Healthcare providers' perceptions of a situational awareness display for emergency department resuscitation: a simulation qualitative study.

IMPORTANCE: Emergency resuscitation of critically ill patients can challenge team communication and situational awareness. Tools facilitating team performance may enhance patient safety. OBJECTIVES: To determine resuscitation team members' perceptions of the Situational Awareness Display's utility. DESIGN: We conducted focus groups with healthcare providers during Situational Awareness Display development. After simulations assessing the display, we conducted debriefs with participants. SETTING: Dual site tertiary care level 1 trauma centre in Ottawa, Canada. PARTICIPANTS: We recruited by email physicians, nurses and respiratory therapist. INTERVENTION: Situational Awareness Display, a visual cognitive aid that provides key clinical information to enhance resuscitation team communication and situational awareness. MAIN OUTCOMES AND MEASURES: Themes emerging from focus groups and simulation debriefs. Three reviewers independently coded and analysed transcripts using content qualitative analysis. RESULTS: We recruited a total of 33 participants in two focus groups (n = 20) and six simulation debriefs with three 4-5 member teams (n = 13). Majority of participants (10/13) strongly endorsed the Situational Awareness Display's utility in simulation (very or extremely useful). Focus groups and debrief themes included improved perception of patient data, comprehension of context and ability to project to future decisions. Participants described potentially positive and negative impacts on patient safety and positive impacts on provider performance and team communication. Participants expressed a need for easy data entry incorporated into clinical workflow and training on how to use the display. CONCLUSION: Emergency resuscitation team participants felt the Situational Awareness Display has potential to improve provider performance, team communication and situational awareness, ultimately enhancing quality of care.

Human factors considerations in designing for infection prevention and control in neonatal care - findings from a pre-design inquiry.

Qualitative data collection methods drawn from the early stages of human-centred design frameworks combined with thematic analysis were used to develop an understanding of infection prevention practice within an existing neonatal intensive care unit. Findings were used to generate a framework of understanding which in turn helped inform a baseline approach for future research and design development. The study revealed that a lack of clarity between infection transmission zones and a lack of design attributes needed to uphold infection prevention measures may be undermining healthcare workers' understanding and application of good practice. The issue may be further complicated by well-intentioned behavioural attitudes to meeting work objectives; undue influences from spatial constraints; the influence of inadvertent and excessive touch-based interactions; physical and/or cognitive exertion to maintain transmission barriers; and the impact of expanding job design and increased workload to supplement for lack of effective barriers. Practitioner Summary: Despite high hand hygiene compliance within a neonatal intensive care unit, healthcare workers expressed concerns about the unit design and infection prevention practice. Early inquiry methods from human-centred design and thematic analysis helped develop a framework to understand how design can be used to aid infection prevention.

Transferring patient care: patterns of synchronous bidisciplinary communication between physicians and nurses during handoffs in a critical care unit.

PURPOSE: The transfer of patient care from one health care worker to another involves communication in high-pressure contexts that are often vulnerable to error. This research project captured current practices for handoffs during the critical care stage of surgical recovery in a hospital setting. The objective was to characterize information flow during transfer and identify patterns of communication between nurses and physicians. DESIGN AND METHODS: Observations were used to document communication exchanges. The data were analyzed qualitatively according to the types of information exchanged and verbal behavior types. FINDINGS: Reporting and questions were the most common verbal behaviors, and retrospective medical information was the focus of information exchange. The communication was highly interactive when discussing patient status and future care plans. Nurses proactively asked questions to capture a large proportion of the information they needed. CONCLUSIONS: Findings reflect positive and constructive patterns of communication during handoffs in the observed hospital unit.

Using team cognitive work analysis to reveal healthcare team interactions in a birthing unit.

Cognitive work analysis (CWA) as an analytical approach for examining complex sociotechnical systems has shown success in modelling the work of single operators. The CWA approach incorporates social and team interactions, but a more explicit analysis of team aspects can reveal more information for systems design. In this paper, Team CWA is explored to understand teamwork within a birthing unit at a hospital. Team CWA models are derived from theories and models of teamwork and leverage the existing CWA approaches to analyse team interactions. Team CWA is explained and contrasted with prior approaches to CWA. Team CWA does not replace CWA, but supplements traditional CWA to more easily reveal team information. As a result, Team CWA may be a useful approach to enhance CWA in complex environments where effective teamwork is required. PRACTITIONER SUMMARY: This paper looks at ways of analysing cognitive work in healthcare teams. Team Cognitive Work Analysis, when used to supplement traditional Cognitive Work Analysis, revealed more team information than traditional Cognitive Work Analysis. Team Cognitive Work Analysis should be considered when studying teams.

Communication and team situation awareness in the OR: Implications for augmentative information display.

Team Situation Awareness (TSA) is one of the critical factors in effective Operating Room (OR) teamwork and can impact patient safety and quality of care. While previous research showed a relationship between situation awareness, as measured by communication events, and team performance, the implications for developing technology to augment and facilitate TSA were not examined. This research aims to further study situation-related communications in the cardiac OR in order to uncover potential degradation in TSA which may lead to adverse events. The communication loop construct-the full cycle of information flow between the participants in the sequence-was used to assess susceptibility to breakdown. Previous research and the findings here suggest that communication loops that are open, non-directed, or with delayed closure, can be susceptible to information loss. These were quantitatively related to communication indicators of TSA such as questions, replies, and announcements. Taken together, both qualitative and quantitative analyses suggest that a high proportion of TSA-related communication (63%) can be characterized as susceptible to information loss. The findings were then used to derive requirements and design a TSA augmentative display. The design principles and potential benefits of such a display are outlined and discussed.

Using human factors methods to evaluate the labelling of injectable drugs.

Adverse drug events, including in-hospital medication errors, are a well-documented world-wide problem. This interdisciplinary team set out to examine the issues related to the labelling of injectable drugs. We sought answers to the following two questions: (1) To what extent do injectable drug labels adhere to existing Canadian design practice recommendations and regulations for labelling and (2) is there a need to make changes to the recommendations or regulations for labelling of injectable drugs in Canada? The project contained three phases. The first phase involved taking a sample of vials and ampoules from a hospital pharmacy and identifying adherence to the 1999 Canadian Standards Association standard for the labelling of drug ampoules, vials and prefilled syringes, as well as with the Canadian (Health Canada) Food and Drug Regulations for labelling. The second phase involved a failure mode and effects analysis of the label-reading process in order to identify information on the label considered critical for safe medication use. The third phase involved a preliminary human factors experiment addressing one problem identified with existing labels. Our finding is that existing injectable drug labels do not adhere sufficiently to available best design standards for labels and also do not adhere to all Canadian Food and Drug Regulations. Recommendations are made to inform future enhancements to labelling standards, guidelines and regulations.

Effects of a computerized cardiac teletriage decision support system on nurse performance: results of a controlled human factors experiment using a mid-fidelity prototype.

A gap exists in cardiac care between known best practices and the actual level of care administered. To help bridge this gap, a proof of concept interface for a PDA-based decision support system (DSS) was designed for cardiac care nurses engaged in teletriage. This interface was developed through a user-centered design process. Quality of assessment, quality of recommendations, and number of questions asked were measured. Cardiac floor nurses' assessment quality performance, but not their recommendation quality performance, improved with the DSS. Nurses asked more questions with the DSS than without it, and these additional questions were predominantly classifiable as essential or beneficial to a good assessment. The average participant satisfaction score with the DSS was above neutral.

Using personal digital assistants and patient care algorithms to improve access to cardiac care best practices.

In order to facilitate knowledge transfer between specialists and generalists and between experts and novices, and to promote interdisciplinary communication, there is a need to provide methods and tools for doing so. This interdisciplinary research team developed and evaluated a decision support tool (DST) on a personal digital assistant (PDA) for cardiac tele-triage/tele-consultation when the presenting problem was chest pain. The combined human factors methods of cognitive work analysis during the requirements-gathering phase and ecological interface design during the design phase were used to develop the DST. A pilot clinical trial was conducted at a quaternary cardiac care hospital over a 3-month period. During this time, the DST was used by the nine nursing coordinators who provide tele-triage/tele-consultation 24/7. This clinical trial validated the design and demonstrated its usefulness to advanced cardiac care nurses, its potential for use by nurses less experienced in cardiac care, and for its potential use in an interdisciplinary team environment.

Getting a Picture.

Delivery of care by nurses in virtual environments is rapidly increasing with uptake of digitally mediated technologies, such as remote patient monitoring (RPM). Knowing the person is a phenomenon in nursing practice deemed requisite to building relationships and informing clinical decisions, but it has not been studied in virtual environments. PURPOSE OF STUDY: The intent of this study was to explicate the processes of how nurses come to know the person using RPM, one form of telehealth technology used in a virtual environment. STUDY DESIGN AND METHOD: The study was informed by Charmaz's constructivist grounded theory and included 33 interviews and 5 observational experiences of nurses using RPM in 7 different settings. FINDINGS: Getting a Picture evolved as the core category to a theoretical conceptualization of nurses knowing the person through use of RPM and other technologies, such as telephone and electronic medical records. Getting a Picture reflected a dynamic flow and integration of seven processes, such as Connecting With the Person and Recording and Reflecting, to describe how nurses strove to attain a visualization of the person. CONCLUSIONS: While navigating disparate and disconnected information and communication technologies, Getting a Picture was important for providing safe, holistic, person-centered care.

Building an Electronic Handover Tool for Physicians Using a Collaborative Approach between Clinicians and the Development Team.

In an effort by The Ottawa Hospital (TOH) to become one of the top 10% performers in patient safety and quality of care, the hospital embarked on improving the communication process during handover between physicians by building an electronic handover tool. It is expected that this tool will decrease information loss during handover. The Information Systems (IS) department engaged a workgroup of physicians to become involved in defining requirements to build an electronic handover tool that suited their clinical handover needs. This group became ultimately responsible for defining the graphical user interface (GUI) and all functionality related to the tool. Prior to the pilot, the Information Systems team will run a usability testing session to ensure the application is user friendly and has met the goals and objectives of the workgroup. As a result, The Ottawa Hospital has developed a fully integrated electronic handover tool built on the Clinical Mobile Application (CMA) which allows clinicians to enter patient problems, notes and tasks available to all physicians to facilitate the handover process.

Applications of ecological interface design in supporting the nursing process.

Today's nursing environment is complex, with many sources of data that are often poorly displayed. Ecological interface design (EID) is a systematic approach to designing interfaces to complex systems. EID has been used to design interfaces for aviation displays, power plant monitoring and control, human hemodynamic monitoring, anesthesia monitoring, and neonatal intensive care monitoring and diagnosis. EID makes critical relationships easily visible, eliminating the mental workload of integrating, calculating, or remembering multiple values. This paper reviews past experimental studies of EID in healthcare applications and discusses the application of EID to a decision-support tool for diabetic patients using personal digital assistants. The authors also discuss other contributions that EID could make to the nursing process in the areas of physiological monitoring, decision support, database design, and the measurement and analysis of nurse-sensitive outcomes, including patient safety outcomes.

Patients' understanding of cardiac risk factors: a point-prevalence study.

A 1-day point-prevalence study was conducted in our 141-bed tertiary cardiac care hospital in order to determine our patients' and their significant others' level of understanding of cardiac risk factors in general and of the patients' personal cardiac risk factors. There were 3 parts to the study: patient interviews, significant other (SO) interviews, and an audit of the participating patients' charts. Of the 87 patients who were able to participate, 71 completed the interviews as did 53 significant others. From recall, only 14 patients and 11 significant others were able to define what a cardiac risk factor was ("Habits or factors that contribute to heart disease") and they were unable to identify many general risk factors. However, when given a recognition task where cardiac risk factors were interspersed with sham factors, the overall mean general knowledge score was 13.6 for patients and 13.9 for significant others out of 16. The correlation between the patients' understanding of their cardiac risk factors and the significant others' understanding of them was reasonably good (r = 0.58, P < .0001), as was the correlation between the SOs' understanding and the charts (r = 0.58, P < .0001). There was less agreement between the patients' understanding and the chart documentation of cardiac risk factors (r = 0.36, P < .01). The findings of this study have implications for patient teaching as well as for documentation of cardiac risk factors.