Danny Ho

An algorithm for processing vital sign monitoring data to remotely identify operating room occupancy in real-time

We developed an algorithm for processing networked vital signs (VS) to remotely identify in real-time when a patient enters and leaves a given operating room (OR). The algorithm addresses two types of mismatches between OR occupancy and VS: a patient is in the OR but no VS are available (e.g., patient is being hooked up), and no patient is in the OR but artifactual VS are present (e.g., because of staff handling of sensors). The algorithm was developed with data from 7 consecutive days (122 cases) in a 6 OR trauma center. The algorithm was then tested on data from another 7 consecutive days (98 cases), against patient in- and out-times captured by OR surveillance videos. When pulse oximetry, electrocardiogram, and temperature readings were used, OR occupancy was correctly identified 96% (95% confidence interval [CI] 95%–97%) and OR vacancy >99% of the time. Identified patient in- and out-times were accurate within 4.9 min (CI 4.2–5.7) and 2.8 min (CI 2.3–3.5), respectively, and were not different in accuracy from times reported by staff on OR records. The algorithm’s usefulness was demonstrated partly by its continued operational use. We conclude that VS can be processed to accurately report OR occupancy in real-time.

Coordination of appointments for anesthesia care outside of operating rooms using an enterprise-wide scheduling system.

BACKGROUND:An anesthesia department implemented scheduling of anesthetics outside of operating rooms (non-OR) by clerks and nurses from other departments using its hospitals enterprise-wide scheduling system. METHODS:Observational studies chronicled the change over 2 yr as non-OR time was allocated by specialty, and nonanesthesia clerks and nurses scheduled anesthesia teams. Experimental studies investigated how tabular and graphical displays affected the scheduling of milestones (e.g., NPO times) and appointments before anesthetics. RESULTS:Anesthetics performed in allocated time increased progressively from 0% to 75%. Scheduling of anesthetics by nonanesthesia clerks and nurses increased progressively from 0% to 77%. Consistency of patient instructions was improved. The quality of resulting schedules was good. Implementation was not associated with worsening of multiple operational measures of performance such as cancellation rates, turnover times, or complaints. However, schedulers struggled to understand fasting and arrival times of patients, despite using a web site with statistically generated values in tabular formats. Experiments revealed that people ignored their knowledge that anesthetics can start earlier than scheduled. Participants made good decisions with both tabular and graphical displays when scheduling appointments preceding anesthesia. CONCLUSIONS:Enterprise-wide scheduling can coordinate anesthetics with other appointments on the same date and improve consistency and accuracy of patient instructions customized to the probability of an anesthetic starting early. The usefulness of implementation depends on the value in having more patient-centered care and/or in having patients arrive just in time for non-OR anesthesia, surgery, or regional block placement (e.g., at facilities with limited physical space).

Advanced Visualization Platform for Surgical Operating Room Coordination: Distributed Video Board System

One of the major challenges for day-of-surgery operating room coordination is accurate and timely situation awareness. Distributed and secure real-time status information is key to addressing these challenges. This article reports on the design and implementation of a passive status monitoring system in a 19-room surgical suite of a major academic medical center. Key design requirements considered included integrated real-time operating room status display, access control, security, and network impact. The system used live operating room video images and patient vital signs obtained through monitors to automatically update events and operating room status. Images were presented on a “need-to-know” basis, and access was controlled by identification badge authorization. The system delivered reliable real-time operating room images and status with acceptable network impact. Operating room status was visualized at 4 separate locations and was used continuously by clinicians and operating room service providers to coordinate operating room activities.

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.

Artifacts Use in Safety Critical Information Transfer: A Preliminary Study of the Information Arena

Highly skilled professionals in mission critical work domains communicate complicated, critical information, frequently under time pressure. For example, sustained operations require shift work, which results in hand-offs of responsibilities and need of information transfers. There is a growing interest to support their communications through advanced information technology. We observed usage of information artifacts in a pediatric intensive care unit to study information transfers to guide the design of support technology. In contrast to published studies, we examined the context of supporting environment that contains rich information sources gathered or tailored for verbal discourses. We called the supporting environment “information arena.” Clinicians prepare for their personal information arena as well as the shared information arena (e.g., paper notes, charts, mobile computers). Patterns of artifact uses during discourses revealed several distinct roles of artifacts, as well as constraints on design of such artifacts. For example, artifacts in shared information arena should be easily manageable to support fluid and dynamic conversation flow. We also uncover several potential future roles for information artifacts to support information transfer.

Three perspectives of rounds: Choreographing information flow in an intensive care unit

Communication in acute hospital care occurs frequently in group settings, with “rounds” as the prototypical forum for care providers to review and plan for patient care. Many care providers spend hours each day in rounds. While studies have demonstrated the importance of rounds as a mechanism to improve care coordination, care providers frequently express frustration about rounds. Previous observational studies of rounds have identified factors influencing information transfer: physical, social, cognitive, and supporting artifacts. In this paper, we adopt three perspectives in advancing our understanding of communication during rounds and in devising interventions: distributed cognition, computer-supported cooperative work, and common ground. We use video recordings of rounds discussion of one patient in a pediatric intensive care unit to illustrate the choreography of information flow aided by artifacts, the use of visual “text” in discourse, and the scaffolding process of incrementally building a shared understanding about the care and the status of the patient. We highlight the importance of detailed studies of communication in embedded work practices and the need for a multi-theoretical approach for future studies of communication.

Handbooks or Mentors? the Role of a Resident Physician Manual in Resident Education

Teaching hospitals with rotating residents face the challenge of training and orienting new personnel. We studied a pocket-sized resident manual used for meeting these challenges in a leading trauma center. This study examines motivations and barriers associated with adopting the resident manual through structured survey and semi-formal interview. Multiple factors shaped the use and effectiveness of the manual, including learning style, organizational culture, and specific usability issues. Findings suggest that organizational culture was the primary determinant of how the resident manual was used, as residents strongly favor attending physicians, fellows, and other residents as their first source of knowledge. Meanwhile, the small form factor of the resident manual afforded optimal accessibility as a quick reference source, but findings suggest enhanced searchability is necessary to realize the manuals full potential. Recommendations for future implementation strategies are made.