Readmission Risk Assessment Technologies and the Anchoring and Adjustment Heuristic.

Approximately 23% of patients discharged from primary healthcare facilities are readmitted within 30 days at an annual cost of roughly $42 billion. To remedy this problem, healthcare providers are attempting to deploy readmission risk estimation tools, but how they might be used in the traditional, human-expert-centered decision process is not well understood. One such tool estimates readmission risk based on 50 patient-specific factors. This paper reports on a study performed in collaboration with Order of St. Francis Healthcare to determine how healthcare workers' own risk estimates are influenced by the tool, specifically testing the hypothesis that they will first anchor towards tool results while making adjustments based on their expertise, and then make further adjustments when additional human expert opinions are presented. Task analysis was performed, fictional patient scenarios were developed, and a survey of 56 subjects in two stratified groups of case managers was conducted. Data from the control and experiment groups were analyzed using ANOVA/GLM and t-tests. Results indicate that the healthcare workers' risk estimates were influenced by the anchor provided by the tool, then adjusted based on their expertise. The workers further adjusted their estimates in response to new expert human inputs. Thus, a reliance on both the predictive model and human expertise was observed.

The Equivalence of Video Self-review Versus Debriefing After Simulation: Can Faculty Resources Be Reallocated?

INTRODUCTION: Traditional simulation debriefing is both time- and resource-intensive. Shifting the degree of primary learning responsibility from the faculty to the learner through self-guided learning has received greater attention as a means of reducing this resource intensity. The aim of the study was to determine if video-assisted self-debriefing, as a form of self-guided learning, would have equivalent learning outcomes compared to standard debriefing. METHODS: This randomized cohort study consisting of 49 PGY-1 to -3 emergency medicine residents compared performance after video self-assessment utilizing an observer checklist versus standard debriefing for simulated emergency department procedural sedation (EDPS). The primary outcome measure was performance on the second EDPS scenario. RESULTS: Independent-samples t-test found that both control (standard debrief) and intervention (video self-assessment) groups demonstrated significantly increased scores on Scenario 2 (standard-t(40) = 2.20, p < 0.05; video-t(45) = 3.88, p < 0.05). There was a large and significant positive correlation between faculty and resident self-evaluation (r = 0.70, p < 0.05). There was no significant difference between faculty and residents self-assessment mean scores (t(24) = 1.90, p = 0.07). CONCLUSIONS: Residents receiving feedback on their performance via video-assisted self-debriefing improved their performance in simulated EDPS to the same degree as with standard faculty debriefing. Video-assisted self-debriefing is a promising avenue for leveraging the benefits of simulation-based training with reduced resource requirements.

Measuring Real-Time Team Cognition During Team Training.

OBJECTIVE: A method for detecting real-time changes in team cognition in the form of significant communication reorganizations is described. We demonstrate the method in the context of scenario-based simulation training. BACKGROUND: We present the dynamical view that individual- and team-level aspects of team cognition are temporally intertwined in a team's real-time response to challenging events. We suggest that this real-time response represents a fundamental team cognitive skill regarding the rapidity and appropriateness of the response, and methods and metrics are needed to track this skill. METHOD: Communication data from medical teams (Study 1) and submarine crews (Study 2) were analyzed for significant communication reorganization in response to training events. Mutual information between team members informed post hoc filtering to identify which team members contributed to reorganization. RESULTS: Significant communication reorganizations corresponding to challenging training events were detected for all teams. Less experienced teams tended to show delayed and sometimes ineffective responses that more experienced teams did not. Mutual information and post hoc filtering identified the individual-level inputs driving reorganization and potential mechanisms (e.g., leadership emergence, role restructuring) underlying reorganization. CONCLUSION: The ability of teams to rapidly and effectively reorganize coordination patterns as the situation demands is a team cognitive skill that can be measured and tracked. APPLICATION: Potential applications include team monitoring and assessment that would allow for visualization of a team's real-time response and provide individualized feedback based on team member's contributions to the team response.

Advancing Our Understandings of Healthcare Team Dynamics From the Simulation Room to the Operating Room: A Neurodynamic Perspective.

The initial models of team and team member dynamics using biometric data in healthcare will likely come from simulations. But how confident are we that the simulation-derived high-resolution dynamics will reflect those of teams working with live patients? We have developed neurodynamic models of a neurosurgery team while they performed a peroneal nerve decompression surgery on a patient to approach this question. The models were constructed from EEG-derived measures that provided second-by-second estimates of the neurodynamic responses of the team and team members to task uncertainty. The anesthesiologist and two neurosurgeons developed peaks, often coordinated, of elevated neurodynamic organization during the patient preparation and surgery which were similar to those seen during simulation training, and which occurred near important episodes of the patient preparation and surgery. As the analyses moved down the neurodynamic hierarchy, and the simulation and live patient neurodynamics occurring during the intubation procedure were compared at progressively smaller time scales, differences emerged across scalp locations and EEG frequencies. The most significant was the pronounced suppression of gamma rhythms detected by the frontal scalp sensors during the live patient intubation which was absent in simulation trials of the intubation procedure. These results indicate that while profiles of the second-by-second neurodynamics of teams were similar in both the simulation and live patient environments, a deeper analysis revealed differences in the EEG frequencies and scalp locations of the signals responsible for those team dynamics. As measures of individual and team performance become more micro-scale and dynamic, and simulations become extended into virtual environments, these results argue for the need for parallel studies in live environments to validate the dynamics of cognition being observed.

Neuroergonomics: Quantitative Modeling of Individual, Shared, and Team Neurodynamic Information.

OBJECTIVE: The aim of this study was to use the same quantitative measure and scale to directly compare the neurodynamic information/organizations of individual team members with those of the team. BACKGROUND: Team processes are difficult to separate from those of individual team members due to the lack of quantitative measures that can be applied to both process sets. METHOD: Second-by-second symbolic representations were created of each team member's electroencephalographic power, and quantitative estimates of their neurodynamic organizations were calculated from the Shannon entropy of the symbolic data streams. The information in the neurodynamic data streams of health care ( n = 24), submarine navigation ( n = 12), and high school problem-solving ( n = 13) dyads was separated into the information of each team member, the information shared by team members, and the overall team information. RESULTS: Most of the team information was the sum of each individual's neurodynamic information. The remaining team information was shared among the team members. This shared information averaged ~15% of the individual information, with momentary levels of 1% to 80%. CONCLUSION: Continuous quantitative estimates can be made from the shared, individual, and team neurodynamic information about the contributions of different team members to the overall neurodynamic organization of a team and the neurodynamic interdependencies among the team members. APPLICATION: Information models provide a generalizable quantitative method for separating a team's neurodynamic organization into that of individual team members and that shared among team members.

Alternative Markers of Performance in Simulation: Where We Are and Where We Need To Go.

This article on alternative markers of performance in simulation is the product of a session held during the 2017 Academic Emergency Medicine Consensus Conference "Catalyzing System Change Through Health Care Simulation: Systems, Competency, and Outcomes." There is a dearth of research on the use of performance markers other than checklists, holistic ratings, and behaviorally anchored rating scales in the simulation environment. Through literature review, group discussion, and consultation with experts prior to the conference, the working group defined five topics for discussion: 1) establishing a working definition for alternative markers of performance, 2) defining goals for using alternative performance markers, 3) implications for measurement when using alternative markers, identifying practical concerns related to the use of alternative performance markers, and 5) identifying potential for alternative markers of performance to validate simulation scenarios. Five research propositions also emerged and are summarized.

Using conversational agents to explain medication instructions to older adults.

In an effort to guide the development of a computer agent (CA)-based adviser system that presents patient-centered language to older adults (e.g., medication instructions in portal environments or smartphone apps), we evaluated 360 older and younger adults' responses to medication information delivered by a set of CAs. We assessed patient memory for medication information, their affective responses to the information, their perception of the CA's teaching effectiveness and expressiveness, and their perceived level of similarity with each CA. Each participant saw CAs varying in appearance and levels of realism (Photo-realistic vs Cartoon vs Emoji, as control condition). To investigate the impact of affective cues on patients, we varied CA message framing, with effects described either as gains of taking or losses of not taking the medication. Our results corroborate the idea that CAs can produce a significant effect on older adults' learning in part by engendering social responses.

Operating room managerial decision-making on the day of surgery with and without computer recommendations and status displays.

BACKGROUND: There are three basic types of decision aids to facilitate operating room (OR) management decision-making on the day of surgery. Decision makers can rely on passive status displays (e.g., big screens or whiteboards), active status displays (e.g., text pager notification), and/or command displays (e.g., text recommendations about what to do). METHODS: Anesthesiologists, OR nurses, and housekeepers were given nine simulated scenarios (vignettes) involving multiple ORs to study their decision-making. Participants were randomized to one of four groups, all with an updated paper OR schedule: with/without command display and with/without passive status display. RESULTS: Participants making decisions without command displays performed no better than random chance in terms of increasing the predictability of work hours, reducing over-utilized OR time, and increasing OR efficiency. Status displays had no effect on these end-points, whereas command displays improved the quality of decisions. In the scenarios for which the command displays provided recommendations that adversely affected safety, participants appropriately ignored advice. CONCLUSIONS: Anesthesia providers and nursing staff made decisions that increased clinical work per unit time in each OR, even when doing so resulted in an increase in over-utilized OR time, higher staffing costs, unpredictable work hours, and/or mandatory overtime. Organizational culture and socialization during clinical training may be a cause. Command displays showed promise in mitigating this tendency. Additional investigations are in our companion paper.

Anesthesia concerns for children with tuberous sclerosis.

Tuberous sclerosis (TS) is a relatively rare, autosomal dominant syndrome that displays high genetic penetrance in affected families. It is identified by a classic triad of symptoms including epilepsy, skin lesions, and mental retardation. Tuberous sclerosis causes hamartomas in multiple organ systems, including the brain, skin, heart, kidneys, lungs, and liver. Awareness of the signs and symptoms and the organs involved is critical to provide safe and effective anesthesia care. We describe a 10-year-old girl with TS scheduled to receive a general anesthetic for laser treatment of facial angiofibromas. The patient had several coexisting maladies from TS, including hypertension, autism, seizure disorder, cardiac rhabdomyomas, developmental delay, and bilateral polycystic renal disease. The laser procedure was performed, and there were no surgical or anesthetic complications. However, the potential for complications due to TS remained high throughout the provision of anesthesia care. Increased knowledge of TS and diligence in anesthesia practice can greatly reduce these risks.