A pharmacokinetic-pharmacodynamic real-time display may change anesthesiologists' behavior.

We have developed a real-time graphical display that presents anesthetic pharmacology data (drug effect site concentrations (Ce) and probability of anesthetic effects including hypnosis, loss of response to tracheal intubation), improving a previous prototype. We hypothesized that the use of the display alters (1) clinical behavior of anesthesiologists (i.e., Ce of isoflurane and fentanyl at the end of anesthesia), (2) fentanyl dose during the first 30 min of recovery in the post anesthesia care unit (PACU), and that the response of clinicians to the display in terms of workload and utility is favorable. The display was evaluated in a two-group, non-randomized prospective observational study of 30 patients undergoing general anesthesia using isoflurane and fentanyl. The isoflurane-predicted Ce was lower in the display group (without-display: 0.64% ± 0.06%; with-display: 0.42 ± 0.04%; t23.9 = 3.17, P = 0.004 < adjusted alpha 0.05/2). The difference in fentanyl-predicted Ce did not achieve statistical significance (without-display: 1.5 ± 0.1 ng/ml; with-display: 2.0 ± 0.2 ng/ml; t25.5 = 2.26, P = 0.03 > adjusted alpha 0.05/2) (means ± standard error). A joint test of isoflurane and fentanyl Ce with respect to the display condition rejected the null hypothesis of no differences (Hotelling T2, P = 0.01), supporting our primary hypothesis. The total fentanyl per patient during the first 30 min in the PACU with the display was 75.0 ± 62.7 µg and that without the display was 83.0 ± 74.7 µg. There was no significant difference between the groups (means ± standard deviation, P = 0.75). There were no differences in perceived workload. Use of the display does not appear to be cognitively burdensome and may change the anesthesiologist's dosing regimen.

Feasibility of implementing an electronic social support and resource visualization tool for caregivers in a neuro-oncology clinic.

PURPOSE: The goals of this study were to assess the feasibility of a web-based application-electronic Social Network Assessment Program (eSNAP)-to automate the capture and visualization of family caregiver social network data of neuro-oncology patients. METHODS: Caregivers were recruited from a neuro-oncology clinic at an NCI-designated comprehensive cancer center. Participants completed baseline questionnaires on a laptop in clinic assessing demographic characteristics. After baseline, participants were randomly assigned to either create a social network visualization using eSNAP (intervention) or to usual care (control) condition. Those who used eSNAP provided likeability/usability data. All participants were asked to complete follow-up questionnaires at 3 and 6 weeks after baseline to determine feasibility of longitudinal study. RESULTS: We recruited 40 caregivers of patients with primary malignant brain tumor to participate in this study. Participants rated eSNAP usability and likeability highly, indicating that eSNAP would help them consider their available social support. At 3 weeks, 90% of participants completed questionnaires and 82.5% completed questionnaires at 6 weeks. CONCLUSIONS: There is a need to encourage family caregivers of patients with primary malignant brain tumor to engage their existing social network resources to help alleviate caregiver burden. Our findings suggest that our web-based application to address this issue is feasible to implement with high usability and likeability. This pilot study identified minor changes to the intervention to improve effectiveness and has implications for future research in this understudied population. TRIAL REGISTRATION: clinicaltrials.gov, protocol number NCT03026699.

Outcomes of an electronic social network intervention with neuro-oncology patient family caregivers.

INTRODUCTION: Informal family caregivers (FCG) are an integral and crucial human component in the cancer care continuum. However, research and interventions to help alleviate documented anxiety and burden on this group is lacking. To address the absence of effective interventions, we developed the electronic Support Network Assessment Program (eSNAP) which aims to automate the capture and visualization of social support, an important target for overall FCG support. This study seeks to describe the preliminary efficacy and outcomes of the eSNAP intervention. METHODS: Forty FCGs were enrolled into a longitudinal, two-group randomized design to compare the eSNAP intervention in caregivers of patients with primary brain tumors against controls who did not receive the intervention. Participants were followed for six weeks with questionnaires to assess demographics, caregiver burden, anxiety, depression, and social support. Questionnaires given at baseline (T1) and then 3-weeks (T2), and 6-weeks (T3) post baseline questionnaire. RESULTS: FCGs reported high caregiver burden and distress at baseline, with burden remaining stable over the course of the study. The intervention group was significantly less depressed, but anxiety remained stable across groups. CONCLUSIONS: With the lessons learned and feedback obtained from FCGs, this study is the first step to developing an effective social support intervention to support FCGs and healthcare providers in improving cancer care.

Evaluation of the effect of information integration in displays for ICU nurses on situation awareness and task completion time: A prospective randomized controlled study.

OBJECTIVE: The study measured whether nurses' situation awareness would increase and task completion time decrease when they used an integrated information display compared to traditional displays for medication management, patient awareness and team communication. SETTING: The Burn Trauma Intensive Care Unit (BTICU) at the University Hospital, University of Utah Health Science Center, Salt Lake City, Utah, USA. PARTICIPANTS: 12 experienced BTICU nurses. MEASURES: Situation awareness (accuracy of the participants' answer) and task completion time (response time from seeing the question to submitting the answer) were measured using paper prototypes of both displays. STUDY DESIGN: Counter-balanced (on display order), repeated-measures design. MAIN RESULTS: Nurses had a higher situation awareness when using the integrated display, with an overall accuracy of 85.3% compared to 61.8% with the traditional displays (odds ratio 3.61, P<.001, 95% CI=2.34…5.57). Task completion times were nearly half with integrated displays compared to traditional displays (median 26.0 and 42.1s, hazard ratio 2.31, P<.001, CI=1.83…2.93). CONCLUSIONS: An integrated ICU information display increased nurses' situation awareness and decreased task completion time. Information integration has the potential to decrease errors, increase nurses' productivity and may allow nurses to react faster to a patient's clinical needs. Bidirectional device communication is needed for these displays to achieve full potential in improving patient safety.

ICU nurses' evaluations of integrated information displays on user satisfaction and perceived mental workload.

Consolidated information from multiple sources (patient monitors, electronic medical records, infusion pumps, ventilators, medication references) may improve nurses' work and patient safety. Objective. Two hypotheses were tested, that integrated information displays (a) improve nurses' satisfaction and (b) lower perceived mental workload. Methods. In a counter-balanced, repeated measures design (integrated vs. traditional display) 12 ICU nurses performed realistic tasks using both display types. Results. Nurses' user interaction satisfaction was higher with the integrated display and it received more positive comments. Nurses' mean perceived mental workload scores were also lower, having significant differences in effort and frustration dimensions. A lower mental workload may reduce errors and improve treatment times. Integrated information displays have great promise, but technological factors such as bidirectional device communication must be addressed if these displays are to achieve their potential for improving patient safety.

Evaluation of an integrated graphical display to promote acute change detection in ICU patients.

OBJECTIVE: The purpose of this study was to evaluate ICU nurses' ability to detect patient change using an integrated graphical information display (IGID) versus a conventional tabular ICU patient information display (i.e. electronic chart). DESIGN: Using participants from two different sites, we conducted a repeated measures simulator-based experiment to assess ICU nurses' ability to detect abnormal patient variables using a novel IGID versus a conventional tabular information display. Patient scenarios and display presentations were fully counterbalanced. MEASUREMENTS: We measured percent correct detection of abnormal patient variables, nurses' perceived workload (NASA-TLX), and display usability ratings. RESULTS: 32 ICU nurses (87% female, median age of 29 years, and median ICU experience of 2.5 years) using the IGID detected more abnormal variables compared to the tabular display [F(1, 119)=13.0, p<0.05]. There was a significant main effect of site [F(1, 119)=14.2], with development site participants doing better. There were no significant differences in nurses' perceived workload. The IGID display was rated as more usable than the conventional display [F(1, 60)=31.7]. CONCLUSION: Overall, nurses reported more important physiological information with the novel IGID than tabular display. Moreover, the finding of site differences may reflect local influences in work practice and involvement in iterative display design methodology. Information displays developed using user-centered design should accommodate the full diversity of the intended user population across use sites.

Intensive care unit nurses' information needs and recommendations for integrated displays to improve nurses' situation awareness.

OBJECTIVE: Fatal errors can occur in intensive care units (ICUs). Researchers claim that information integration at the bedside may improve nurses' situation awareness (SA) of patients and decrease errors. However, it is unclear which information should be integrated and in what form. Our research uses the theory of SA to analyze the type of tasks, and their associated information gaps. We aimed to provide recommendations for integrated, consolidated information displays to improve nurses' SA. MATERIALS AND METHODS: Systematic observations methods were used to follow 19 ICU nurses for 38 hours in 3 clinical practice settings. Storyboard methods and concept mapping helped to categorize the observed tasks, the associated information needs, and the information gaps of the most frequent tasks by SA level. Consensus and discussion of the research team was used to propose recommendations to improve information displays at the bedside based on information deficits. RESULTS: Nurses performed 46 different tasks at a rate of 23.4 tasks per hour. The information needed to perform the most common tasks was often inaccessible, difficult to see at a distance or located on multiple monitoring devices. Current devices at the ICU bedside do not adequately support a nurse's information-gathering activities. Medication management was the most frequent category of tasks. DISCUSSION: Information gaps were present at all levels of SA and across most of the tasks. Using a theoretical model to understand information gaps can aid in designing functional requirements. CONCLUSION: Integrated information that enhances nurses' Situation Awareness may decrease errors and improve patient safety in the future.

A far-view intensive care unit monitoring display enables faster triage.

Although nurses perform the majority of the clinical tasks in an intensive care unit, current patient monitors were not designed to support a nurse's workflow. Nurses constantly triage patients, deciding which patient is currently in the most need of care. To make this decision, nurses must observe the patient's vital signs and therapeutic device information from multiple sources. To obtain this information, they often have to enter the patient's room. This study addresses 3 hypotheses. Information provided by far-view monitoring displays (1) reduces the amount of time to determine which patient needs care first, (2) increases the accuracy of assigning priority to the right patient, and (3) reduces nurses mental workload. We developed 2 far-view displays to be read from a distance of 3 to 5 m without entering the patient's room. Both display vital signs, trends, alarms, infusion pump status, and therapy support indicators. To evaluate the displays, nurses were asked to use the displays to decide which of 2 patients required their attention first. They made 60 decisions: 20 with each far-view display and 20 decisions with a standard patient monitor next to an infusion pump. Sixteen nurses (median age of 27.5 years with 2.75 years of experience) participated in the study. Using the 2 far-view displays, nurses more accurately and rapidly identified stable patients and syringe pumps that were nearly empty. Median decision times were 11.3 and 12.4 seconds for the 2 far-view displays and 17.2 seconds for the control display. The 2 far-view displays reduced median decision-making times by 4.8 to 5.9 seconds, increased accuracy in assignment of priority in 2 of 7 patient conditions, and reduced nurses' frustration with the triaging task. In a clinical setting, the proposed far-view display might reduce nurses' mental workload and thereby increase patient safety.

Graphical arterial blood gas visualization tool supports rapid and accurate data interpretation.

A visualization tool that integrates numeric information from an arterial blood gas report with novel graphics was designed for the purpose of promoting rapid and accurate interpretation of acid-base data. A study compared data interpretation performance when arterial blood gas results were presented in a traditional numerical list versus the graphical visualization tool. Critical-care nurses (n = 15) and nursing students (n = 15) were significantly more accurate identifying acid-base states and assessing trends in acid-base data when using the graphical visualization tool. Critical-care nurses and nursing students using traditional numerical data had an average accuracy of 69% and 74%, respectively. Using the visualization tool, average accuracy improved to 83% for critical-care nurses and 93% for nursing students. Analysis of response times demonstrated that the visualization tool might help nurses overcome the "speed/accuracy trade-off" during high-stress situations when rapid decisions must be rendered. Perceived mental workload was significantly reduced for nursing students when they used the graphical visualization tool. In this study, the effects of implementing the graphical visualization were greater for nursing students than for critical-care nurses, which may indicate that the experienced nurses needed more training and use of the new technology prior to testing to show similar gains. Results of the objective and subjective evaluations support the integration of this graphical visualization tool into clinical environments that require accurate and timely interpretation of arterial blood gas data.

Graphical arterial blood gas visualization tool supports rapid and accurate data interpretation.

A visualization tool that integrates numeric information from an arterial blood gas report with novel graphics was designed for the purpose of promoting rapid and accurate interpretation of acid-base data. A study compared data interpretation performance when arterial blood gas results were presented in a traditional numerical list versus the graphical visualization tool. Critical-care nurses (n = 15) and nursing students (n = 15) were significantly more accurate identifying acid-base states and assessing trends in acid-base data when using the graphical visualization tool. Critical-care nurses and nursing students using traditional numerical data had an average accuracy of 69% and 74%, respectively. Using the visualization tool, average accuracy improved to 83% for critical-care nurses and 93% for nursing students. Analysis of response times demonstrated that the visualization tool might help nurses overcome the "speed/accuracy trade-off" during high-stress situations when rapid decisions must be rendered. Perceived mental workload was significantly reduced for nursing students when they used the graphical visualization tool. In this study, the effects of implementing the graphical visualization were greater for nursing students than for critical-care nurses, which may indicate that the experienced nurses needed more training and use of the new technology prior to testing to show similar gains. Results of the objective and subjective evaluations support the integration of this graphical visualization tool into clinical environments that require accurate and timely interpretation of arterial blood gas data.

The employment of an iterative design process to develop a pulmonary graphical display.

OBJECTIVE: Data representations on today's medical monitors need to be improved to advance clinical awareness and prevent data vigilance errors. Simply building graphical displays does not ensure an improvement in clinical performance because displays have to be consistent with the user's clinical processes and mental models. In this report, the development of an original pulmonary graphical display for anesthesia is used as an example to show an iterative design process with built-in usability testing. DESIGN: The process reported here is rapid, inexpensive, and requires a minimal number of subjects per development cycle. Three paper-based tests evaluated the anatomic, variable mapping, and graphical diagnostic meaning of the pulmonary display. MEASUREMENTS: A confusion matrix compared the designer's intended answer with the subject's chosen answer. Considering deviations off the diagonal of the confusion matrix as design weaknesses, the pulmonary display was modified and retested. The iterative cycle continued until the anatomic and variable mapping cumulative test scores for a chosen design scored above 90% and the graphical diagnostic meaning test scored above 75%. RESULTS: The iterative development test resulted in five design iterations. The final graphical pulmonary display improved the overall intuitiveness by 18%. The display was tested in three categories: anatomic features, variable mapping, and diagnostic accuracy. The anatomic intuitiveness increased by 25%, variable mapping intuitiveness increased by 34%, and diagnostic accuracy decreased slightly by 4%. CONCLUSION: With this rapid iterative development process, an intuitive graphical display can be developed inexpensively prior to formal testing in an experimental setting.