Joanna Abraham

Challenges to effective crisis management: Using information and communication technologies to coordinate emergency medical services and emergency department teams

OBJECTIVE The purpose of this study is to identify the major challenges to coordination between emergency department (ED) teams and emergency medical services (EMS) teams. DESIGN We conducted a series of focus groups involving both ED and EMS team members using a crisis scenario as the basis of the focus group discussion. We also collected organizational workflow data. RESULTS We identified three major challenges to coordination between ED and EMS teams including ineffectiveness of current information and communication technologies, lack of common ground, and breakdowns in information flow. DISCUSSION The three challenges highlight the importance of designing systems from socio-technical perspective. In particular, these inter-team coordination systems must support socio-technical issues such as awareness, context, and workflow between the two teams.

Challenges to inter-departmental coordination of patient transfers: A workflow perspective

OBJECTIVE The purpose of this study is to identify challenges to inter-departmental coordination activities that affect patient transfer workflow and to provide socio-technical requirements for the design of technologies to better support patient transfer workflow. DESIGN We conducted our study in two clinical and one non-clinical department at a major academic hospital. We utilized qualitative data collection techniques including observations of patient transfer practices of the different departments and interviews with departmental staff to collect data on the inter-departmental coordination activities and its effect on patient transfer workflow. RESULTS We identified three inter-departmental challenges that affected the patient transfer workflow: ineffective inter-departmental interactions, ineffective information handoffs, and ineffectiveness of current information technologies. DISCUSSION To address these challenges, we discuss three socio-technical design requirements that designers need to pay attention to while developing inter-departmental healthcare information systems. To ensure effective inter-departmental coordination, the systems should incorporate features that can support the mediating role of integrators, the collaborative balancing of goals, and the collaborative prioritization of resources.

Moving patients around: a field study of coordination between clinical and non-clinical staff in hospitals

Effective coordination is central to work in organizations. We conducted a field study examining challenges to coordination between clinical and non-clinical staff in the patient transfer process of a major academic hospital. We present one major challenge: lack of information sharing between these staff members and discuss the reasons for and consequences of this challenge to the work in the hospital.

Comparative evaluation of the content and structure of communication using two handoff tools: Implications for patient safety

PURPOSE Handoffs vary in their structure and content, raising concerns regarding standardization. We conducted a comparative evaluation of the nature and patterns of communication on 2 functionally similar but conceptually different handoff tools: Subjective, Objective, Assessment and Plan, based on a patient problem-based format, and Handoff Intervention Tool (HAND-IT), based on a body system-based format. METHOD A nonrandomized pre-post prospective intervention study supported by audio recordings and observations of 82 resident handoffs was conducted in a medical intensive care unit. Qualitative analysis was complemented with exploratory sequential pattern analysis techniques to capture the characteristics and types of communication events (CEs) and breakdowns. RESULTS Use of HAND-IT led to fewer communication breakdowns (F1,80 = 45.66: P < .0001), greater number of CEs (t40 = 4.56; P < .001), with more ideal CEs than Subjective, Objective, Assessment and Plan (t40 = 9.27; P < .001). In addition, the use of HAND-IT was characterized by more request-response CE transitions. CONCLUSION The HAND-ITs body system-based structure afforded physicians the ability to better organize and comprehend patient information and led to an interactive and streamlined communication, with limited external input. Our results also emphasize the importance of information organization using a medical knowledge hierarchical format for fostering effective communication.

R-CAST-MED: Applying Intelligent Agents to Support Emergency Medical Decision-Making Teams

Decision-making is a crucial aspect of emergency response during mass casualty incidents (MCIs). MCIs require rapid decisions to be taken by geographically-dispersed teams in an environment characterized by insufficient information, ineffective collaboration and inadequate resources. Despite the increasing adoption of decision support systems in healthcare, there is limited evidence of their value in large-scale disasters. We conducted focus groups with emergency medical services and emergency department personnel who revealed that one of the main challenges in emergency response during MCIs is information management. Therefore, to alleviate the issues arising from ineffective information management, we propose R-CAST-MED, an intelligent agent architecture built on Recognition-Primed Decision-making (RPD) and Shared Mental Models (SMMs). A simulation of R-CAST-MED showed that this tool enabled efficient information management by identifying relevant information, inferring missing information and sharing information with other agents, which led to effective collaboration and coordination of tasks across teams.

Integrative review of clinical decision support for registered nurses in acute care settings

Objective: To report on the state of the science of clinical decision support (CDS) for hospital bedside nurses. Materials and Methods: We performed an integrative review of qualitative and quantitative peer-reviewed original research studies using a structured search of PubMed, Embase, Cumulative Index to Nursing and Applied Health Literature (CINAHL), Scopus, Web of Science, and IEEE Xplore (Institute of Electrical and Electronics Engineers Xplore Digital Library). We included articles that reported on CDS targeting bedside nurses and excluded in stages based on rules for titles, abstracts, and full articles. We extracted research design and methods, CDS purpose, electronic health record integration, usability, and process and patient outcomes. Results: Our search yielded 3157 articles. After removing duplicates and applying exclusion rules, 28 articles met the inclusion criteria. The majority of studies were single-site, descriptive or qualitative (43%) or quasi-experimental (36%). There was only 1 randomized controlled trial. The purpose of most CDS was to support diagnostic decision-making (36%), guideline adherence (32%), medication management (29%), and situational awareness (25%). All the studies that included process outcomes (7) and usability outcomes (4) and also had analytic procedures to detect changes in outcomes demonstrated statistically significant improvements. Three of 4 studies that included patient outcomes and also had analytic procedures to detect change showed statistically significant improvements. No negative effects of CDS were found on process, usability, or patient outcomes. Discussion and Conclusions: Clinical support systems targeting bedside nurses have positive effects on outcomes and hold promise for improving care quality; however, this research is lagging behind studies of CDS targeting medical decision-making in both volume and level of evidence.

Characterizing the structure and content of nurse handoffs

Effective communication during nurse handoffs is instrumental in ensuring safe and quality patient care. Much of the prior research on nurse handoffs has utilized retrospective methods such as interviews, surveys and questionnaires. While extremely useful, an in-depth understanding of the structure and content of conversations, and the inherent relationships within the content is paramount to designing effective nurse handoff interventions. In this paper, we present a methodological framework-Sequential Conversational Analysis (SCA)-a mixed-method approach that integrates qualitative conversational analysis with quantitative sequential pattern analysis. We describe the SCA approach and provide a detailed example as a proof of concept of its use for the analysis of nurse handoff communication in a medical intensive care unit. This novel approach allows us to characterize the conversational structure, clinical content, disruptions in the conversation, and the inherently phasic nature of nurse handoff communication. The characterization of communication patterns highlights the relationships underlying the verbal content of nurse handoffs with specific emphasis on: the interactive nature of conversation, relevance of role-based (incoming, outgoing) communication requirements, clinical content focus on critical patient-related events, and discussion of pending patient management tasks. We also discuss the applicability of the SCA approach as a method for providing in-depth understanding of the dynamics of communication in other settings and domains.

Towards an Ontology for Interdisciplinary Handoff Communication in Intensive Care: Implications for Tool Resiliency and Patient Safety

Handoffs are considered a vulnerable point in the clinical workflow. A recent report by The Joint Commission (TJC) found that nearly 80% of communication errors occur during care transitions. While there has been significant research on handoff tools and their use, it can be argued that there is variability among the handoff tools used in current practice. We conducted a multi-year, longitudinal evaluation on the nature of content and structure of handoffs among residents and nurses in a medical intensive care unit (MICU). In this paper, we report on our top-level findings regarding the use of a body-systems based formatted tool that supported standardized, interactive and effective communication for both medical and nursing practice. We discuss the theoretical and practical implications of our results for the design and development of future handoff tools.

Methodological framework for evaluating clinical processes: A cognitive informatics perspective

We propose a methodological framework for evaluating clinical cognitive activities in complex real-world environments that provides a guiding framework for characterizing the patterns of activities. This approach, which we refer to as a process-based approach, is particularly relevant to cognitive informatics (CI) research-an interdisciplinary domain utilizing cognitive approaches in the study of computing systems and applications-as it provides new ways for understanding human information processing, interactions, and behaviors. Using this approach involves the identification of a process of interest (e.g., a clinical workflow), and the contributing sequences of activities in that process (e.g., medication ordering). A variety of analytical approaches can then be used to characterize the inherent dependencies and relations within the contributing activities within the considered process. Using examples drawn from our own research and the extant research literature, we describe the theoretical foundations of the process-based approach, relevant practical and pragmatic considerations for using such an approach, and a generic framework for applying this approach for evaluation studies in clinical settings. We also discuss the potential for this approach in future evaluations of interactive clinical systems, given the need for new approaches for evaluation, and significant opportunities for automated, unobtrusive data collection.

Measuring content overlap during handoff communication using distributional semantics: An exploratory study

OBJECTIVE We develop and evaluate a methodological approach to measure the degree and nature of overlap in handoff communication content within and across clinical professions. This extensible, exploratory approach relies on combining techniques from conversational analysis and distributional semantics. MATERIALS AND METHODS We audio-recorded handoff communication of residents and nurses on the General Medicine floor of a large academic hospital (n=120 resident and n=120 nurse handoffs). We measured semantic similarity, a proxy for content overlap, between resident-resident and nurse-nurse communication using multiple steps: a qualitative conversational content analysis; an automated semantic similarity analysis using Reflective Random Indexing (RRI); and comparing semantic similarity generated by RRI analysis with human ratings of semantic similarity. RESULTS There was significant association between the semantic similarity as computed by the RRI method and human rating (ρ=0.88). Based on the semantic similarity scores, content overlap was relatively higher for content related to patient active problems, assessment of active problems, patient-identifying information, past medical history, and medications/treatments. In contrast, content overlap was limited on content related to allergies, family-related information, code status, and anticipatory guidance. CONCLUSIONS Our approach using RRI analysis provides new opportunities for characterizing the nature and degree of overlap in handoff communication. Although exploratory, this method provides a basis for identifying content that can be used for determining shared understanding across clinical professions. Additionally, this approach can inform the development of flexibly standardized handoff tools that reflect clinical content that are most appropriate for fostering shared understanding during transitions of care.