Anna Grome

Critical care physician cognitive task analysis: an exploratory study

IntroductionFor better or worse, the imposition of work-hour limitations on house-staff has imperiled continuity and/or improved decision-making. Regardless, the workflow of every physician team in every academic medical centre has been irrevocably altered. We explored the use of cognitive task analysis (CTA) techniques, most commonly used in other high-stress and time-sensitive environments, to analyse key cognitive activities in critical care medicine. The study objective was to assess the usefulness of CTA as an analytical tool in order that physician cognitive tasks may be understood and redistributed within the work-hour limited medical decision-making teams.MethodsAfter approval from each Institutional Review Board, two intensive care units (ICUs) within major university teaching hospitals served as data collection sites for CTA observations and interviews of critical care providers.ResultsFive broad categories of cognitive activities were identified: pattern recognition; uncertainty management; strategic vs. tactical thinking; team coordination and maintenance of common ground; and creation and transfer of meaning through stories.ConclusionsCTA within the framework of Naturalistic Decision Making is a useful tool to understand the critical care process of decision-making and communication. The separation of strategic and tactical thinking has implications for workflow redesign. Given the global push for work-hour limitations, such workflow redesign is occurring. Further work with CTA techniques will provide important insights toward rational, rather than random, workflow changes.

Relation of repeated low-level blast exposure with symptomology similar to concussion.

Objective:To investigate anecdotal reports suggesting that repeated exposure to low-level explosive blast has myriad health impacts, including an array of neurological effects. Participants:A total of 184 anonymous survey respondents from military and nonmilitary law enforcement populations (135 exposed to occupational blast and 49 controls). Design:Survey of self-reported history of occupational exposure to repeated low-level blast (breaching blast) and symptomology similar to concussion. Results:Findings suggest that number and severity of symptoms increase with history of chronic blast exposure (F = 18.26, P < .001) and that symptoms can interfere with daily activity (t = 2.60, P = .010). Conclusion:Given the prevalence of repeated exposure to blast among some military and civilian law enforcement occupations, the results of this survey study support a role for blast surveillance programs as well as continued research on health impacts of low-level repeated blast exposure.

Developing a Cognitive and Communications Tool for Burn Intensive Care Unit Clinicians

BACKGROUND Burn Intensive Care Unit (BICU) work is necessarily complex and depends on clinician actions, resources, and variable patient responses to interventions. Clinicians use large volumes of data that are condensed in time, but separated across resources, to care for patients. Correctly designed health information technology (IT) systems may help clinicians to treat these patients more efficiently, accurately, and reliably. We report on a 3-year project to design and develop an ecologically valid IT system for use in a military BICU. METHODS We use a mixed methods Cognitive Systems Engineering approach for research and development. Observations, interviews, artifact analysis, survey, and thematic analysis methods were used to reveal underlying factors that mold the work environment and affect clinician decisions that may affect patient outcomes. Participatory design and prototyping methods have been used to develop solutions. RESULTS We developed 39 requirements for the IT system and used them to create three use cases to help developers better understand how the system might support clinician work to develop interface prototypes. We also incorporated data mining functions that offer the potential to aid clinicians by recognizing patterns recognition of clinically significant events, such as incipient sepsis. The gaps between information sources and accurate, reliable, and efficient clinical decision that we have identified will enable us to create scenarios to evaluate prototype systems with BICU clinicians, to develop increasingly improved designs, and to measure outcomes. CONCLUSION The link from data to analyses, requirements, prototypes, and their evaluation ensures that the solution will reflect and support work in the BICU as it actually occurs, improving staff efficiency and patient care quality.

A Case Study of Source Triangulation Using Artifacts as Knowledge Elicitation Tools in Healthcare Space Design

The importance of triangulating multiple sources of data in the design of tools, technology, and clinical workspaces has not been explicitly addressed in the applied human factors literature. In this paper, we describe an applied human factors case study in which Cognitive Task Analysis was used to triangulate the needs, goals, and design requirements from various stakeholder groups for the design of a Newborn Intensive Care Unit. To facilitate development of common ground on the design goals, in our interviews, we asked questions about (a) stated design goals to elicit the perspectives of meaning across the user groups and (b) schematic renderings of the proposed space. They served as a way to establish a representative definition of each design goal accounting for the perspectives of all user groups. We found that each role brought a perspective and a level of detail based on his/her role goals and lived experience to the design goals. The goals and tradeoffs illuminated by our approach can only be identified when multiple perspectives are collected. Source triangulation should be pursued as part of standard human factors methods to achieve design and evaluation objectives in the context of complex sociotechnical systems.

The Role of Monitor Technicians in Enhancing Alarm Response

We report a study of monitor alarm response conducted in the newly designed Transitional Care Center (TCC) at Cincinnati Children’s Hospital Medical Center. A key component of the new TCC design has been the development and implementation of a Monitor Technician (MT) position. We examined the MT role from a human factors perspective, with particular focus on the MT’s coordination and communication with nurses (RNs) and respiratory therapists (RTs). We conducted observations and Cognitive Task Analysis interviews of MTs, RNs, and RTs. In this paper, we describe the value of the MT’s role and define the challenges associated with the MT’s responsibilities. MTs serve an important support function, but they face challenges in locating RNs/RTs to respond to alarms and at times, may be the only “eyes on” the patients, making training and preparation a critical aspect of the MT’s function. In response to findings, CCHMC has taken a number of steps to improve alarm and alert responses and provide further support to the MT’s role. The current study serves as a demonstration of the principles and methods that human factors can offer to healthcare organizations to support patient safety and quality of care.