Improved recall of handover information in a simulated emergency - A randomised controlled trial.

Background: Handovers during medical emergencies are challenging due to time-critical, dynamic and oftentimes unorderly and distracting situations. We evaluated the effect of distraction-reduced clinical surroundings during handover on (1) the recall of handover information, (2) the recall of information from the surroundings and (3) self-reported workload in a simulated in-hospital cardiac arrest scenario. Methods: In a parallel group design, emergency team leaders were randomly assigned to receive a structured handover of a cardio-pulmonary resuscitation (CPR) either inside the room ("inside group") right next to the ongoing CPR or in front of the room ("outside group") with no audio-visual distractions from the ongoing CPR. Based on the concept of situation awareness, the primary outcome was a handover score for the content of the handover (0-19 points) derived from the pieces of information given during handover. Furthermore, we assessed team leaders' perception of their surroundings during the scenario (0-5 points) and they rated their subjective workload using the NASA Task Load Index. Results: The outside group (n = 30) showed significant better recall of handover information than the inside group (n = 30; mean difference = 1.86, 95% CI = 0.67 to 3.06, p = 0.003). The perception of the surroundings (n = 60; mean difference = -0.27, 95% CI = -0.85 to 0.32, p = 0.365) and the NASA Task Load Index (n = 58; mean difference = 1.1; p = 0.112) did not differ between the groups. Conclusions: Concerning in-hospital emergencies, a structured handover in a distraction reduced environment can improve information uptake of the team leader.

Guiding Attention via a Cognitive Aid During a Simulated In-Hospital Cardiac Arrest Scenario: A Salience Effort Expectancy Value Model Analysis.

OBJECTIVE: To investigate the effect of a cognitive aid on the visual attention distribution of the operator using the Salience Effort Expectancy Value (SEEV) model. BACKGROUND: Cognitive aids aim to support an operator during the execution of a task. The effect of cognitive aids on performance is frequently evaluated but whether a cognitive aid improved, for example, attention distribution has not been considered. METHOD: We built the Expectancy Value (EV) model version which can be considered to indicate optimal attention distribution for a given event. We analyzed the eye tracking data of emergency physicians while using a cognitive aid application versus no application during a simulated in-hospital cardiac arrest scenario. RESULTS: The EV model could fit the attention distribution in such a simulated emergency situation. Partially supporting our hypothesis, the cognitive aid application group showed a significantly better EV model fit than the no application group in the first phases of the event, but a worse fit in the last phase. CONCLUSION: We demonstrated that a cognitive aid affected attention distribution and that the SEEV model provides the means of capturing these effects. We suggest that the aid supported and improved visual attention distribution in the stressful first phases of a cardiopulmonary resuscitation but may have focused attention on objects that are relevant for lower priority goals in the last phase. APPLICATION: The SEEV model can provide insights into expected and unexpected effects of cognitive aids on visual attention distribution and may help to design better artifacts.

Improving procedural skills acquisition of students during medical device training: experiments on e-Learning vs. e-Learning with hands-on.

In the context of medical device training, e-Learning can address problems like unstandardized content and different learning paces. However, staff and students value hands-on activities during medical device training. In a blended learning approach, we examined whether using a syringe pump while conducting an e-Learning program improves the procedural skills needed to operate the pump compared to using the e-Learning program only. In two experiments, the e-Learning only group learned using only the e-Learning program. The e-Learning + hands-on group was instructed to use a syringe pump during the e-Learning to repeat the presented content (section "Experiment 1") or to alternate between learning on the e-Learning program and applying the learned content using the pump (section "Experiment 2"). We conducted a skills test, a knowledge test, and assessed confidence in using the pump immediately after learning and two weeks later. Simply repeating the content (section "Experiment 1") did not improve performance of e-Learning + hands-on compared with e-Learning only. The instructed learning process (section "Experiment 1") resulted in significantly better skills test performance for e-Learning + hands-on compared to the e-Learning only. Only a structured learning process based on multi-media learning principles and memory research improved procedural skills in relation to operating a medical device.

Attention to Changes on a Head-Worn Display: Two Preclinical Studies with Healthcare Scenarios.

OBJECTIVE: In two experiments, we examined how quickly different visual alerts on a head-worn display (HWD) would capture participants' attention to a matrix of patient vital sign values, while multitasking. BACKGROUND: An HWD could help clinicians monitor multiple patients, regardless of where the clinician is located. We sought effective ways for HWDs to alert multitasking wearers to important events. METHODS: In two preclinical experiments, university student participants performed a visuomotor tracking task while simultaneously monitoring simulated patient vital signs on an HWD to detect abnormal values. Methods to attract attention to abnormal values included highlighting abnormal vital signs and imposing a white flash over the entire display. RESULTS: Experiment 1 found that participants detected abnormal values faster with high contrast than low contrast greyscale highlights, even while performing difficult tracking. In Experiment 2, a white flash of the entire screen quickly and reliably captured attention to vital signs, but less so on an HWD than on a conventional screen. CONCLUSION: Visual alerts on HWDs can direct users' attention to patient transition events (PTEs) even under high visual-perceptual load, but not as quickly as visual alerts on fixed displays. Aspects of the results have since been tested in a healthcare context. APPLICATION: Potential applications include informing the design of HWD interfaces for monitoring multiple processes and informing future research on capturing attention to HWDs.

The Validity of the SEEV Model as a Process Measure of Situation Awareness: The Example of a Simulated Endotracheal Intubation.

OBJECTIVE: In the context of anesthesiology, we investigated whether the salience effort expectancy value (SEEV) model fit is associated with situation awareness and perception scores. BACKGROUND: The distribution of visual attention is important for situation awareness-that is, understanding what is going on-in safety-critical domains. Although the SEEV model has been suggested as a process situation awareness measure, the validity of the model as a predictor of situation awareness has not been tested. METHOD: In a medical simulation, 31 senior and 30 junior anesthesiologists wore a mobile eye tracker and induced general anesthesia into a simulated patient. When inserting a breathing tube into the mannequin's trachea (endotracheal intubation), the scenario included several clinically relevant events for situation awareness and general events in the environment. Both were assessed using direct awareness measures. RESULTS: The overall SEEV model fit was good with no difference between junior and senior anesthesiologists. Overall, the situation awareness scores were low. As expected, the SEEV model fits showed significant positive correlations with situation awareness level 1 scores. CONCLUSION: The SEEV model seems to be suitable as a process situation awareness measure to predict and investigate the perception of changes in the environment (situation awareness level 1). The situation awareness scores indicated that anesthesiologists seem not to perceive the environment well during endotracheal intubation. APPLICATION: The SEEV model fit can be used to capture and assess situation awareness level 1. During endotracheal intubation, anesthesiologists should be supported by technology or staff to notice changes in the environment.

Why and How to Approach User Experience in Safety-Critical Domains: The Example of Health Care.

OBJECTIVE: To highlight the importance of the personal experience of users who interact with technology in safety-critical domains and summarize three interaction concepts and the associated theories that provide the means for addressing user experience. BACKGROUND: In health care, the dominant concepts of interaction are based on theories arising from classic cognitive psychology. These concepts focus mainly on safety and efficiency, with too little consideration being given to user experience. METHOD: Users in complex socio-technical and safety-critical domains such as health care interact with many technological devices. Enhancing the user experience could improve the design of technology, enhance the well-being of staff, and contribute to modern safety management. We summarize concepts of "interaction" based on modern theories of human-computer interaction, which include the personal experience of users as an important construct. RESULTS AND CONCLUSION: Activity theory, embodiment, and interaction as experience provide a theoretical foundation for considering user experience in safety-critical domains. Using an example from anesthesiology, we demonstrate how each theory provides a unique but complementary view on experience. Finally, the methodological possibilities for considering personal experience in design and evaluations vary among the theories. APPLICATION: Considering user experience in health care and potentially other safety-critical domains can provide an additional means of optimizing interaction with technology, contributing to the well-being of staff, and improving safety.

Interruptions in Health Care: Assessing Their Connection With Error and Patient Harm.

OBJECTIVE: We address the problem of how researchers investigate the actual or potential causal connection between interruptions and medical errors, and whether interventions might reduce the potential for harm. BACKGROUND: It is widely assumed that interruptions lead to errors and patient harm. However, many reviewers and authors have commented that there is not strong evidence for a causal connection. METHOD: We introduce a framework of criteria for assessing how strongly evidence implies causality: the so-called Bradford Hill criteria. We then examine four key "metanarratives" of research into interruptions in health care-applied cognitive psychology, epidemiology, quality improvement, and cognitive systems engineering-and assess how each tradition has addressed the causal connection between interruptions and error. RESULTS: Outcomes of applying the Bradford Hill criteria are that the applied cognitive psychology and epidemiology metanarratives address the causal connection relatively directly, whereas the quality improvement metanarrative merely assumes causality, and the cognitive systems engineering metanarrative either implicitly or explicitly questions the feasibility of finding a direct causal connection with harm. CONCLUSION: The Bradford Hill criteria are useful for evaluating the existing literature on the relationship between interruptions in health care, clinical errors, and the potential for patient harm. In the future, more attention is needed to the issue of why interruptions usually do not lead to harm, and the implications for how we approach patient safety.

Supporting multiple patient monitoring with head-worn displays and spearcons.

In hospitals, clinicians often need to monitor several patients while performing other tasks. However, visual displays that show patients' vital signs are in fixed locations and auditory alarms intended to alert clinicians may be missed. Information such as spearcons (time-compressed speech earcons) that 'travels' with the clinician and is delivered by earpiece and/or head-worn displays (HWDs), might overcome these problems. In this study, non-clinicians monitored five simulated patients in three 10-min scenarios while performing a demanding tracking task. Monitoring accuracy was better for participants using spearcons and a HWD (88.7%) or a HWD alone (86.2%) than for participants using spearcons alone (74.1%). Participants using the spearcons and HWD (37.7%) performed the tracking task no differently from participants using spearcons alone (37.1%) but participants using the HWD alone performed worse overall (33.1%). The combination of both displays may be a suitable solution for monitoring multiple patients.

Commission errors with forced response lag.

It is often necessary to retrieve intentions once a certain cue occurs in the environment. However, such prospective memory (PM) tasks can also be erroneously recalled even though they are no longer relevant and may result in commission errors. According to the dual mechanism account, commission errors occur because the intention is spontaneously retrieved, and there is a subsequent failure to suppress the associated action, resulting in erroneous instant execution. In three experiments, we tested whether failed response suppression is a prerequisite for commission errors. We set up a response lag condition in which participants had to delay their response to ongoing task trials for 1 s (Experiment 1) or 2 s (Experiments 2 and 3) and a pause condition in which the delay occurred between ongoing task trials. In both conditions, participants learned about a PM task and were then told that the PM task was cancelled. In addition, a control group with response lag executed the PM task and was subsequently told the task was finished. Later, all participants encountered several irrelevant PM cues. If failed response suppression is a prerequisite for commission errors, commission error rates should be non-existent in the response lag conditions, because participants had designated time to suppress the PM action. However, commission errors occurred at an equal rate in all lag and pause conditions. Due to this contradiction to the dual mechanism account, we suggest that the process for commission error occurrence should be reconsidered. Because commission errors appear not to be caused by failed response suppression, we discuss the idea that erroneous intentions might be formed when encountering the former PM cue and persist over delays between formation and execution.

An exploratory clinical evaluation of a head-worn display based multiple-patient monitoring application: impact on supervising anesthesiologists' situation awareness.

PURPOSE: Supervising anesthesiologists overseeing several operating rooms must be aware of the status of multiple patients, so they can consult with the anesthetist in single operating rooms or respond quickly to critical events. However, maintaining good situation awareness can be challenging when away from patient bedsides or a central monitoring station. In this proof-of-concept study, we evaluated the potential of a head-worn display that showed multiple patients' vital signs and alarms to improve supervising anesthesiologists' situation awareness. METHODS: Eight supervising anesthesiologists each monitored the vital signs of patients in six operating rooms for 3 h with the head-worn display, and for another 3 h without the head-worn display. In interviews with each anesthesiologist, we assessed in which situations the head-worn display was used and whether the continuous availability of the vital signs improved situation awareness. We also measured situation awareness quantitatively from six of the eight anesthesiologists, by instructing them to press a button whenever they noticed a patient alarm. RESULTS: The median number of patient alarms occurring was similar when the anesthesiologists monitored with the head-worn display (42.0) and without the head-worn display (40.5). However, the anesthesiologists noticed significantly more patient alarms with the head-worn display (66.7%) than without (7.1%), P = 0.028, and they reported improved situation awareness with the head-worn display. The head-worn display helped the anesthesiologists to perceive and comprehend patients' current status and to anticipate future developments. A negative effect of the head-worn display was its tendency to distract during demanding procedures. CONCLUSIONS: Head-worn displays can improve supervising anesthesiologists' situation awareness in multiple-patient monitoring situations. The anesthesiologists who participated in the study expressed enthusiasm about monitoring patients with a head-worn display and wished to use and evaluate it further.

The effect of different distractions on remembering delayed intentions.

In safety-critical domains, frequently intentions need to be delayed until an ongoing task is completed. Research using the delay-execute paradigm showed that interruptions during the delay cause forgetting. However, staff members often handle an initial distraction not by interrupting the ongoing task but by acknowledging the distraction or multitasking. In Experiments 1a and 1b, we observed that, compared to a no distraction condition, multitasking significantly decreased remembering of intentions and interrupting decreased remembering even further. In Experiment 2, interruptions with context change reduced remembering of intentions compared to uninterrupted delays, and at the same time, interruptions without context change improved memory performance compared to uninterrupted delays. However, improved memory performance resulted in decreased interrupting task performance. Theoretically, the results support the contextual cueing mechanism of delay-execute tasks. Considering safety-critical domains, multitasking, interruptions and context changes can contribute to forgetting of tasks.

Commission errors in delay-execute prospective memory tasks.

Individuals frequently retrieve an intention, but the execution of the task needs to be delayed due to ongoing task demands - so-called delay-execute prospective memory (PM) tasks. We investigated commission errors in the delay-execute paradigm. Participants were told that a PM task is finished (PM task has been executed and is now finished for a final phase) or cancelled (PM task has been cancelled immediately after introduction). We observed commission errors and ongoing task performance in the final phase which included several irrelevant PM cues. In two experiments, we observed significantly more commission errors for cancelled compared to the finished intentions. In Experiment 2, commission errors were eliminated if the final phase required divided attention, regardless of PM task status. In addition, we observed significantly more PM cue interference on the ongoing task in the cancelled compared to the finished group, indicating that the PM task was retrieved in the cancelled group but not in the finished group. As retrieval and execution of the PM task were separated by a delay, the results indicate that commission errors are not always the result of a quick, spontaneous retrieval-execution sequence and may also occur when retrieval and execution are temporally separated.

Training students to use syringe pumps: an experimental comparison of e-learning and classroom training.

The inadequate use of syringe pumps can jeopardize patient safety, and syringe pump trainings are conducted to manage this risk. A critical step in this risk management process is the learning success of trainees. In the present paper, we compared an e-learning approach with standard classroom training in learning success effectives, trainees' opinion on the trainings, and investigated the relation between technological affinity and learning success. The results showed that e-learning was as effective as classroom training but nursing students' confidence in using the pump and satisfaction with the training was decreased for e-learning compared with classroom training. We discuss the results in context of the nursing e-learning literature. Finally, we discuss the literature for risk identification, risk analysis, risk treatment, and risk monitoring and control in the context of syringe pump training and add the lessons learned from the evaluated e-learning program.

Emergency medical equipment storage: benefits of visual cues tested in field and simulated settings.

OBJECTIVE: We tested the effectiveness of an illustrated divider ("the divider") for bedside emergency equipment drawers in an intensive care unit (ICU). In Study I, we assessed whether the divider increases completeness and standardizes the locations of emergency equipment within the drawer. In Study 2, we investigated whether the divider decreases nurses' restocking and retrieval times and decreases their workload. BACKGROUND: Easy access to fully stocked emergency equipment is important during emergencies. However, inefficient equipment storage and cognitively demanding work settings might mean that drawers are incompletely stocked and access to items is slow. METHOD: A pre-post-post study investigated drawer completeness and item locations before and after the introduction of the divider to 30 ICU drawers. A subsequent experiment measured item restocking time, item retrieval time, and subjective workload for nurses. RESULTS: At 2 weeks and 10 weeks after the divider was introduced, the completeness of the drawer increased significantly compared with before the divider was introduced. The divider decreased the variability of the locations of the 17 items in the drawer to 16% of its original value. Study 2 showed that restocking times but not retrieval times were significantly faster with the divider present For both tasks, nurses rated their workload lower with the divider. CONCLUSIONS: The divider improved the standardization and completeness of emergency equipment. In addition, restocking times and workload were decreased with the divider. APPLICATION: Redesigning storage for certain equipment using human factors design principles can help to speed and standardize restocking and ease access to equipment.

Effects of sleep deprivation on prospective memory.

Sleep deprivation reduces cognitive performance; however, its effects on prospective memory (remembering to perform intended actions) are unknown. One view suggests that effects of sleep deprivation are limited to tasks associated with prefrontal functioning. An alternative view suggests a global, unspecific effect on human cognition, which should affect a variety of cognitive tasks. We investigated the impact of sleep deprivation (25 hours of sleep deprivation vs. no sleep deprivation) on prospective-memory performance in more resource-demanding and less resource-demanding prospective-memory tasks. Performance was lower after sleep deprivation and with a more resource-demanding prospective-memory task, but these factors did not interact. These results support the view that sleep deprivation affects cognition more globally and demonstrate that sleep deprivation increases failures to carry out intended actions, which may have severe consequences in safety-critical situations.

Noncompetitive retrieval practice causes retrieval-induced forgetting in cued recall but not in recognition.

Retrieving a subset of learned items can lead to the forgetting of related items. Such retrieval-induced forgetting (RIF) can be explained by the inhibition of irrelevant items in order to overcome retrieval competition when the target item is retrieved. According to the retrieval inhibition account, such retrieval competition is a necessary condition for RIF. However, research has indicated that noncompetitive retrieval practice can also cause RIF by strengthening cue-item associations. According to the strength-dependent competition account, the strengthened items interfere with the retrieval of weaker items, resulting in impaired recall of weaker items in the final memory test. The aim of this study was to replicate RIF caused by noncompetitive retrieval practice and to determine whether this forgetting is also observed in recognition tests. In the context of RIF, it has been assumed that recognition tests circumvent interference and, therefore, should not be sensitive to forgetting due to strength-dependent competition. However, this has not been empirically tested, and it has been suggested that participants may reinstate learned cues as retrieval aids during the final test. In the present experiments, competitive practice or noncompetitive practice was followed by either final cued-recall tests or recognition tests. In cued-recall tests, RIF was observed in both competitive and noncompetitive conditions. However, in recognition tests, RIF was observed only in the competitive condition and was absent in the noncompetitive condition. The result underscores the contribution of strength-dependent competition to RIF. However, recognition tests seem to be a reliable way of distinguishing between RIF due to retrieval inhibition or strength-dependent competition.

Evaluating the effectiveness of a memory aid system.

BACKGROUND: The ability to remember future intentions is compromised in both healthy and cognitively impaired older adults. Assistive technology provides older adults with promising solutions to cope with this age-related problem. However, the effectiveness and efficiency of such systems as memory aids is seldom evaluated in controlled, randomized trials. OBJECTIVES: We evaluated the effectiveness of a memory aid system, the InBad (engl. InBath), for bathroom-related daily care. Conceptually, the InBad learns user behavior patterns and detects deviations from the learned pattern in order to notify the user of a forgotten task. METHODS: We simulated a challenging morning routine consisting of 22 bathroom activities with a sample of 60 healthy older adults. Participants were randomly assigned to three groups: (1) 'no memory support', i.e., participants received no support at all, (2) 'list support', i.e., participants could retrieve a list of all activities, and (3) 'system support', i.e., participants received prompts for specific activities that had not yet been executed. RESULTS: Both support groups executed significantly more activities compared to the 'no support' group. In addition, system support resulted in significantly better performance compared to list support with no significant differences between the two groups in overall task duration. CONCLUSION: The assistive support system was the most effective and efficient memory aid. The results suggest that assistive technology has the potential to enable older adults to remain safe and independent in their own home.

Interruption management in the intensive care unit: Predicting resumption times and assessing distributed support.

Interruptions are frequent in many work domains. Researchers in health care have started to study interruptions extensively, but their studies usually do not use a theoretically guided approach. Conversely, researchers conducting theoretically rich laboratory studies on interruptions have not usually investigated how effectively their findings account for humans working in complex systems such as intensive care units. In the current study, we use the memory for goals theory and prospective memory theory to investigate which properties of an interruption influence how long it takes nurses to resume interrupted critical care tasks. We collected data with a mobile eye tracker in an intensive care unit and developed multiple regression models to predict resumption times. In 55.8% of all interruptions there was a finite-and therefore analyzable-resumption lag. For these cases, the main regression model explained 30.9% (adjusted R²) of the variance. Longer interruptions (ß=.36, p<.001) and changes in physical location due to interruptions (ß=.40, p<.001) lengthened the resumption lag. We also calculated regression models on subsets of the data to investigate the generality of the above findings across different situations. In a further 37.6% of all interruptions, nurses used behavioral strategies that greatly diminished or eliminated individual prospective memory demands caused by interruptions, resulting in no analyzable resumption lag. We introduce a descriptive model that accounts for how nurses' behaviors affect the cognitive demand of resuming an interrupted task. Finally, we discuss how the disruptive effects of interruptions in the intensive care unit could be diminished or prevented.

Interruptions and blood transfusion checks: lessons from the simulated operating room.

Interruptions occur frequently in the operating room with both positive and negative consequences. Interruptions can distract anesthesiologists from safety-critical tasks, such as the pretransfusion blood check. In a simulated operating room, 12 anesthesiologists requested blood as part of a "bleeding patient" scenario. They were distracted while their assistant accepted delivery of the product and began transfusing without performing the standard check. Anesthesiologists who immediately engaged with the interruption failed to notice the omission, whereas those who rejected or deferred the interruption all noted and remedied the omitted check (P < 0.05). We discuss the role of displays and strategies on safety.