Transitioning Cognitive Aids into Decision Support Platforms: Requirements and Design Guidelines.

Digital cognitive aids have the potential to serve as clinical decision support platforms, triggering alerts about process delays and recommending interventions. In this mixed-methods study, we examined how a digital checklist for pediatric trauma resuscitation could trigger decision support alerts and recommendations. We identified two criteria that cognitive aids must satisfy to support these alerts: (1) context information must be entered in a timely, accurate, and standardized manner, and (2) task status must be accurately documented. Using co-design sessions and near-live simulations, we created two checklist features to satisfy these criteria: a form for entering the pre-hospital information and a progress slider for documenting the progression of a multi-step task. We evaluated these two features in the wild, contributing guidelines for designing these features on cognitive aids to support alerts and recommendations in time- and safety-critical scenarios.

Factors Affecting Peripheral Intravenous Catheter Placement During Pediatric Trauma Resuscitation.

INTRODUCTION: Intravenous access is required for resuscitation of injured patients but may be delayed in children because of challenges associated with peripheral intravenous (PIV) catheter placement. Early identification of factors predisposing patients to difficult PIV placement can assist in deciding strategies for timely intravenous access. METHODS: We conducted a retrospective, video-based review of injured children and adolescents treated between April 2018 and May 2019. Patient demographic, physiological, injury, and resuscitation characteristics were obtained from the patient record, including age, race, weight, injury type, Injury Severity Score, initial systolic blood pressure, initial Glasgow Coma Score, intubation status, activation level, and presence of prearrival notification. Video review was used to determine the time to PIV placement, the number of attempts required, the purpose for additional access, and the reason for abandonment of PIV placement. Multivariable regressions were used to determine factors associated with successful placement. RESULTS: During the study period, 154 consented patients underwent attempts at PIV placement in the trauma bay. Placement was successful in 139 (90.3%) patients. Older patients (OR [odds ratio]: 0.9, 95% confidence interval [CI]: 0.9, 0.9) and patients who required the highest level activation response (OR: 0.0, 95% CI: 0.0, 0.3) were less likely to have an attempt at PIV placement abandoned. Children with nonblunt injuries (OR: 11.6, 95% CI: 1.3, 119.2) and pre-existing access (OR: 39.6, 95% CI: 7.0, 350.6) were more likely to have an attempt at PIV placement abandoned. Among patients with successful PIV placement, the time required for establishing PIV access was faster as age increased (-0.5 s, 95% CI: -1.1, -0.0). CONCLUSIONS: Younger age was associated with abandonment of PIV attempts and, when successful, increased time to placement. Strategies to improve successful PIV placement and alternate routes of access should be considered early to prevent treatment delays in younger children.

Analysis of Task Attributes Associated with Crisis Checklist Compliance in Pediatric Trauma Resuscitation.

Although checklists can improve overall team performance during medical crises, non-compliant checklist use poses risks to patient safety. We examined how task attributes affected checklist compliance by studying the use of a digital checklist during trauma resuscitation. We first determined task attributes and checklist compliance behaviors for 3,131 resuscitation tasks. Using statistical analyses and qualitative video review, we then identified barriers to accurately tracking task status, finding that certain task attributes were associated with non-compliant checklist behaviors. For example, tasks with multiple steps were more likely to be incorrectly recorded as completed when the task was not performed to completion. We discuss challenges in capturing and tracking the status of tasks with attributes that contribute to non-compliant checklist use. We also contribute a framework for understanding how tasks with certain attributes can be designed on checklists to improve compliance.

Transitioning to Remote User-Centered Design Activities in the Emergency Medical Field During a Pandemic.

During the COVID-19 pandemic, we had to transition our user-centered research and design activities in the emergency medical domain of trauma resuscitation from in-person settings to online environments. This transition required that we replicate the in-person interactions remotely while maintaining the critical social connection and the exchange of ideas with medical providers. In this paper, we describe how we designed and conducted four user-centered design activities from our homes: participatory design workshops, near-live simulation sessions, usability evaluation sessions, and interviews and design walkthroughs. We discuss the differences we observed in our interactions with participants in remote sessions, as well as the differences in the interactions among the research team members. From this experience, we draw several lessons and outline the best practices for remotely conducting user-centered design activities that have been traditionally held in person.

Designing Interactive Alerts to Improve Recognition of Critical Events in Medical Emergencies.

Vital sign values during medical emergencies can help clinicians recognize and treat patients with life-threatening injuries. Identifying abnormal vital signs, however, is frequently delayed and the values may not be documented at all. In this mixed-methods study, we designed and evaluated a two-phased visual alert approach for a digital checklist in trauma resuscitation that informs users about undocumented vital signs. Using an interrupted time series analysis, we compared documentation in the periods before (two years) and after (four months) the introduction of the alerts. We found that introducing alerts led to an increase in documentation throughout the post-intervention period, with clinicians documenting vital signs earlier. Interviews with users and video review of cases showed that alerts were ineffective when clinicians engaged less with the checklist or set the checklist down to perform another activity. From these findings, we discuss approaches to designing alerts for dynamic team-based settings.

Exploring the Design of Streaming Data Interfaces for Emergency Medical Contexts.

In this late-breaking work, we describe the design of an interface for displaying streaming vital sign data on a digital checklist used in the emergency medical setting of pediatric trauma resuscitation. We used feedback from interviews and participatory design workshops with clinicians to develop two prototypes of the streaming vital sign interface. We evaluated these prototypes in design-walkthroughs, finding that clinicians preferred the design displaying trend graphs for all four vital signs at once. We discuss how streaming data interfaces on interactive mobile devices can be used to provide situational awareness while unobtrusively supporting different levels of clinical experience.

Understanding Digital Checklist Use Through Team Communication.

Introducing technology support in a complex, team-based work setting requires a study of teamwork effects on technology use. In this paper, we present our initial analysis of team communications in a trauma resuscitation setting, where we deployed a digital checklist to support trauma team leaders in guiding patient care. By analyzing speech transcripts, checklist interaction logs, and videos of 15 resuscitations, we identified several tensions that arose from the use of a checklist in a team-based process with multi-step tasks. The tensions included incorrect markings of in-progress tasks as completed, failure to mark completed tasks due to missed communications, failure to record planned tasks, and difficulties in recording dynamic values. From these findings, we discuss design implications for checklist design for dynamic, team-based activities.