Strategies for case-based training with virtual patients: An experimental study of the impact of integrating mental model articulation and self-reflection.

Resilient system performance in high-stakes settings, which includes the ability to monitor, respond, anticipate, and learn, can be enhanced for trainees through simulation of realistic scenarios enhanced by augmented reality. Active learning strategies can enhance simulation-based training, particularly the mental model articulation principle where students are prompted to anticipate what will happen next and the reflection principle where students self-assess their performance compared to a gold standard expert model. In this paper, we compared simulation-based training for trauma care with and without active learning strategies during pauses in the simulated action for progressively deteriorating patients. The training was conducted online and real-time without a facilitator, with 42 medical students viewing training materials and then immediately taking an online quiz for three types of trauma cases: hemorrhage, airway obstruction, and tension pneumothorax. Participants were randomly assigned to either the experimental or control condition in a between-subjects design. We compared performance in the control and experimental conditions based on: A) the proportion of cues correctly recognized, B) the proportion of accurate diagnoses, C) the proportion of appropriate treatment interventions, and D) verbal briefing quality on a 1-5 scale. We found that the training intervention increased recognition of subtle cues critical for accurate diagnosis and appropriate treatment interventions; the training did not improve the accuracy of diagnoses or the quality of the verbal briefing. We conclude that incorporating active learning strategies in simulation-based training improved foundational capabilities in detecting subtle cues and intervening to rescue deteriorating patients that can increase the readiness for trainees to contribute to resilient system performance in the high-stakes setting of emergency care in hospitals.

Hemoglobin on Admission for Childbirth and Postpartum Acute Care Use in a Southeastern Health Care System.

OBJECTIVE: Our objective was to evaluate whether hemoglobin on admission for childbirth is associated with postpartum acute care use (ACU). STUDY DESIGN: We conducted a retrospective cohort study of patients giving birth at a southeastern quaternary care hospital from January 2018 through June 2021 using electronic health records. Predelivery hemoglobin was categorized as <9, 9- < 10, 10- < 11, 11- < 12, and ≥12 g/dL. Acute care was defined as a visit to obstetric triage, the emergency department, or inpatient admission within 90 days postpartum. Generalized estimating equations quantified the crude and multivariable-adjusted association between predelivery hemoglobin and ACU. RESULTS: Among 8,677 pregnancies, 1,467 (17%) used acute care in the system within 90 days postpartum. In unadjusted models, those with predelivery hemoglobin <9 had twice the risk of postpartum ACU compared to those with hemoglobin ≥12 (95% confidence interval [CI]: 1.59-2.69), with a decrease in risk for each increase in hemoglobin category (9- < 10 g/dL: risk ratio [RR]: 1.47, CI: 1.21-1.79; 10- < 11 g/dL: RR: 1.44, CI: 1.26-1.64; 11- < 12 g/dL: RR: 1.20, CI: 1.07-1.34). The adjusted model showed a similar trend with smaller effect estimates (<9 g/dL: RR: 1.50, CI: 1.14-1.98; 9- < 10 g/dL: RR: 1.22, CI: 1.00-1.48; 10- < 11 g/dL: RR: 1.22, CI: 1.07-1.40; 11- < 12 g/dL: RR: 1.09, CI: 0.98-1.22). CONCLUSION: Low hemoglobin at childbirth admission was associated with increased postpartum ACU. Low hemoglobin on admission could signal to providers that additional follow-up, resources, and ongoing support are warranted to identify and address underlying health needs. Because hemoglobin is routinely assessed during the childbirth hospitalization, this indicator may be especially valuable for risk assessment among patients with limited prior engagement in health care. KEY POINTS: · Low hemoglobin on admission for birth is associated with postpartum acute care use.. · Hemoglobin on admission may aid in risk-stratification during childbirth hospitalization.. · Point-of-care metrics may help identify high-risk patients with limited preventive health care..

Perceptually Discriminating the Highest Priority Alarms Reduces Response Time: A Retrospective Pre-Post Study at Four Hospitals.

OBJECTIVE: Reduce nurse response time for emergency and high-priority alarms by increasing discriminability between emergency and all other alarms and suppressing redundant and likely false high-priority alarms in a secondary alarm notification system (SANS). BACKGROUND: Emergency alarms are the most urgent, requiring immediate action to address a dangerous situation. They are clinician-triggered and have higher positive predictive value (PPV). High-priority alarms are automatically triggered and have lower PPV. METHOD: We performed a retrospective pre-post study, analyzing data 15 months before and 25 months after a SANS redesign was implemented in four hospitals. For emergency alarms, we incorporated digitized human speech to distinguish them from automatically triggered alarms, leaving their onset and escalation pathways unchanged. For automatically triggered alarms, we suppressed some by delaying initial onset and escalation by 20 s. We used linear mixed models to assess the change in response time, Fisher's exact test for the proportion of response times longer than 120 s, and control charts for process stability. RESULTS: Response time for emergency alarms decreased at all hospitals (main, from 26.91 s to 22.32 s, p < .001; cardiac, from 127.10 s to 52.43 s, p < .001; cancer, from 18.03 s to 15.39 s, p < .001). Improvements were sustained. Automatically triggered alarms decreased 25.0%. Response time for the three automatically triggered cardiac alarms increased at the four hospitals. CONCLUSION: Auditory sound disambiguation was associated with a sustained reduced nurse response time for emergency alarms, but suppressing some high-priority automatically triggered alarms was not. APPLICATION: Distinguishing and escalating urgent, actionable alarms with higher PPV improves response time.

Applying Human Factors Engineering to Address the Telemetry Alarm Problem in a Large Medical Center.

OBJECTIVE: Address the alarm problem by redesigning, reorganizing, and reprioritizing to better discriminate alarm sounds and displays in a hospital. BACKGROUND: Alarms in hospitals are frequently misunderstood, disregarded, and overridden. METHOD: Discovery-oriented, intervention, and translational studies were conducted. Study objectives and measures varied, but had the shared goals of increasing positive predictive value (PPV) of critical alarms by reducing low-PPV alarms in the background, prioritizing alarms, redesigning alarm sounds to increase information content, and transparently conveying who initiated alarms. An alarm ontology was iteratively generated and refined until consensus was achieved. RESULTS: The ontology distinguishes five levels of urgency that incorporate likely PPV, three categories for who initiates the alarm (hospital staff, patient, or machine), whether it is clinical or technical, and clinical functions. CONCLUSION: This unique collaboration allowed us to make progress on the alarm problem by making unintuitive leaps, avoiding common missteps, and refuting conventional healthcare approaches. APPLICATION: Hospitals can consistently redesign, reorganize, reprioritize, and better discriminate alarms by priority, PPV, and content to reduce nurse response times.

Lessons from the Glass Cockpit: Innovation in Alarm Systems to Support Cognitive Work.

Nurses working in the hospital setting increasingly have become overburdened by managing alarms that, in many cases, provide low information value regarding patient health. The current trend, aided by disposable, wearable technologies, is to promote patient monitoring that does not require entering a patient's room. The development of telemetry alarms and middleware escalation devices adds to the continued growth of auditory, visual, and haptic alarms to the hospital environment but can fail to provide a more complete understanding of patient health. As we begin to innovate to both address alarm overload and improve patient management, perhaps using fundamentally different integration architectures, lessons from the aviation flight deck are worth considering. Commercial jet transport systems and their alarms have evolved slowly over many decades and have developed integration methods that account for operational context, provide multiple response protocol levels, and present a more integrated view of the airplane system state. We articulate three alarm system objectives: (1) supporting hazard management, (2) establishing context, and (3) supporting alarm prioritization. More generally, we present the case that alarm design in aviation can spur directions for innovation for telemetry monitoring systems in hospitals.

Patients Are Knowledge Workers in the Clinical Information Space.

BACKGROUND: Limited research exists on patient knowledge/cognition or "getting inside patients' heads." Because patients possess unique and privileged knowledge, clinicians need this information to make patient-centered and coordinated treatment planning decisions. To achieve patient-centered care, we characterize patient knowledge and contributions to the clinical information space. METHODS AND OBJECTIVES: In a theoretical overview, we explore the relevance of patient knowledge to care provision, apply historical perspectives of knowledge acquisition to patient knowledge, propose a representation of patient knowledge types across the continuum of care, and include illustrative vignettes about Mr. Jones. We highlight how the field of human factors (a core competency of health informatics) provides a perspective and methods for eliciting and characterizing patient knowledge. CONCLUSION: Patients play a vital role in the clinical information space by possessing and sharing unique knowledge relevant to the clinical picture. Without a patient's contributions, the clinical picture of the patient is incomplete. A human factors perspective informs patient-centered care and health information technology solutions to support clinical information sharing.

A Qualitative Analysis of Outpatient Medication Use in Community Settings: Observed Safety Vulnerabilities and Recommendations for Improved Patient Safety.

OBJECTIVE: The aim of the study was to analyze diverse patients' experiences throughout the medication use process to inform the development of overarching interventions that support safe medication use in community settings. METHODS: Using a qualitative observational approach, we conducted approximately 18 hours of direct observation of the medication use process across multiple settings for a sample of vulnerable, high-risk patients. Observers recorded detailed field notes during the observations. To enrich the observational findings, we also conducted six semistructured interviews with medication safety experts representing a diversity of perspectives. Barriers and facilitators to safe medication use were identified based on inductive coding of the data. RESULTS: A variety of safety vulnerabilities plague all stages of the medication use process and many of the well-established evidence-based interventions aimed at improving the safety of medication use at key stages of the process have not been widely implemented in community settings observed in this study. Key safety vulnerabilities identified include: limited English proficiency, low health literacy, lack of clinician continuity, incomplete medication reconciliation and counseling, unsafe medication storage and disposal habits, and conflicting healthcare agendas with caregivers. CONCLUSIONS: Our findings underscore a need for overarching, comprehensive interventions that span the entire process of medication use, including integrated communication systems between clinicians, pharmacies, and patients, and a "patient navigator" program that assists patients in navigating the entire medication-taking process. Collective ownership of the medication management system and mutual motivation for devising collaborative solutions is needed among key sectors.

Efficacy of a patient decision aid for improving person-centered decision-making by older adults with obstructive sleep apnea.

STUDY OBJECTIVES: Person-centered obstructive sleep apnea (OSA) care is a collaborative approach that is respectful of an individual's health priorities. Informed decision-making is essential to person-centered care, especially as patients age. In a feasibility study, we evaluated the effects of a new decision aid (Decide2Rest) on OSA treatment decision-making in older adults. METHODS: Patients (aged ≥ 60 years) with newly diagnosed OSA were recruited from two health care systems and randomized either to Decide2Rest or to a control program. Postintervention outcomes included 1) Decisional Conflict Scale (0-100, where 0 = low and 100 = high conflict), which measures perceptions of uncertainty, whether decisions reflect what matters most to patients, and whether patients feel supported in decision-making; 2) Preparation for Decision-Making scale (0-100, where 0 = least and 100 most prepared); and 3) OSA knowledge (0-100, where 0 = poor and 100 = outstanding). Multivariable linear regression models examined relationships between Decide2Rest and outcomes (Decisional Conflict Scale, Preparation for Decision-Making, OSA knowledge). RESULTS: Seventy-three patients were randomized to Decide2Rest (n = 36; mean age, 69 years; 72% male) vs control (n = 37; mean age, 69 years; 70% male). Results from the regressions, controlling for study site, indicate that the Decide2Rest program resulted in less decisional conflict (20.5 vs 32.7 on the Decisional Conflict Scale; P = .014), more preparedness for decision-making (87.8 vs 66.2 on the Preparation for Decision-Making scale; P < .001), and greater OSA knowledge (75.1 vs 65.3 OSA knowledge score; P = .04) scores than in the control group. CONCLUSIONS: The Decide2Rest program promotes person-centered OSA decision-making for older patients with newly diagnosed OSA. Future studies are needed to optimize implementation of the program. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov, Name: Improving Older Adults' Decision-Making for OSAT (eDecide2Rest); URL: https://clinicaltrials.gov/ct2/show/NCT03138993; Identifier: NCT03138993.

SCHEDULING DELAYED TREATMENT AND SURGERIES POST-PANDEMIC: A STAKEHOLDER ANALYSIS.

Many are interested in how to safely ramp up elective surgeries after national, state, and voluntary shutdowns of operating rooms to minimize the spread of COVID-19 infections to patients and providers. We conducted an analysis of diverse perspectives from stakeholders regarding how to trade off risks and benefits to patients, healthcare providers, and the local community. Our findings indicate that there are a large number of different categories of stakeholders impacted by the post-pandemic decisions to reschedule delayed treatments and surgeries. For a delayed surgery, the primary stakeholders are the surgeon with expertise about the clinical benefits of undergoing an operation and the patient's willingness to tolerate uncertainty and the increased risk of infection. For decisions about how much capacity in the operating rooms and in the inpatient setting after the surgery, the primary considerations are minimizing staff infections, preventing patients from getting COVID-19 during operations and during post-surgical recovery at the hospital, conserving critical resources such as PPE, and meeting the needs of hospital staff for quality of life, such as child care needs and avoiding infecting members of their household. The timing and selection of elective surgery cases has an impact on the ability of hospitals to steward finances, which in turns affects decisions about maintaining employment of staff when operating rooms and inpatient rooms are not being used.

ENHANCING USEFULNESS AND USABILITY OF A CLINICAL DECISION SUPPORT PROTOTYPE FOR ANTIBIOTIC STEWARDSHIP.

Human factors engineering can enhance software usefulness and usability. We describe a multi-method approach to improve clinical decision support (CDS) for antibiotic stewardship. We employed a heuristic review to generate recommendations to improve the usability of a prototype CDS to support empiric antibiotic prescribing in the hospital setting. We then engaged in a design improvement cycle in collaboration with software programmers, which resulted in additional enhancements to our prototype. Finally, we used the revised prototype during three walkthrough demonstration interviews with physician and pharmacist subject matter experts. These walkthrough interviews generated recommendations to improve the interface, functionality, and tailoring for groups of users. We discuss common elements of the recommendations for models for using clinical decision support in general.

Uncovering the Value of a Historical Paper-Based Collaborative Artifact: The Nursing Unit's Kardex System.

We identify useful functions and usability characteristics of a historical cognitive artifact used by nurses working in a hospital unit, the Kardex. By identifying aspects of a widely used artifact, we uncover opportunities to improve the usefulness of current systems for hospital nurses. We conducted semi-structured interviews with registered nurses about their prior experience with the Kardex. Questions included what elements of the Kardex are missing from their current electronic support. Memos were generated iteratively from interview transcript data and grouped into themes. Eighteen nurses from multiple clinical areas participated and had a median of 25-29 years of nursing experience. The themes were: (1) a status at a glance summary for each patient, (2) a prospective memory aid, (3) efficiency and ease of use, (4) updating information required to maintain value, (5) activity management, (6) verbal handover during shift-to-shift report, (7) narrative charting and personalized care, and (8) non-clinical care communication. Implications for digital support are to provide immediate, portable access to a standardized patient summary, support for nurses to manage their planned activities during a series of shifts, provide unstructured text fields for narrative charting, and to support adding informal notes for personalized care.

Developing Evidence-Based Design Guidelines for Medical/Surgical Hospital Patient Rooms That Meet the Needs of Staff, Patients, and Visitors.

OBJECTIVES: This research investigated medical/surgical (Med/Surg) patient room design to accommodate the needs of hospital staff, while at the same time accommodating the needs of patients and their visitors. BACKGROUND: Designing hospital patient rooms that provide a comfortable healing experience for patients, while at the same time meeting the needs of the hospital staff, is a challenging process. Prior research has shown that many hospital patient room designs adversely affect the ability of hospital staff to perform their tasks effectively, efficiently, and safely. METHOD: Twenty-seven design sessions were conducted in which 104 participants, representing 24 different occupations, worked in small mixed occupational groups to design an ideal single patient Med/Surg patient room to fit their collective needs using a full-scale mock-up. During analysis, the investigators reduced the resulting 27 room designs to 5 hybrid designs that were sequentially reviewed by patients and visitors and by staff to address design conflicts. RESULTS: This design process identified 51 desirable room design features that were incorporated into 66 evidence-based design guidelines for the different areas within the Med/Surg patient room including the entry way (16 guidelines), the patient clinical area (22 guidelines), the bathroom (17 guidelines), the family area (8 guidelines), and storage areas for patients and their visitors (3 guidelines). CONCLUSIONS: The guidelines developed through this study identified many opportunities for improving the design of hospital Med/Surg rooms to allow staff to be more effective, efficient, and safer, while at the same time addressing the design needs of patients and their visitors.

Reducing delays to diagnosis in ambulatory care settings: A macrocognition perspective.

We aim to use a macrocognition theoretical perspective to characterize contributors to diagnostic delays by physicians that can be mitigated by work system redesign. As experienced with other complex, sociotechnical domains, system redesign is anticipated to be more effective at improving safety than training-based solutions. In the outpatient care setting, complex tasks, conducted by a primary care provider, are provided for five macrocognition functions: sensemaking, re-planning, detecting problems, deciding, and coordinating. Redesigning systems could reduce delays to diagnosis by helping users to avoid missed symptoms, forgotten follow-up activities, and delayed actions. Health information technology could support resilience strategies by offloading documentation burdens, recording working diagnoses, displaying planned follow-up activities at the correct time interval, and supporting recognition of patterns in patient care. These insights suggest a path forward for future research on system design innovations to reduce diagnostic delays, and ultimately, reduce patient harm.

Using timbre to improve performance of larger auditory alarm sets.

Identifiability and perceived urgency were compared for two sets of alarms in a healthcare inpatient setting. One contained currently used alarms where possible, with new sounds added as needed. The other was designed together, was more heterogenous, used timbre to encode intended similarities and explicitly encoded intended urgency across the set. Twenty nurses reported the identity and perceived urgency of the sounds in each set. Participants correctly identified the sound (0.89 vs. 0.77) and alarm category (0.93 vs. 0.82) more often in the new set than in the baseline set. In addition, multiple sounds in the new set were more identifiable. The new sounds also had a larger range of perceived urgency and better urgency match. The results indicate that timbre is well-suited to encode alarm groupings in larger alarm sets and that this, along with increased heterogeneity and explicit urgency mapping, improves alarm set performance. Practitioner summary: Clinical alarms are frequently misidentified. We found that making alarms more acoustically rich, using timbre to convey alarm groups, and explicitly encoding intended urgency improved identifiability and urgency match. These findings can be used to improve alarm performance across all safety-critical industries.

Descriptive Usability Study of CirrODS: Clinical Decision and Workflow Support Tool for Management of Patients With Cirrhosis.

BACKGROUND: There are gaps in delivering evidence-based care for patients with chronic liver disease and cirrhosis. OBJECTIVE: Our objective was to use interactive user-centered design methods to develop the Cirrhosis Order Set and Clinical Decision Support (CirrODS) tool in order to improve clinical decision-making and workflow. METHODS: Two work groups were convened with clinicians, user experience designers, human factors and health services researchers, and information technologists to create user interface designs. CirrODS prototypes underwent several rounds of formative design. Physicians (n=20) at three hospitals were provided with clinical scenarios of patients with cirrhosis, and the admission orders made with and without the CirrODS tool were compared. The physicians rated their experience using CirrODS and provided comments, which we coded into categories and themes. We assessed the safety, usability, and quality of CirrODS using qualitative and quantitative methods. RESULTS: We created an interactive CirrODS prototype that displays an alert when existing electronic data indicate a patient is at risk for cirrhosis. The tool consists of two primary frames, presenting relevant patient data and allowing recommended evidence-based tests and treatments to be ordered and categorized. Physicians viewed the tool positively and suggested that it would be most useful at the time of admission. When using the tool, the clinicians placed fewer orders than they placed when not using the tool, but more of the orders placed were considered to be high priority when the tool was used than when it was not used. The physicians' ratings of CirrODS indicated above average usability. CONCLUSIONS: We developed a novel Web-based combined clinical decision-making and workflow support tool to alert and assist clinicians caring for patients with cirrhosis. Further studies are underway to assess the impact on quality of care for patients with cirrhosis in actual practice.

Value and Usage of a Workaround Artifact: A Cognitive Work Analysis of "Brains" Use by Hospital Nurses.

We identify the value and usage of a cognitive artifact used by hospital nurses. By analyzing the value and usage of workaround artifacts, unmet needs using intended systems can be uncovered. A descriptive study employed direct observations of registered nurses at two hospitals using a paper workaround ("brains") and the Electronic Health Record. Field notes and photographs were taken; the format, size, layout, permanence, and content of the artifact were analyzed. Thirty-nine observations, spanning 156 hr, were conducted with 20 nurses across four clinical units. A total of 322 photographs of paper-based artifacts for 161 patients were collected. All participants used and updated "brains" during report, and throughout the shift, most were self-generated. These artifacts contained patient identifiers in a header with room number, last name, age, code status, and physician; clinical data were recorded in the body with historical chronic issues, detailed assessment information, and planned activities for the shift. Updates continuously made during the shift highlighted important information, updated values, and tracked the completion of activities. The primary functional uses of "brains" are to support nurses' needs for clinical immediacy through personally generated snapshot overviews for clinical summaries and updates to the status of planned activities.

Nursing Handovers in Critical Care: A Retrospective Analysis of Information Content and Function.

Translating validated handover protocols from physicians in non-critical care settings to nursing report in critical care is challenging. Our objectives are to identify information content in verbal reports, where information is documented, and the function of non-documented communication. This is a descriptive study of 20 reports describing 27 patients from two medical intensive care units. Analysis involved unique coding of phrases and emergent themes analysis. Information categories included: Identify patient (51.9%); Narrative history (96.3%); Unusual symptoms (88.9%); Response to care (37%); Status of tasks (100%); Expectations of patients and families (55.6%). Information is documented in progress notes, the medication administration record, nursing flowsheets, lab results, orders, and past medical history. Information not typically documented supports providing patient-centered care, sharing clinical judgments, coordinating work, and mentorship. These objectives may guide nursing administrators in tailoring policies and procedures for nursing report to the needs of registered nurses in a critical care setting.

Predicting mortality with applied machine learning: Can we get there?

There is growing interest in using AI-based algorithms to support clinician decision-making. An important consideration is how transparent complex algorithms can be for predictions, particularly with respect to imminent mortality in a hospital environment. Understanding the basis of predictions, the process used to generate models and recommendations, how to generalize models based on one patient population to another, and the role of oversight organizations such as the Food and Drug Administration are important topics. In this paper, we debate opposing positions regarding whether these algorithms are 'ready yet' for use today in clinical settings for physicians, patients and caregivers. We report voting results from participating audience members in attendance at the conference debate for each of these positions obtained real-time from a smartphone-based platform.