Understanding Emergency Care Delivery Through Computer Simulation Modeling.

In 2017, Academic Emergency Medicine convened a consensus conference entitled, "Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes." This article, a product of the breakout session on "understanding complex interactions through systems modeling," explores the role that computer simulation modeling can and should play in research and development of emergency care delivery systems. This article discusses areas central to the use of computer simulation modeling in emergency care research. The four central approaches to computer simulation modeling are described (Monte Carlo simulation, system dynamics modeling, discrete-event simulation, and agent-based simulation), along with problems amenable to their use and relevant examples to emergency care. Also discussed is an introduction to available software modeling platforms and how to explore their use for research, along with a research agenda for computer simulation modeling. Through this article, our goal is to enhance adoption of computer simulation, a set of methods that hold great promise in addressing emergency care organization and design challenges.

Usability evaluation of an emergency department information system prototype designed using cognitive systems engineering techniques.

This article presents an evaluation of novel display concepts for an emergency department information system (EDIS) designed using cognitive systems engineering methods. EDISs assist emergency medicine staff with tracking patient care and ED resource allocation. Participants performed patient planning and orientation tasks using the EDIS displays and rated the display's ability to support various cognitive performance objectives along with the usability, usefulness, and predicted frequency of use for 18 system components. Mean ratings were positive for cognitive performance support objectives, usability, usefulness, and frequency of use, demonstrating the successful application of design methods to create useful and usable EDIS concepts that provide cognitive support for emergency medicine staff. Nurse and provider roles had significantly different perceptions of the usability and usefulness of certain EDIS components, suggesting that they have different information needs while working.

Rasmussen number greater than one.

This essay describes the ramifying influence of Jens Rasmussen, illustrating how his work lives on through people whom he has influenced, even though they may have never directly collaborated. I approach this in three ways: a social network analysis of the 'Rasmussen number' (an analogue of the Erdös number); and two citations network analyses based on different search domains and different network structures.

Communication in the Electronic Age: an Analysis of Face-to-Face Physician-Nurse Communication in the Emergency Department.

We describe the patterns and content of nurse to physician verbal conversations in three emergency departments (EDs) with electronic health records. Emergency medicine physicians and nurses were observed for 2 h periods. Researchers used paper notes to document the characteristics (e.g., partners involved, location of communication, who initiated communication) and content of nurse to physician conversations. Eighteen emergency nurses and physicians (nine each) were observed for a total of 36 h. Two hundred and fifty-five unique communication events were recorded across three emergency departments spread evenly across day, evening, and night shifts. A qualitative analysis of communication event content revealed 5 types of communication and 13 content themes. Content themes covered a broad range of topics including exchange of patient health information, management of the ED, and coordination of orders. Physician participants experienced significantly more communication events than nurse participants, while nurses initiated significantly more communication events than physicians. Most of the communication events occurred at the physician workstation followed by patient treatment areas. This study describes nature of verbal nurse to physician communication in the ED. Direct communication is still used to communicate important information, such as information about patients' status, in EDs with established electronic health records. Our results provide an overview of information exchanged in the ED which can serve as a basis for designing improved information support systems.

Naloxone Triggering the RRT: A Human Antidote?

OBJECTIVES: At our institution, we observed an increase in opioid-related adverse events after instituting a new pain treatment protocol. To prevent this, we programmed the Omnicell drug dispensing system to page the RRT whenever naloxone was withdrawn on the general wards. METHODS: Retrospective review of a prospectively collected database with a before and after design. RESULTS: When comparing the two 12-month periods, there was a decrease in monthly opioid-related cardiac arrests from 0.75 to 0.25 per month (difference = 0.5; 95% CI, 0.04-0.96, P = 0.03) and a nearly significant decrease in code deaths from 0.25 to 0 per month (difference = -0.25; 95% CI, -0.02-0.52, P = 0.07) without a significant decrease in pain satisfaction scores (difference = -2.3; 95% CI, -4.4 to 9.0, P = 0.48) over the study period. There were also decreased RRT interventions from 7.3 to 5.6 per month (difference = -1.7; 95% CI, -0.31 to -3.03, P = 0.02) and decreased inpatient transfers from 2.9 to 1.8 transfers per month (difference = -1.2; 95% CI, -0.38 to -1.96, P = 0.005). When adjusting for inpatient admissions and inpatient days, there was a decrease in opioid-related cardiac arrests from 2.9 to 0.1 per 10,000 admissions (difference = -2.0; 95% CI, -0.2 to -3.8, P = 0.03) and a decrease in cardiac arrests from 0.5 to 0.2 per 10,000 patients (difference = -0.34; 95% CI, -.02 to -0.65, P = 0.04). CONCLUSION: Naloxone-triggered activation of the RRT resulted in reduced opioid-related inpatient cardiac arrests without adversely affecting pain satisfaction scores.

Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?

BACKGROUND: Despite over a decade of efforts to reduce the adverse event rate in healthcare, the rate has remained relatively unchanged. Root cause analysis (RCA) is a process used by hospitals in an attempt to reduce adverse event rates; however, the outputs of this process have not been well studied in healthcare. This study aimed to examine the types of solutions proposed in RCAs over an 8-year period at a major academic medical institution. METHODS: All state-reportable adverse events were gathered, and those for which an RCA was performed were analysed. A consensus rating process was used to determine a severity rating for each case. A qualitative approach was used to categorise the types of solutions proposed by the RCA team in each case and descriptive statistics were calculated. RESULTS: 302 RCAs were reviewed. The most common event types involved a procedure complication, followed by cardiopulmonary arrest, neurological deficit and retained foreign body. In 106 RCAs, solutions were proposed. A large proportion (38.7%) of RCAs with solutions proposed involved a patient death. Of the 731 proposed solutions, the most common solution types were training (20%), process change (19.6%) and policy reinforcement (15.2%). We found that multiple event types were repeated in the study period, despite repeated RCAs. CONCLUSIONS: This study found that the most commonly proposed solutions were weaker actions, which were less likely to decrease event recurrence. These findings support recent attempts to improve the RCA process and to develop guidance for the creation of effective and sustainable solutions to be used by RCA teams.

End-tidal carbon dioxide and occult injury in trauma patients: ETCO2 does not rule out severe injury.

OBJECTIVE: To determine if early measurement of end-tidal carbon dioxide (ETCO2) in nonintubated patients triaged to a level 1 trauma center has utility in ruling out severe injury. METHODS: We performed a prospective cohort study of adult patients triaged to our urban, academic, level 1 trauma center. Included patients had ETCO2 measured within 30 minutes of arrival. Chart review was performed on enrolled patients to identify severe injury defined by: admission to an intensive care unit, need for an invasive procedure, blood product transfusion, acute blood loss anemia, and acute clinically significant finding on computed tomographic scan. RESULTS: Of 170 patients enrolled, 115 met the outcome of no severe injury. Mean ETCO2 for patients without and with severe injury was 33.1 mm Hg (SD, 5.8) and 30.3 mm Hg (SD, 6.7), respectively. This difference reached statistical significance (P=.05), but did not demonstrate added clinical utility when combined with Glasgow Coma Scale, systolic blood pressure, and age in predicting the primary outcome (area under curve, 0.70 with ETCO2 vs area under curve, 0.68 without ETCO2, P=.5). Patients with ETCO2 ≤30 mm Hg were found to be older, more likely to require intensive care unit admission or emergency operative intervention, develop acute blood loss anemia, and have an acute finding on computed tomography than patients with a higher ETCO2. CONCLUSION: End-tidal carbon dioxide cannot be used to rule out severe injury in patients meeting criteria for trauma center care. The ETCO2 ≤30 mm Hg may be associated with increased risk of traumatic severe injury.

Understanding Overuse of Computed Tomography for Minor Head Injury in the Emergency Department: A Triangulated Qualitative Study.

BACKGROUND: Overuse of computed tomography (CT) for minor head injury continues despite developed and rigorously validated clinical decision rules like the Canadian CT Head Rule (CCHR). Adherence to this sensitive and specific rule could decrease the number of CT scans performed in minor head injury by 35%. But in practice, the CCHR has failed to reduce testing, despite its accurate performance. OBJECTIVES: The objective was to identify nonclinical, human factors that promote or inhibit the appropriate use of CT in patients presenting to the emergency department (ED) with minor head injury. METHODS: This was a qualitative study in three phases, each with interview guides developed by a multidisciplinary team. Subjects were recruited from patients treated and released with minor head injuries and providers in an urban academic ED and a satellite community ED. Focus groups of patients (four groups, 22 subjects total) and providers (three groups, 22 subjects total) were conducted until thematic saturation was reached. The findings from the focus groups were triangulated with a cognitive task analysis, including direct observation in the ED (>150 hours), and individual semistructured interviews using the critical decision method with four senior physician subject matter experts. These experts are recognized by their peers for their skill in safely minimizing testing while maintaining patient safety and engagement. Focus groups and interviews were audio recorded and notes were taken by two independent note takers. Notes were entered into ATLAS.ti and analyzed using the constant comparative method of grounded theory, an iterative coding process to determine themes. Data were double-coded and examined for discrepancies to establish consensus. RESULTS: Five core domains emerged from the analysis: establishing trust, anxiety (patient and provider), constraints related to ED practice, the influence of others, and patient expectations. Key themes within these domains included patient engagement, provider confidence and experience, ability to identify and manage patient anxiety, time constraints, concussion knowledge gap, influence of health care providers, and patient expectations to get a CT. CONCLUSIONS: Despite high-quality evidence informing use of CT in minor head injury, multiple factors influence the decision to obtain CT in practice. Identifying and disseminating approaches and designing systems that help clinicians establish trust and manage uncertainty within the ED context could optimize CT use in minor head injury.

Resilient health care: turning patient safety on its head.

The current approach to patient safety, labelled Safety I, is predicated on a 'find and fix' model. It identifies things going wrong, after the event, and aims to stamp them out, in order to ensure that the number of errors is as low as possible. Healthcare is much more complex than such a linear model suggests. We need to switch the focus to what we have come to call Safety II: a concerted effort to enable things to go right more often. The key is to appreciate that healthcare is resilient to a large extent, and everyday performance succeeds much more often than it fails. Clinicians constantly adjust what they do to match the conditions. Facilitating work flexibility, and actively trying to increase the capacity of clinicians to deliver more care more effectively, is key to this new paradigm. At its heart, proactive safety management focuses on how everyday performance usually succeeds rather than on why it occasionally fails, and actively strives to improve the former rather than simply preventing the latter.