A mobile application to support collection and analytics of real-time critical care data.

BACKGROUND AND OBJECTIVES: Data collection, in high intensity environments, poses several challenges including the ability to observe multiple streams of information. These problems are especially evident in critical care, where monitoring of the Advanced Trauma Life Support (ATLS) protocol provides an excellent opportunity to study the efficacy of applications that allow for the rapid capture of event information, providing theoretically-driven feedback using the data. Our goal was, (a) to design and implement a way to capture data on deviation from the standard practice based on the theoretical foundation of error classification from our past research, (b) to provide a means to meaningfully visualize the collected data, and (c) to provide a proof-of-concept for this implementation, using some understanding of user experience in clinical practice. METHODS: We present the design and development of a web application designed to be used primarily on mobile devices and a summary data viewer to allow clinicians to, (a) track their activities, (b) provide real-time feedback of deviations from guidelines and protocols, and (c) provide summary feedback highlighting decisions made. We used a framework previously developed to classify activities in trauma as the theoretical foundation of the rules designed to do the same algorithmically, in our application. Attending physicians at a Level 1 trauma center used the application in the clinical setting and provided feedback for iterative development. Informal interviews and surveys were used to gain some deeper understanding of the user experience using this application in-situ. RESULTS: Activity visualizations were created highlighting decisions made during a trauma code as well as classification of tasks per the theoretical framework. The attendings reviewed the efficacy of the data visualizations as part of their interviews. We also conducted a proof-of-concept evaluation by way of usability questionnaire. Two attendings rated 4 out of the usability 6 categories highly (inter-rater reliability: R = 0.87; weighted kappa = 0.59). This could be attributed to the fact that they were able to fit the use of the application into their regular workflow during a trauma code relatively seamlessly. A deeper evaluation is required to answer explain this further. CONCLUSIONS: Our application can be used to capture and present data to provide an accurate reflection of work activities in real-time in complex critical care environments, without any significant interruptions to workflow.

Collaborative virtual reality based advanced cardiac life support training simulator using virtual reality principles.

BACKGROUND: Advanced Cardiac Life Support (ACLS) is a series of team-based, sequential and time constrained interventions, requiring effective communication and coordination of activities that are performed by the care provider team on a patient undergoing cardiac arrest or respiratory failure. The state-of-the-art ACLS training is conducted in a face-to-face environment under expert supervision and suffers from several drawbacks including conflicting care provider schedules and high cost of training equipment. OBJECTIVE: The major objective of the study is to describe, including the design, implementation, and evaluation of a novel approach of delivering ACLS training to care providers using the proposed virtual reality simulator that can overcome the challenges and drawbacks imposed by the traditional face-to-face training method. METHODS: We compare the efficacy and performance outcomes associated with traditional ACLS training with the proposed novel approach of using a virtual reality (VR) based ACLS training simulator. One hundred and forty-eight (148) ACLS certified clinicians, translating into 26 care provider teams, were enrolled for this study. Each team was randomly assigned to one of the three treatment groups: control (traditional ACLS training), persuasive (VR ACLS training with comprehensive feedback components), or minimally persuasive (VR ACLS training with limited feedback components). The teams were tested across two different ACLS procedures that vary in the degree of task complexity: ventricular fibrillation or tachycardia (VFib/VTach) and pulseless electric activity (PEA). RESULTS: The difference in performance between control and persuasive groups was not statistically significant (P=.37 for PEA and P=.1 for VFib/VTach). However, the difference in performance between control and minimally persuasive groups was significant (P=.05 for PEA and P=.02 for VFib/VTach). The pre-post comparison of performances of the groups showed that control (P=.017 for PEA, P=.01 for VFib/VTach) and persuasive (P=.02 for PEA, P=.048 for VFib/VTach) groups improved their performances significantly, whereas minimally persuasive group did not (P=.45 for PEA, P=.46 for VFib/VTach). Results also suggest that the benefit of persuasiveness is constrained by the potentially interruptive nature of these features. CONCLUSIONS: Our results indicate that the VR-based ACLS training with proper feedback components can provide a learning experience similar to face-to-face training, and therefore could serve as a more easily accessed supplementary training tool to the traditional ACLS training. Our findings also suggest that the degree of persuasive features in VR environments have to be designed considering the interruptive nature of the feedback elements.

Design and evaluation of theory-informed technology to augment a wellness motivation intervention.

Integrating mobile technology into health promotion strategies has the potential to support healthy behaviors. A new theory-informed app was designed to augment an intervention promoting wellness motivation in older adults with fall risk and low levels of physical activity. The app content was evaluated for clarity, homogeneity, and validity of motivational messages; both the app and device were evaluated for acceptability and usability. The initial evaluation included nine adults (mean age, 75); four of whom also assessed the app's sensing abilities in the field. As part of an intervention feasibility study, 14 older adults (mean age, 84) also provided a follow-up evaluation of app usability. Evaluation participants assessed the app as valid, usable, acceptable, and able to sense most reported free-living activities, and provided feedback for improving the app. Design processes illustrate methodologic and interpretive efforts to operationalize motivational content in a theory-informed app promoting change in physical activity behavior.

Design and development of a virtual reality simulator for advanced cardiac life support training.

The use of virtual reality (VR) training tools for medical education could lead to improvements in the skills of clinicians while providing economic incentives for healthcare institutions. The use of VR tools can also mitigate some of the drawbacks currently associated with providing medical training in a traditional clinical environment such as scheduling conflicts and the need for specialized equipment (e.g., high-fidelity manikins). This paper presents the details of the framework and the development methodology associated with a VR-based training simulator for advanced cardiac life support, a time critical, team-based medical scenario. In addition, we also report the key findings of a usability study conducted to assess the efficacy of various features of this VR simulator through a postuse questionnaire administered to various care providers. The usability questionnaires were completed by two groups that used two different versions of the VR simulator. One version consisted of the VR trainer with it all its features and a minified version with certain immersive features disabled. We found an increase in usability scores from the minified group to the full VR group.

Mobile computer application for promoting physical activity.

Despite evidence that physical activity reduces the risk of falls and other causes of disability and death, the majority of older adults do not engage in physical activity on a regular basis. Mobile technology applications have emerged as potential resources for promoting physical activity behavior. This article describes features of a new application, Ready∼Steady, highlighting approaches used in its design and development, and implications for clinical practice. Iterative processes enabled the design, development, implementation, and evaluation of the application consistent with the wellness motivation theory, as well as established user-specific strategies and theoretical design principles. Implications in terms of potential benefits and constraints are discussed. Integrating technology that promotes health and wellness in the form of mobile computer applications is a promising adjunct to nursing practice.

ReadySteady: app for accelerometer-based activity monitoring and wellness-motivation feedback system for older adults.

Increased physical activity and exercise have been found to reduce falls and decrease mortality and age-related morbidity in older adults. However, a large percentage of this population fail to achieve the necessary levels of activity needed to support health living. In this work, we present a mobile app developed on the iOS platform that monitors activity levels using accelerometry. The data captured by the sensor is utilized to provide real-time motivational feedback to enable reinforcement of positive behaviors in older adults. Pilot experiments (conducted with younger adults) performed to assess validity of activity measurement showed that system accurately measures sedentary, light, moderate and vigorous activities in a controlled lab setting. Pilot tests (conducted with older adults) in the user setting showed that while the app is adept at capturing gross body activity (such as sitting, walking and jogging), additional sensors may be required to capture activities involving the extremities.

Adaptive behaviors of experts in following standard protocol in trauma management: implications for developing flexible guidelines.

Critical care environments are complex and dynamic. To adapt to such environments, clinicians may be required to make alterations to their workflows resulting in deviations from standard procedures. In this work, deviations from standards in trauma critical care are studied. Thirty trauma cases were observed in a Level 1 trauma center. Activities tracked were compared to the Advance Trauma Life Support standard to determine (i) if deviations had occurred, (ii) type of deviations and (iii) whether deviations were initiated by individuals or collaboratively by the team. Results show that expert clinicians deviated to innovate, while deviations of novices result mostly in error. Experts' well developed knowledge allows for flexibility and adaptiveness in dealing with standards, resulting in innovative deviations while minimizing errors made. Providing informatics solution, in such a setting, would mean that standard protocols would have be flexible enough to "learn" from new knowledge, yet provide strong support for the trainees.

Deviations from protocol in a complex trauma environment: errors or innovations?

Protocol standardizations are important for consistent and safe practices. However, complex clinical environments are highly dynamic in nature and often require clinicians, confronted with non-standard situations, to adjust and deviate from standard protocol. Some of these deviations are errors which can result in harmful outcomes. On the other hand, some of the deviations can be innovations, which are dynamic adjustments to the protocols made by people to adapt the current operational conditions and achieve high accuracy and efficiency. However, there is very little known about the underlying cognitive processes that are related to errors and innovations. In this study we investigate the extent to which deviations are classified as errors or innovations, as a function of expertise in a trauma setting. Field observations were conducted in a Level 1 trauma unit. A total of 10 trauma cases were observed and collected data was analyzed using measures that included customized activity-error-innovation ontology, timestamps and expertise of the team members. The results show that expertise of the caregivers and criticality of a patient's condition in critical care environment influence the number and type of deviations from standard protocol. Experts' deviations were a combination of errors and innovations; whereas the novices' deviations were mostly errors. This research suggests that a novel approach must be taken into consideration for the design of protocols (including standards) and compliance measurements in complex clinical environments.

Toward effective pediatric minimally invasive surgical simulation.

BACKGROUND/PURPOSE: Simulation is increasingly being recognized as an important tool in the training and evaluation of surgeons. Currently, there is no simulator that is specific to pediatric minimally invasive surgery (MIS). A fundamental technical difference between adult and pediatric MIS is the degree of motion scaling. Smaller instruments and areas of dissection under greater optical magnification require finer, more precise hand movements. We hypothesized that this can be used to detect differences in skills proficiency between pediatric and general surgeons. METHODS: We programmed a virtual reality simulation of intracorporeal suturing with modes that used motion scaling to mimic conditions of either adult or pediatric MIS. The participants consisted of pediatric and general surgeons who wore motion-sensing gloves. Metrics included time elapsed, penetration errors, tool movement smoothness, hand movement smoothness, and gesture level proficiency. RESULTS: For all measures, pediatric surgeons demonstrated superior proficiency on exercises conducted in pediatric conditions (P < .05). Performance in adult conditions was similar between the 2 groups. CONCLUSION: Pediatric surgeons possess unique skills compared with general surgeons that relate to the technical challenges they routinely face, reinforcing the need for a surgical simulator specific to pediatric MIS. This validates our simulator and the manipulation of motion scaling as a useful training tool.

Toward automated workflow analysis and visualization in clinical environments.

Lapses in patient safety have been linked to unexpected perturbations in clinical workflow. The effectiveness of workflow analysis becomes critical to understanding the impact of these perturbations on patient outcome. The typical methods used for workflow analysis, such as ethnographic observations and interviewing, are limited in their ability to capture activities from different perspectives simultaneously. This limitation, coupled with the complexity and dynamic nature of clinical environments makes understanding the nuances of clinical workflow difficult. The methods proposed in this research aim to provide a quantitative means of capturing and analyzing workflow. The approach taken utilizes recordings of motion and location of clinical teams that are gathered using radio identification tags and observations. This data is used to model activities in critical care environments. The detected activities can then be replayed in 3D virtual reality environments for further analysis and training. Using this approach, the proposed system augments existing methods of workflow analysis, allowing for capture of workflow in complex and dynamic environments. The system was tested with a set of 15 simulated clinical activities that when combined represent workflow in trauma units. A mean recognition rate of 87.5% was obtained in automatically recognizing the activities.

A virtual reality simulator for orthopedic basic skills: a design and validation study.

Orthopedic drilling as a skill demands high levels of dexterity and expertise from the surgeon. It is a basic skill that is required in many orthopedic procedures. Inefficient drilling can be a source of avoidable medical errors that may lead to adverse events. It is hence important to train and evaluate residents in safe environments for this skill. This paper presents a virtual orthopedic drilling simulator that was designed to provide visiohaptic interaction with virtual bones. The simulation provides a realistic basic training environment for orthopedic surgeons. It contains modules to track and analyze movements of surgeons, in order to determine their surgical proficiency. The simulator was tested with senior surgeons, residents and medical students for validation purposes. Through the multi-tiered testing strategy it was shown that the simulator was able to produce a learning effect that transfers to real-world drilling. Further, objective measures of surgical performance were found to be able to differentiate between experts and novices.

Cognitive simulators for medical education and training.

Simulators for honing procedural skills (such as surgical skills and central venous catheter placement) have proven to be valuable tools for medical educators and students. While such simulations represent an effective paradigm in surgical education, there is an opportunity to add a layer of cognitive exercises to these basic simulations that can facilitate robust skill learning in residents. This paper describes a controlled methodology, inspired by neuropsychological assessment tasks and embodied cognition, to develop cognitive simulators for laparoscopic surgery. These simulators provide psychomotor skill training and offer the additional challenge of accomplishing cognitive tasks in realistic environments. A generic framework for design, development and evaluation of such simulators is described. The presented framework is generalizable and can be applied to different task domains. It is independent of the types of sensors, simulation environment and feedback mechanisms that the simulators use. A proof of concept of the framework is provided through developing a simulator that includes cognitive variations to a basic psychomotor task. The results of two pilot studies are presented that show the validity of the methodology in providing an effective evaluation and learning environments for surgeons.

Visualization and analysis of activities in critical care environments.

Critical care environments are inherently complex and dynamic. Assessment of workflow in such environments is not trivial. While existing approaches for workflow analysis such as ethnographic observations and interviewing provide contextualized information about the overall workflow, they are limited in their ability to capture the workflow from all perspectives. This paper presents a tool for automated activity recognition that can provide an additional point of view. Using data captured by Radio Identification (RID) tags and Hidden Markov Models (HMMs), key activities in the environment can be modeled and recognized. The proposed method leverages activity recognition systems to provide a snapshot of workflow in critical care environments. The activities representing the workflow can be extracted and replayed using virtual reality environments for further analysis.