can be integrated in the HCD process through a range of methods and design principles. That design process can produce a usable technology that provides cognitive support to a large diverse team involved in pediatric trauma care transitions. Future research should continue to focus on HFE-based design of team health IT.

Care transition of trauma patients: Processes with articulation work before and after handoff.

While care transitions influence quality of care, less work studies transitions between hospital units. We studied care transitions from the operating room (OR) to pediatric and adult intensive critical care units (ICU) using Systems Engineering Initiative for Patient Safety (SEIPS)-based process modeling. We interviewed twenty-nine physicians (surgery, anesthesia, pediatric critical care) and nurses (OR, ICU) and administered the AHRQ Hospital Survey on Patient Safety Culture items about handoffs, care transitions and teamwork. Care transitions are complex, spatio-temporal processes and involve work during the transition (i.e., handoff and transport) and preparation and follow up activities (i.e., articulation work). Physicians defined the transition as starting earlier and ending later than nurses. Clinicians in the OR to adult ICU transition without a team handoff reported significantly less information loss and better cooperation, despite positive interview data. A team handoff and supporting articulation work should increase awareness, improving quality and safety of care transitions.

Information flow during pediatric trauma care transitions: things falling through the cracks.

Pediatric trauma is one of the leading causes of morbidity and mortality in children in the USA. Every year, nearly 10 million children are evaluated in emergency departments (EDs) for traumatic injuries, resulting in 250,000 hospital admissions and 10,000 deaths. Pediatric trauma care in hospitals is distributed across time and space, and particularly complex with involvement of large and fluid care teams. Several clinical teams (including emergency medicine, surgery, anesthesiology, and pediatric critical care) converge to help support trauma care in the ED; this co-location in the ED can help to support communication, coordination and cooperation of team members. The most severe trauma cases often need surgery in the operating room (OR) and are admitted to the pediatric intensive care unit (PICU). These care transitions in pediatric trauma can result in loss of information or transfer of incorrect information, which can negatively affect the care a child will receive. In this study, we interviewed 18 clinicians about communication and coordination during pediatric trauma care transitions between the ED, OR and PICU. After the interview was completed, we surveyed them about patient safety during these transitions. Results of our study show that, despite the fact that the many services and units involved in pediatric trauma cooperate well together during trauma cases, important patient care information is often lost when transitioning patients between units. To safely manage the transition of this fragile and complex population, we need to find ways to better manage the information flow during these transitions by, for instance, providing technological support to ensure shared mental models.

Physician Perceptions of the Electronic Problem List in Pediatric Trauma Care.

OBJECTIVE: To describe physician perceptions of the potential goals, characteristics, and content of the electronic problem list (PL) in pediatric trauma. METHODS: We conducted 12 semistructured interviews with physicians involved in the pediatric trauma care process, including residents, fellows, and attendings from four services: emergency medicine, surgery, anesthesia, and pediatric critical care. Using qualitative content analysis, we identified PL goals, characteristics, and patient-related information from these interviews and the hospital's PL etiquette document of guideline. RESULTS: We identified five goals of the PL (to document the patient's problems, to make sense of the patient's problems, to make decisions about the care plan, to know who is involved in the patient's care, and to communicate with others), seven characteristics of the PL (completeness, efficiency, accessibility, multiple users, organized, created before arrival, and representing uncertainty), and 22 patient-related information elements (e.g., injuries, vitals). Physicians' suggested criteria for a PL varied across services with respect to goals, characteristics, and patient-related information. CONCLUSION: Physicians involved in pediatric trauma care described the electronic PL as ideally more than a list of a patient's medical diagnoses and injuries. The information elements mentioned are typically found in other parts of the patient's electronic record besides the PL, such as past medical history and labs. Future work is needed to evaluate the optimal design of the PL so that users with emergent cases, such as pediatric trauma, have access to key information related to the patient's immediate problems.