ABSTRACT
PURPOSE: Cognitive load, specifically extraneous load (EL) reflective of distractions, may provide evidence of a lack of focus, potentially making additional work unsafe. The assessment of trainees performing inpatient consultations provides a helpful model for examining this question. The goal of this study was to provide useful information to clinical and educational leaders to optimize inpatient consultation services and rotations and mitigate potential patient safety risk. METHOD: In 2019, using the Consult Cognitive Load instrument, the authors obtained EL data from inpatient consultations performed by internal medicine fellows and psychiatry residents across 5 University of California hospitals. In 2023, the authors constructed a Wright map to compare the participants' EL data with the number of prior initial consultations performed during the shift. RESULTS: Of 326 trainees contacted, 139 (43%) completed the EL survey items. The Wright map shows that trainees were estimated to agree that interruptions were already distracting at the first consultation of the shift. After 4 consultations, trainees were estimated to strongly agree that interruptions were distracting and to agree that emotions, extraneous information, and technology were distracting. CONCLUSIONS: The authors propose a quantitative, empirically driven, mean safety limit of 4 new inpatient consultations per shift for trainees to avoid cognitive overload, thereby potentially supporting patient safety. Clinical and educational leaders can adjust this limit to fit the unique needs of their practice setting. A similar approach using cognitive load and item response theory could be used to conduct patient safety research in other domains.
ABSTRACT
OBJECTIVE: The Trans Woman Voice Questionnaire (TWVQ) is commonly used to quantify self-perceptions of voice for trans women seeking gender-affirming voice care, but the interpretation of TWVQ scores remains challenging. The objective of this study was to use item-response theory (IRT) to evaluate the relationship between TWVQ items and persons on a common scale and identify improvements to increase the meaningfulness of TWVQ scores. METHODS: A retrospective review of TWVQ scores from trans women patients between 2018-2020 was performed. Rasch-family models were used to generate item-person maps positioning respondent location and item difficulty estimates on a logit scale, which was then converted into a scaled score using linear transformations. RESULTS: TWVQ responses from 86 patients were analyzed. Initial item-person maps demonstrated that the middle response categories ("sometimes" and "often") performed inconsistently across items (poor threshold banding); interpretability improved when these ratings were scored as one category. The models were rerun using revised scoring, which retained high reliability (0.93) and supported a unidimensional construct. Updated item-person maps revealed four scaled score zones (≤54, >54 to ≤101, >101 to ≤140, and >140) that each corresponded to an increasing pattern of item thresholds (probability of selecting one response category vs. others). These ranges can be interpreted as minimal, low, moderate, and high, respectively. CONCLUSIONS: Empiric data from Rasch analysis supports new interval scoring for the TWVQ that advances the clinical and research utility of the instrument and lays the foundation for future improvements in clinical care and outcomes assessment. LEVEL OF EVIDENCE: NA Laryngoscope, 133:1197-1204, 2023.
