Colin F. Mackenzie

Trauma Resuscitation Errors and Computer-Assisted Decision Support

HYPOTHESISnThis project tested the hypothesis that computer-aided decision support during the first 30 minutes of trauma resuscitation reduces management errors.nnnDESIGNnOurs was a prospective, open, randomized, controlled interventional study that evaluated the effect of real-time, computer-prompted, evidence-based decision and action algorithms on error occurrence during initial resuscitation between January 24, 2006, and February 25, 2008.nnnSETTINGnA level I adult trauma center.nnnPATIENTSnSeverely injured adults.nnnMAIN OUTCOME MEASURESnThe primary outcome variable was the error rate per patient treated as demonstrated by deviation from trauma care algorithms. Computer-assisted video audit was used to assess adherence to the algorithms.nnnRESULTSnA total of 1171 patients were recruited into 3 groups: 300 into a baseline control group, 436 into a concurrent control group, and 435 into the study group. There was a reduction in error rate per patient from the baseline control group to the study group (2.53 to 2.13, P = .004) and from the control group to the study group (2.30 to 2.13, P = .04). The difference in error rate per patient from the baseline control group to the concurrent control group was not statistically different (2.53 to 2.30, P = .21). A critical decision was required every 72 seconds, and error-free resuscitations were increased from 16.0% to 21.8% (P = .049) during the first 30 minutes of resuscitation. Morbidity from shock management (P = .03), blood use (P < .001), and aspiration pneumonia (P = .046) were decreased.nnnCONCLUSIONSnComputer-aided, real-time decision support resulted in improved protocol compliance and reduced errors and morbidity. Trial Registration clinicaltrials.gov Identifier: NCT00164034.

Video techniques and data compared with observation in emergency trauma care

Video recording is underused in improving patient safety and understanding performance shaping factors in patient care. We report our experience of using video recording techniques in a trauma centre, including how to gain cooperation of clinicians for video recording of their workplace performance, identify strengths of video compared with observation, and suggest processes for consent and maintenance of confidentiality of video records. Video records are a rich source of data for documenting clinician performance which reveal safety and systems issues not identified by observation. Emergency procedures and video records of critical events identified patient safety, clinical, quality assurance, systems failures, and ergonomic issues. Video recording is a powerful feedback and training tool and provides a reusable record of events that can be repeatedly reviewed and used as research data. It allows expanded analyses of time critical events, trauma resuscitation, anaesthesia, and surgical tasks. To overcome some of the key obstacles in deploying video recording techniques, researchers should (1) develop trust with video recorded subjects, (2) obtain clinician participation for introduction of a new protocol or line of investigation, (3) report aggregated video recorded data and use clinician reviews for feedback on covert processes and cognitive analyses, and (4) involve multidisciplinary experts in medicine and nursing.

Measuring team performance in healthcare: Review of research and implications for patient safety

Effective team performance is important to measure in order to determine how clinicians should be trained for safe and effective patient care. Team performance is challenging to measure. In this paper, we describe different methodologies used to capture team performance metrics including clinical surveys, direct observation, and video-based analyses of real-life clinical performance. Despite much effort, the instruments reported thus far suffer from a variety of shortcomings that prevent their wide application in assessing team behaviors and performance. A consensus is needed on a conceptual model of clinical team performance that can encompass many real and simulated healthcare settings and account for interdependencies of their outcome criteria.

Decision Making in Dynamic Environments: Fixation Errors and Their Causes:

One of the goals of naturalistic studies of human decision making is to reveal the cognitive loads or task difficulties imposed on the decision maker in real work environments. Fixation errors or cognitive lockups have been reported as a unique type of performance failure in dynamic work environments, and are thus particularly valuable to the understanding of the challenges and difficulties confronting practitioners in dynamic environments. In this paper, we present the analysis of fixation errors during real-life trauma patient resuscitation. The analysis elicits two factors, both rooted in the inherent complexity of the domain, that contributed to the occurrence of fixation errors: unreliable monitoring devices and delayed feedback. The former induces the behavior of preferring confirmatory information, partly for redundancy checks. The latter may create a false sense of system stability and divert attention away from the correct diagnosis.

Identification of dynamic prehospital changes with continuous vital signs acquisition.

OBJECTIVEnIn most trauma registries, prehospital trauma data are often missing or unreliable because of the difficult dual task consigned to prehospital providers of recording vital signs and simultaneously resuscitating patients. The purpose of this study was to test the hypothesis that the analysis of continuous vital signs acquired automatically, without prehospital provider input, improves vital signs data quality, captures more extreme values that might be missed with conventional human data recording, and changes Trauma Injury Severity Scores compared with retrospectively compiled prehospital trauma registry data.nnnMETHODSnA statewide vital signs collection network in 6 medevac helicopters was deployed for prehospital vital signs acquisition using a locally built vital signs data recorder (VSDR) to capture continuous vital signs from the patient monitor onto a memory card. VSDR vital signs data were assessed by 3 raters, and intraclass correlation coefficients were calculated to test interrater reliability. Agreement between VSDR and trauma registry data was compared with the methods of Altman and Bland including corresponding calculations for precision and bias.nnnRESULTSnAutomated prehospital continuous VSDR data were collected in 177 patients. There was good agreement between the first recorded vital signs from the VSDR and the trauma registry value. Significant differences were observed between the highest and lowest heart rate, systolic blood pressure, and pulse oximeter from the VSDR and the trauma registry data (P< .001). Trauma Injury Severity Scores changed in 12 patients (7%) when using data from the VSDR.nnnCONCLUSIONnReal-time continuous vital signs monitoring and data acquisition can identify dynamic prehospital changes, which may be missed compared with vital signs recorded manually during distinct prehospital intervals. In the future, the use of automated vital signs trending may improve the quality of data reported for inclusion in trauma registries. These data may be used to develop improved triage algorithms aimed at optimizing resource use and enhancing patient outcomes.

Challenges to remote emergency decision-making for disasters or Homeland Security

New technology allows information gathering and collaboration across information networks that would be of benefit to emergency response. In a Homeland Security Exercise we compared the utility of fixed and mobile video and high quality still images on remote expert decision-making. Sixteen experts situated in three countries viewed and seven evaluated events of the exercise assisted by audio commentary of local knowledge experts. They evaluated the usefulness of black and white (B/W) compared to color images, fixed fast video versus slow video and still images. Technical difficulties interrupted image transmission to one remote site for half the Exercise. However, the images were found useful, color more so than B/W, mobile more so than fixed. The combination of still images and video was best. Playback of recorded images was especially useful for remote evaluation and decision-making. Improved reliability for these imaging technologies could improve shared awareness and large-scale coordination for Homeland Security events.

Just-in-time Training for Medical Emergencies: Computer versus Paper Checklists for a Tracheal Intubation Task

Responding to medical emergencies quickly and effectively is essential. In remote or hostile environments, fully trained medical personnel are not always available, so clear and effective guidance is required. This paper reports a comparison of paper-based and computer-based checklists for just-in-time training for medical emergencies. In a between-subjects experiment, untrained participants carried out an emergency airway management task on a patient simulator either using a paper-based checklist with text and still images or using a computer-based checklist that included identical text plus video clips. Participants using the computer-based checklist performed significantly faster and more proficiently than those using the paper checklist. Subjective usability and preference measures were also superior for computer checklist. The results suggest the clear superiority of the computer-based checklist for untrained responders. We discuss which aspects of the computer-based checklist may contribute to its superiority.