Planning the Episode: Home Care Admission Nurse Decision-Making Regarding the Patient Visit Pattern.

During home health care (HHC) admissions, nurses provide input into decisions regarding the skilled nursing visit frequency and episode duration. This important clinical decision can impact patient outcomes including hospitalization. Episode duration has recently gained greater importance due to the Centers for Medicare and Medicaid Services (CMS) decrease in reimbursable episode length from 60 to 30 days. We examined admissions nurses' visit pattern decision-making and whether it is influenced by documentation available before and during the first home visit, agency standards, other disciplines being scheduled, and electronic health record (EHR) use. This observational mixed-methods study included admission document analysis, structured interviews, and a think-aloud protocol with 18 nurses from 3 diverse HHC agencies (6 at each) admitting 2 patients each (36 patients). Findings show that prior to entering the home, nurses had an information deficit; they either did not predict the patient's visit frequency and episode duration or stated them based on experience with similar patients. Following patient interaction in the home, nurses were able to make this decision. Completion of documentation using the EHR did not appear to influence visit pattern decisions. Patient condition and insurance restrictions were influential on both frequency and duration. Given the information deficit at admission, and the delay in visit pattern decision making, we offer health information technology recommendations on electronic communication of structured information, and EHR documentation and decision support.

Getting to Complete and Accurate Medication Lists During the Transition to Home Health Care.

OBJECTIVES: Characterize the work that home health care (HHC) admission nurses complete as part of the medication reconciliation tasks, explore the impact of shared electronic medication data (interoperability) from the referral source on medication reconciliation, and highlight opportunities to enhance medication reconciliation with respect to transition in care to HHC agencies. DESIGN: Observational field study. SETTINGS AND PARTICIPANTS: Three diverse Pennsylvania HHC agencies; each used different electronic health record systems with different interoperability characteristics. Six nurses per site admitted 2 patients each (36 patients total). METHODS: Researchers observed the admission process in the patient home and at the HHC agency. The nurses' tasks related to medication reconciliation were characterized by (1) number and change types (ie, medications dropped or added; changes to dose, frequency/administration time, or tablet types) made to the referrer medication list during and after the home visit, and (2) reasons that the nurse called the health provider (doctor, pharmacy) to resolve medication-related issues. Differences between interoperable and non-interoperable observations were explored. RESULTS: Polypharmacy (on average, study patients were taking more than 12 medications) and high-risk medications (on average, more than 8 per patient) were pervasive. For 91% of patients, the number of medications decreased between pre- and post-reconciliation medication lists; 41% of the medications required changes. Nurses using interoperable systems needed to make fewer changes than nurses using non-interoperable systems. In two-thirds of observations, the nurse called a provider. CONCLUSIONS AND IMPLICATIONS: Changes to the referrer medication list and calls to providers highlighted the nurses' effort to complete the medication reconciliation. Interoperability appeared to reduce the number of changes required, but did not eliminate changes or calls to providers. We highlight opportunities to enhance medication reconciliation with respect to transition in care to HHC agencies.

There's a Problem With the Problem List: Incongruence of Patient Problem Information Across the Home Care Admission.

OBJECTIVES: Illustrate patterns of patient problem information received and documented across the home health care (HHC) admission process and offer practice, policy, and health information technology recommendations to improve information transfer. DESIGN: Observational field study. SETTING AND PARTICIPANTS: Three diverse HHC agencies using different commercial point-of-care electronic health records (EHRs). Six nurses per agency each admitted 2 patients (36 total). METHODS: Researchers observed the admission process and photographed documents and EHR screens across 3 phases: referral, assessment, and plan of care (POC). To create a standardized data set, we mapped terms within medical diagnoses, signs, symptoms, and Problems to 5 of the 42 Omaha System Problem Classification Scheme problem terms. This created 180 problem pattern cases (5 problem patterns per patient). RESULTS: Each pattern of problem information being present or absent was observed. In 52 cases (28.9%), a problem did not appear. In 36 cases (20%), the problem appeared in all 3 phases. In 46 cases (25.6%), the problem appeared in referral and/or assessment phases and not on the POC. Conversely, in 37 cases (20.5%), the problem appeared in referral or assessment phases and on the POC. In 9 cases (5%), the problem only appeared on the POC. Within the EHRs, there were no rationale fields to clarify including Problems or not and no problem status fields to identify active, resolved, or potential ones. CONCLUSIONS AND IMPLICATIONS: Diagnosis or problem information transferred from the referral source or gathered during an in-home assessment did not appear in the POC. Because of the EHR structure, clinicians could not identify inactive problem or problem priority. Documentation or mapping of a structured problem list using a standardized interprofessional terminology such as the Omaha System coupled with identification of rationale could support the documentation of problem status and priority and reduce information loss.

Human factors in police mobile computer terminals: A systematic review and survey of recent literature, guideline formulation, and future research directions.

The objectives of this research were to: (1) identify Mobile Computer Terminal (MCT) human factors issues, (2) formulate guidelines and an enhanced MCT for improving interface design and implementation in police patrols, and (3) identify areas of future research to fill gaps in the literature. A systematic literature search was conducted leading to results categorized in four groups including: productivity, physical discomfort, interface usability, and driving distraction. Although MCT use has increased officer productivity, several usability issues need to be resolved. The MCT has also increased officer physical discomfort and distraction. MCT design and implementation guidelines that resolve human factors issues in police patrols were identified along with an enhanced design concept. Guidelines for MCT design were validated with an online survey completed by 81 police officers. Future research directions were proposed to recognize police officer needs and work context.

The effect of navigation display clutter on performance and attention allocation in presentation- and simulator-based driving experiments.

Display clutter can have differential effects based on environmental factors, such as workload, stress, and experiment paradigm. The objectives of the current study were to assess the effects of display clutter on driver performance and attention allocation and compare results across two experimental paradigms. Forty-two participants searched high- and low-clutter in-car navigation displays for routine information either during a static, presentation-based experiment or in a dynamic, driving simulator experiment. Results revealed display clutter to significantly alter attention allocation and degrade performance in the presentation experiment, but had little to no effect on driver performance or attention allocation in the driving simulator experiment. Results suggest that display clutter may have its greatest effect on performance and attention allocation in domains requiring extended attention to the cluttered display compared to tasks in which the cluttered display acts as a support tool for secondary tasks.

An integrated measure of display clutter based on feature content, user knowledge and attention allocation factors.

Existing measures of display clutter in the literature generally exhibit weak correlations with task performance, which limits their utility in safety-critical domains. A literature review led to formulation of an integrated display data- and user knowledge-driven measure of display clutter. A driving simulation experiment was conducted in which participants were asked to search 'high' and 'low' clutter displays for navigation information. Data-driven measures and subjective perceptions of clutter were collected along with patterns of visual attention allocation and driving performance responses during time periods in which participants searched the navigation display for information. The new integrated measure was more strongly correlated with driving performance than other, previously developed measures of clutter, particularly in the case of low-clutter displays. Integrating display data and user knowledge factors with patterns of visual attention allocation shows promise for measuring display clutter and correlation with task performance, particularly for low-clutter displays. Practitioner Summary: A novel measure of display clutter was formulated, accounting for display data content, user knowledge states and patterns of visual attention allocation. The measure was evaluated in terms of correlations with driver performance in a safety-critical driving simulation study. The measure exhibited stronger correlations with task performance than previously defined measures.

Driver performance and attention allocation in use of logo signs on freeway exit ramps.

The objective of this research was to quantify the effects of driver age, ramp signage configuration, including number of panels, logo format and sign familiarity, on driver performance and attention allocation when exiting freeways. Sixty drivers participated in a simulator study and analysis of variance models were used to assess response effects of the controlled manipulations. Results revealed elderly drivers to demonstrate worse performance and conservative control strategies as compared to middle-aged and young drivers. Elderly drivers also exhibited lower off-road fixation frequency and shorter off-road glance durations compared to middle-aged and young drivers. In general, drivers adopted a more conservative strategy when exposed to nine-panel signs as compared to six-panel signs and were more accurate in target detection when searching six-panels vs. nine and with familiar vs. unfamiliar logos. These findings provide an applicable guide for agency design of freeway ramp signage accounting for driver demographics.

The role of driver age in performance and attention allocation effects of roadway sign count, format and familiarity.

White-on-blue logo signs are used to inform drivers of food, gas, lodging, and attraction businesses at highway interchanges. In this study, 60 drivers were asked to look for food and attraction targets on logo signs while driving in a realistic freeway simulation. The objective of the study was to quantify effects of the number of sign panels (six vs. nine), logo familiarity (familiar vs. unfamiliar), logo format (text vs. pictorial), and driver age (young, middle, and elderly) on performance, attention allocation and target identification accuracy. Results revealed elderly drivers to exhibit worse performance in comparison to middle-age and young groups even though they adopted a more conservative driving strategy. There was no significant effect of the number of panels, logo familiarity, and logo format on driver performance or attention allocation. In target identification, drivers were more accurate with familiar or text-based panels appearing in six-panel signs.

Effect of physical workload and modality of information presentation on pattern recognition and navigation task performance by high-fit young males.

Many occupations require both physical exertion and cognitive task performance. Knowledge of any interaction between physical demands and modalities of cognitive task information presentation can provide a basis for optimising performance. This study examined the effect of physical exertion and modality of information presentation on pattern recognition and navigation-related information processing. Results indicated males of equivalent high fitness, between the ages of 18 and 34, rely more on visual cues vs auditory or haptic for pattern recognition when exertion level is high. We found that navigation response time was shorter under low and medium exertion levels as compared to high intensity. Navigation accuracy was lower under high level exertion compared to medium and low levels. In general, findings indicated that use of the haptic modality for cognitive task cueing decreased accuracy in pattern recognition responses. Practitioner Summary: An examination was conducted on the effect of physical exertion and information presentation modality in pattern recognition and navigation. In occupations requiring information presentation to workers, who are simultaneously performing a physical task, the visual modality appears most effective under high level exertion while haptic cueing degrades performance.

The effects of interruption similarity and complexity on performance in a simulated visual-manual assembly operation.

The objective of the study was to assess the effects of interruption task similarity and complexity on performance of a simulated industrial assembly operation. Eighteen participants performed a simulated industrial assembly operation, including one trial with no interruption and eight others presenting an interruption task. Interruption conditions comprised a full crossing of task similarity to the primary assembly operation (similar, dissimilar) and complexity (simple, complex) with replication for each participant. Order of condition presentation was randomized. Findings revealed greater time to return to primary visual-manual assembly performance after a similar task interruption. Results also indicated complex interruptions may promote cognitive arousal that increases productivity following assembly interruptions. The majority of results are explained in terms of the Activation-Based Memory for Goals model. Findings provide some guidance for interruption management protocol design for workers engaged in procedural visual-manual assembly operations.

Driver behavior in use of guide and logo signs under distraction and complex roadway conditions.

White-on-blue logo signs on the sides of highways are typically used to notify drivers of food, gas, and lodging at an upcoming interchange. The current research assessed driver performance and attention allocation in a simulated freeway driving task when exposed to six-panel logo signs, nine-panel logo signs, mileage guide signs, and roadway work zones both with and without an in-car navigation device. The objective was to identify the impact of signage types on driver behavior under realistic driving conditions. Results revealed glance durations and fixation frequencies to guide signs to be significantly lower than with six-panel and nine-panel logo signs, but no differences were found between six-panel and nine-panel logo signs. There were also statistical differences among the independent variables for speed deviation and lane deviation, but magnitudes were not large enough to be considered practically significant in terms of driving safety. Overall, there were minor differences in sign processing time between logo signs and mileage guide signs, but such differences did not translate to degradations in vehicle control.

Cockpit displays of traffic information and pilot bias in time-to-contact judgments.

INTRODUCTION: Pilots are susceptible to over-reliance on distance when making relative time-to-contact (TTC) judgments of surrounding intruders, referred to as "the distance bias." We tested the effect of adding perceptual cues and an information feature to cockpit displays of traffic information to mitigate this bias. METHOD: There were 14 general aviation pilots who participated in a simulated flight scenario and were asked to make relative TTC judgments. Three levels of perceptual cue (blinking, color-change, and no-cue) were crossed with two levels of velocity data tag (present and absent) with identification of the highest risk intruder as a response. RESULTS: Perceptual cues were associated with more accurate high-risk intruder selection (color = 95.95% correct, blinking = 95.98%, no-cue = 87.89%), decreased response time (color = 3.68 s, blinking = 3.19 s, no-cue = 6.08 s), reduced visual attention demand (color = 57% of attention, blinking = 58%, no-cue = 62%), lower workload ratings (color = 28.38/100, blinking = 29.66/100, no-cue = 48.91/100), and higher performance confidence ratings (color = 83.92/100, blinking = 82.71/100, no-cue = 58.85/100) than the no-cue displays. There was no difference between blinking and color cue displays. The data tag was associated with lower response times (present = 4.13 s, absent = 4.50 s) and higher confidence ratings (present = 78.69/100, absent = 71.63/100) than displays without. Displays including the blinking cue, color-change cue, and data tag were preferred over displays that did not include these features (color = 8 pilots, blinking = 6, no-cue = 0). DISCUSSION: The added display features were effective in mitigating the effect of the distance bias on pilot performance measures and received favorable subjective ratings.