In situ medical simulation investigation of emergency department procedural sedation with randomized trial of experimental bedside clinical process guidance intervention.

INTRODUCTION: Patient safety during emergency department procedural sedation (EDPS) can be difficult to study. Investigators sought to delineate and experimentally assess EDPS performance and safety practices of senior-level emergency medicine residents through in situ simulation. METHODS: Study sessions used 2 pilot-tested EDPS scenarios with critical action checklists, institutional forms, embedded probes, and situational awareness questionnaires. An experimental informatics system was separately developed for bedside EDPS process guidance. Postgraduate year 3 and 4 subjects completed both scenarios in randomized order; only experimental subjects were provided with the experimental system during second scenarios. RESULTS: Twenty-four residents were recruited into a control group (n = 12; 6.2 ± 7.4 live EDPS experience) and experimental group (n = 12; 11.3 ± 8.2 live EDPS experience [P = 0.10]). Critical actions for EDPS medication selection, induction, and adverse event recognition with resuscitation were correctly performed by most subjects. Presedation evaluations, sedation rescue preparation, equipment checks, time-outs, and documentation were frequently missed. Time-outs and postsedation assessments increased during second scenarios in the experimental group. Emergency department procedural sedation safety probe detection did not change across scenarios in either group. Situational awareness scores were 51% ± 7% for control group and 58% ± 12% for experimental group. Subjects using the experimental system completed more time-outs and scored higher Simulation EDPS Safety Composite Scores, although without comprehensive improvements in EDPS practice or safety. CONCLUSIONS: Study simulations delineated EDPS and assessed safety behaviors in senior emergency medicine residents, who exhibited the requisite medical knowledge base and procedural skill set but lacked some nontechnical skills that pertain to emergency department microsystem functions and patient safety. The experimental system exhibited limited impact only on in-simulation time-out compliance.

Use of in situ simulation and human factors engineering to assess and improve emergency department clinical systems for timely telemetry-based detection of life-threatening arrhythmias.

BACKGROUND AND OBJECTIVES: Medical simulation and human factors engineering (HFE) may help investigate and improve clinical telemetry systems. Investigators sought to (1) determine the baseline performance characteristics of an Emergency Department (ED) telemetry system implementation at detecting simulated arrhythmias and (2) improve system performance through HFE-based intervention. METHODS: The prospective study was conducted in a regional referral ED over three 2-week periods from 2010 to 2012. Subjects were clinical providers working at the time of unannounced simulation sessions. Three-minute episodes of sinus bradycardia (SB) and of ventricular tachycardia (VT) were simulated. An experimental HFE-based multi-element intervention was developed to (1) improve system accessibility, (2) increase system relevance and utility for ED clinical practice and (3) establish organisational processes for system maintenance and user base cultivation. The primary outcome variable was overall simulated arrhythmia detection. Pre-intervention system characterisation, post-intervention end-user feedback and real-world correlates of system performance were secondary outcome measures. RESULTS: Baseline HFE assessment revealed limited accessibility, suboptimal usability, poor utility and general neglect of the telemetry system; one simulated VT episode (5%) was detected during 20 pre-intervention sessions. Systems testing during intervention implementation recorded detection of 4 out of 10 arrhythmia simulations (p=0.03). Twenty post-intervention sessions revealed more VT detections (8 of 10) than SB detections (3 of 10) for a 55% overall simulated arrhythmia detection rate (p=0.001). CONCLUSIONS: Experimental investigations helped reveal and mitigate weaknesses in an ED clinical telemetry system implementation. In situ simulation and HFE methodologies can facilitate the assessment and abatement of patient safety hazards in healthcare environments.

Color-coding and human factors engineering to improve patient safety characteristics of paper-based emergency department clinical documentation.

OBJECTIVE: Investigators studied an emergency department (ED) physical chart system and identified inconsistent, small font labeling; a single-color scheme; and an absence of human factors engineering (HFE) cues. A case study and description of the methodology with which surrogate measures of chart-related patient safety were studied and subsequently used to reduce latent hazards are presented. BACKGROUND: Medical records present a challenge to patient safety in EDs. Application of HFE can improve specific aspects of existing medical chart organization systems as they pertain to patient safety in acute care environments. METHODS: During 10 random audits over 5 consecutive days (573 data points), 56 (9.8%) chart binders (range 0.0-23%) were found to be either misplaced or improperly positioned relative to other chart binders; 12 (21%) were in the critical care area. HFE principles were applied to develop an experimental chart binder system with alternating color-based chart groupings, simple and prominent identifiers, and embedded visual cues. RESULTS: Post-intervention audits revealed significant reductions in chart binder location problems overall (p < 0.01), for Urgent Care A and B pods (6.4% to 1.2%; p < 0.05), Fast Track C pod (19.3% to 0.0%; p < 0.05) and Behavioral/Substance Abuse D pod (15.7% to 0.0%; p < 0.05) areas of the ED. The critical care room area did not display an improvement (11.4% to 13.2%; p = 0.40). CONCLUSIONS: Application of HFE methods may aid the development, assessment, and modification of acute care clinical environments through evidence-based design methodologies and contribute to safe patient care delivery.