Publications by authors named "Melanie C Wright"

29 Publications

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User interface approaches implemented with automated patient deterioration surveillance tools: protocol for a scoping review.

BMJ Open 2022 Jan 13;12(1):e055525. Epub 2022 Jan 13.

College of Pharmacy, Idaho State University, Pocatello, Idaho, USA

Introduction: Early identification of patients who may suffer from unexpected adverse events (eg, sepsis, sudden cardiac arrest) gives bedside staff valuable lead time to care for these patients appropriately. Consequently, many machine learning algorithms have been developed to predict adverse events. However, little research focuses on how these systems are implemented and how system design impacts clinicians' decisions or patient outcomes. This protocol outlines the steps to review the designs of these tools.

Methods And Analysis: We will use scoping review methods to explore how tools that leverage machine learning algorithms in predicting adverse events are designed to integrate into clinical practice. We will explore the types of user interfaces deployed, what information is displayed, and how clinical workflows are supported. Electronic sources include Medline, Embase, CINAHL Complete, Cochrane Library (including CENTRAL), and IEEE Xplore from 1 January 2009 to present. We will only review primary research articles that report findings from the implementation of patient deterioration surveillance tools for hospital clinicians. The articles must also include a description of the tool's user interface. Since our primary focus is on how the user interacts with automated tools driven by machine learning algorithms, electronic tools that do not extract data from clinical data documentation or recording systems such as an EHR or patient monitor, or otherwise require manual entry, will be excluded. Similarly, tools that do not synthesise information from more than one data variable will also be excluded. This review will be limited to English-language articles. Two reviewers will review the articles and extract the data. Findings from both researchers will be compared with minimise bias. The results will be quantified, synthesised and presented using appropriate formats.

Ethics And Dissemination: Ethics review is not required for this scoping review. Findings will be disseminated through peer-reviewed publications.
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http://dx.doi.org/10.1136/bmjopen-2021-055525DOI Listing
January 2022

Effect of Remote Cardiac Monitoring System Design on Response Time to Critical Arrhythmias.

Simul Healthc 2021 Sep 9. Epub 2021 Sep 9.

From the Department of Anesthesiology (N.S.), Duke University School of Medicine, Durham; Textile Engineering, Chemistry, and Science (J.A.J.), North Carolina State University, Raleigh; Duke University Health System (R.D.B., J.R.E.); Duke Office of Clinical Research (D.B.), Duke University School of Medicine, Durham, NC; Rush University College of Nursing (L.G.C.), Chicago, IL; Saint Alphonsus Regional Medical Center (S.J.), Boise; and College of Pharmacy (M.C.W.), Idaho State University, Pocatello, ID.

Introduction: In many hospitals across the country, electrocardiograms of multiple at-risk patients are monitored remotely by telemetry monitor watchers in a central location. However, there is limited evidence regarding best practices for designing these cardiac monitoring systems to ensure prompt detection and response to life-threatening events. To identify factors that may affect monitoring efficiency, we simulated critical arrhythmias in inpatient units with different monitoring systems and compared their efficiency in communicating the arrhythmias to a first responder.

Methods: This was a multicenter cross-sectional in situ simulation study. Simulation participants were monitor watchers and first responders (usually nurses) in 2 inpatient units in each of 3 hospitals. Manipulated variables included: (1) number of communication nodes between monitor watchers and first responders; (2) central monitoring station location-on or off the patient care unit; (3) monitor watchers' workload; (4) nurses' workload; and (5) participants' experience.

Results: We performed 62 arrhythmia simulations to measure response times of monitor watchers and 128 arrhythmia simulations to measure response times in patient care units. We found that systems in which an intermediary between monitor watchers and nurses communicated critical events had faster response times to simulated arrhythmias than systems in which monitor watchers communicated directly with nurses. Responses were also faster in units colocated with central monitoring stations than in those located remotely. As the perceived workload of nurses increased, response latency also increased. Experience did not affect response times.

Conclusions: Although limited in our ability to isolate the effects of these factors from extraneous factors on central monitoring system efficiency, our study provides a roadmap for using in situ arrhythmia simulations to assess and improve monitoring performance.
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http://dx.doi.org/10.1097/SIH.0000000000000610DOI Listing
September 2021

Evaluation of a Custom EMR-embedded Handoff Support Application's Impact on Resident Handoff Behaviors and Perceptions of Handoff Quality.

Am J Med Qual 2021 Nov-Dec 01;36(6):465-466

Mercy Health, Grand Rapids, MI St. Joseph Mercy, Ann Arbor, MI Brass Tacks Health, Seattle, WA Idaho State University, Meridian, ID.

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http://dx.doi.org/10.1097/01.JMQ.0000741976.34398.cfDOI Listing
November 2021

Organizing Audible Alarm Sounds in the Hospital: A Card-Sorting Study.

IEEE Trans Hum Mach Syst 2020 Dec 14;50(6):623-627. Epub 2020 Sep 14.

Duke University, Durham, NC USA.

In hospitals, clinicians are presented with varied and disorganized alarm sounds from disparate devices. While there has been attention to reducing inactionable alarms to address alarm overload, little effort has focused on organizing, simplifying, or improving the informativeness of alarms. We sought to elicit nurses' tacit interpretation of alarm events to create an organizational structure to inform the design of advanced alarm sounds or integrated alert systems. We used open card sorting to evaluate nurses' perception of the relatedness of different alarm events. Seventy hospital nurses sorted 89 alarm events into groups they believed could or should be indicated by the same sound. We conducted factor analysis on a similarity matrix of frequency of alarm event pairings to interpret how strongly alarm events loaded on different alarm groups (factors). We interpreted participants' grouping rationale from their group labels and comments. Urgency of response was the most common grouping rationale. Participants also grouped: 1) monitoring-related events, 2) device-related events, and 3) events related to calls and patients. Our findings support standardization and integration of alarm sounds across devices toward a simpler and more informative hospital alarm environment.
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http://dx.doi.org/10.1109/thms.2020.3019363DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7996481PMC
December 2020

Preliminary Validation of a Patient-Reported Measure of the Age-Friendliness of Health Care.

J Am Geriatr Soc 2021 01 17;69(1):180-184. Epub 2020 Oct 17.

Board of Directors, The International Foundation for Integrated Care, Utrecht, The Netherlands.

Background/objective: To evaluate the validity and reliability of a patient-reported measure of the "age-friendliness" of health care.

Design: Based on four essential domains of high-quality health care for older outpatients (Medications, Mobility, Mentation and "what Matters," i.e., the 4 M's), we drafted a five-item questionnaire for older outpatients to rate the age-friendliness of their health care. One question addressed each of the 4 M's; the fifth addressed the overall age-friendliness of their care. After feedback from healthcare professionals, quality improvement experts, and a patient-caregiver focus group, we revised the items to create the Age-Friendliness Questionnaire (AFQ). SETTING We tested the AFQ by appending it to two surveys.

Participants: Older outpatients in Idaho during July to October 2019: Survey 1, with 23 other items, was sent to 1,257 older patients who were medically complex; Survey 2, with 35 other items, was sent to 2,873 older patients who visited outpatient primary care providers (PCPs) during the specified time period.

Measurements: Respondents rated their providers' performance using a 1 to 5 ("never" to "always") scale for each of the five items (possible AFQ scores = 5-25).

Results: The response rates were 41.4% and 33.3%, respectively. In Survey 1, the mean AFQ score from patients who had received care from a geriatrics consult clinic was higher than that from patients who had received their care from PCPs (19.3 vs 15.6; P < .001), and AFQ scores correlated with other quality-of-care scores. In Survey 2, AFQ scores predicted respondents' likelihood of recommending their providers to others (P < .001). The AFQ exhibited high internal reliability (interitem correlations = .49-.77; Cronbach's α = .89).

Conclusion: The AFQ appears to be a valid and reliable measure of the age-friendliness of outpatient care for older patients, and it predicts the likelihood that they will recommend their providers to others.
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http://dx.doi.org/10.1111/jgs.16881DOI Listing
January 2021

Iterative heuristic design of temporal graphic displays with clinical domain experts.

J Clin Monit Comput 2021 10 2;35(5):1119-1131. Epub 2020 Aug 2.

College of Pharmacy, University of Idaho, Meridian, USA.

Conventional electronic health record information displays are not optimized for efficient information processing. Graphical displays that integrate patient information can improve information processing, especially in data-rich environments such as critical care. We propose an adaptable and reusable approach to patient information display with modular graphical components (widgets). We had two study objectives. First, reduce numerous widget prototype alternatives to preferred designs. Second, derive widget design feature recommendations. Using iterative human-centered design methods, we interviewed experts to hone design features of widgets displaying frequently measured data elements, e.g., heart rate, for acute care patient monitoring and real-time clinical decision-making. Participant responses to design queries were coded to calculate feature-set agreement, average prototype score, and prototype agreement. Two iterative interview cycles covering 64 design queries and 86 prototypes were needed to reach consensus on six feature sets. Interviewers agreed that line graphs with a smoothed or averaged trendline, 24-h timeframe, and gradient coloring for urgency were useful and informative features. Moreover, users agreed that widgets should include key functions: (1) adjustable reference ranges, (2) expandable timeframes, and (3) access to details on demand. Participants stated graphical widgets would be used to identify correlating patterns and compare abnormal measures across related data elements at a specific time. Combining theoretical principles and validated design methods was an effective and reproducible approach to designing widgets for healthcare displays. The findings suggest our widget design features and recommendations match critical care clinician expectations for graphical information display of continuous and frequently updated patient data.
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http://dx.doi.org/10.1007/s10877-020-00571-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7854828PMC
October 2021

Impact of integrated graphical display on expert and novice diagnostic performance in critical care.

J Am Med Inform Assoc 2020 08;27(8):1287-1292

College of Pharmacy, Idaho State University, Pocatello, Idaho, USA.

Objective: To determine the impact of a graphical information display on diagnosing circulatory shock.

Materials And Methods: This was an experimental study comparing integrated and conventional information displays. Participants were intensivists or critical care fellows (experts) and first-year medical residents (novices).

Results: The integrated display was associated with higher performance (87% vs 82%; P < .001), less time (2.9 vs 3.5 min; P = .008), and more accurate etiology (67% vs 54%; P = .048) compared to the conventional display. When stratified by experience, novice physicians using the integrated display had higher performance (86% vs 69%; P < .001), less time (2.9 vs 3.7 min; P = .03), and more accurate etiology (65% vs 42%; P = .02); expert physicians using the integrated display had nonsignificantly improved performance (87% vs 82%; P = .09), time (2.9 vs 3.3; P = .28), and etiology (69% vs 67%; P = .81).

Discussion: The integrated display appeared to support efficient information processing, which resulted in more rapid and accurate circulatory shock diagnosis. Evidence more strongly supported a difference for novices, suggesting that graphical displays may help reduce expert-novice performance gaps.
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http://dx.doi.org/10.1093/jamia/ocaa086DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7481028PMC
August 2020

High-stakes assessment in anesthesia via simulation: Are we there yet?

Authors:
Melanie C Wright

Can J Anaesth 2019 12 27;66(12):1431-1436. Epub 2019 Sep 27.

Saint Alphonsus Regional Medical Center Research Institute, Trinity Health, 1055 N. Curtis Rd, Boise, ID, 83706, USA.

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http://dx.doi.org/10.1007/s12630-019-01489-3DOI Listing
December 2019

Critical care information display approaches and design frameworks: A systematic review and meta-analysis.

J Biomed Inform X 2019 Sep 22;3. Epub 2019 Jun 22.

Anesthesiology, Duke University, Durham, NC, USA.

Objective: To systematically review original user evaluations of patient information displays relevant to critical care and understand the impact of design frameworks and information presentation approaches on decision-making, efficiency, workload, and preferences of clinicians.

Methods: We included studies that evaluated information displays designed to support real-time care decisions in critical care or anesthesiology using simulated tasks. We searched PubMed and IEEExplore from 1/1/1990 to 6/30/2018. The search strategy was developed iteratively with calibration against known references. Inclusion screening was completed independently by two authors. Extraction of display features, design processes, and evaluation method was completed by one and verified by a second author.

Results: Fifty-six manuscripts evaluating 32 critical care and 22 anesthesia displays were included. Primary outcome metrics included clinician accuracy and efficiency in recognizing, diagnosing, and treating problems. Implementing user-centered design (UCD) processes, especially iterative evaluation and redesign, resulted in positive impact in outcomes such as accuracy and efficiency. Innovative display approaches that led to improved human-system performance in critical care included: (1) improving the integration and organization of information, (2) improving the representation of trend information, and (3) implementing graphical approaches to make relationships between data visible.

Conclusion: Our review affirms the value of key principles of UCD. Improved information presentation can facilitate faster information interpretation and more accurate diagnoses and treatment. Improvements to information organization and support for rapid interpretation of time-based relationships between related quantitative data is warranted. Designers and developers are encouraged to involve users in formal iterative design and evaluation activities in the design of electronic health records (EHRs), clinical informatics applications, and clinical devices.
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http://dx.doi.org/10.1016/j.yjbinx.2019.100041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6696941PMC
September 2019

Novel displays of patient information in critical care settings: a systematic review.

J Am Med Inform Assoc 2019 05;26(5):479-489

Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA.

Objective: Clinician information overload is prevalent in critical care settings. Improved visualization of patient information may help clinicians cope with information overload, increase efficiency, and improve quality. We compared the effect of information display interventions with usual care on patient care outcomes.

Materials And Methods: We conducted a systematic review including experimental and quasi-experimental studies of information display interventions conducted in critical care and anesthesiology settings. Citations from January 1990 to June 2018 were searched in PubMed and IEEE Xplore. Reviewers worked independently to screen articles, evaluate quality, and abstract primary outcomes and display features.

Results: Of 6742 studies identified, 22 studies evaluating 17 information displays met the study inclusion criteria. Information display categories included comprehensive integrated displays (3 displays), multipatient dashboards (7 displays), physiologic and laboratory monitoring (5 displays), and expert systems (2 displays). Significant improvement on primary outcomes over usual care was reported in 12 studies for 9 unique displays. Improvement was found mostly with comprehensive integrated displays (4 of 6 studies) and multipatient dashboards (5 of 7 studies). Only 1 of 5 randomized controlled trials had a positive effect in the primary outcome.

Conclusion: We found weak evidence suggesting comprehensive integrated displays improve provider efficiency and process outcomes, and multipatient dashboards improve compliance with care protocols and patient outcomes. Randomized controlled trials of physiologic and laboratory monitoring displays did not show improvement in primary outcomes, despite positive results in simulated settings. Important research translation gaps from laboratory to actual critical care settings exist.
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http://dx.doi.org/10.1093/jamia/ocy193DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6657276PMC
May 2019

Critical care information display approaches and design frameworks: A systematic review and meta-analysis.

J Biomed Inform 2019 22;100S:100041. Epub 2019 Jun 22.

Anesthesiology, Duke University, Durham, NC, USA.

Objective: To systematically review original user evaluations of patient information displays relevant to critical care and understand the impact of design frameworks and information presentation approaches on decision-making, efficiency, workload, and preferences of clinicians.

Methods: We included studies that evaluated information displays designed to support real-time care decisions in critical care or anesthesiology using simulated tasks. We searched PubMed and IEEExplore from 1/1/1990 to 6/30/2018. The search strategy was developed iteratively with calibration against known references. Inclusion screening was completed independently by two authors. Extraction of display features, design processes, and evaluation method was completed by one and verified by a second author.

Results: Fifty-six manuscripts evaluating 32 critical care and 22 anesthesia displays were included. Primary outcome metrics included clinician accuracy and efficiency in recognizing, diagnosing, and treating problems. Implementing user-centered design (UCD) processes, especially iterative evaluation and redesign, resulted in positive impact in outcomes such as accuracy and efficiency. Innovative display approaches that led to improved human-system performance in critical care included: (1) improving the integration and organization of information, (2) improving the representation of trend information, and (3) implementing graphical approaches to make relationships between data visible.

Conclusion: Our review affirms the value of key principles of UCD. Improved information presentation can facilitate faster information interpretation and more accurate diagnoses and treatment. Improvements to information organization and support for rapid interpretation of time-based relationships between related quantitative data is warranted. Designers and developers are encouraged to involve users in formal iterative design and evaluation activities in the design of electronic health records (EHRs), clinical informatics applications, and clinical devices.
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http://dx.doi.org/10.1016/j.yjbinx.2019.100041DOI Listing
June 2019

Patient information organization in the intensive care setting: expert knowledge elicitation with card sorting methods.

J Am Med Inform Assoc 2018 08;25(8):1026-1035

Trinity Health and Saint Alphonsus Regional Medical Center, Boise, ID, USA.

Introduction: Many electronic health records fail to support information uptake because they impose low-level information organization tasks on users. Clinical concept-oriented views have shown information processing improvements, but the specifics of this organization for critical care are unclear.

Objective: To determine high-level cognitive processes and patient information organization schema in critical care.

Methods: We conducted an open card sort of 29 patient data elements and a modified Delphi card sort of 65 patient data elements. Study participants were 39 clinicians with varied critical care training and experience. We analyzed the open sort with a hierarchical cluster analysis (HCA) and factor analysis (FA). The Delphi sort was split into three initiating groups that resulted in three unique solutions. We compared results between open sort analyses (HCA and FA), between card sorting exercises (open and Delphi), and across the Delphi solutions.

Results: Between the HCA and FA, we observed common constructs including cardiovascular and hemodynamics, infectious disease, medications, neurology, patient overview, respiratory, and vital signs. The more comprehensive Delphi sort solutions also included gastrointestinal, renal, and imaging constructs.

Conclusions: We identified primarily system-based groupings (e.g., cardiovascular, respiratory). Source-based (e.g., medications, laboratory) groups became apparent when participants were asked to sort a longer list of concepts. These results suggest a hybrid approach to information organization, which may combine systems, source, or problem-based groupings, best supports clinicians' mental models. These results can contribute to the design of information displays to better support clinicians' access and interpretation of information for critical care decisions.
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http://dx.doi.org/10.1093/jamia/ocy045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6077790PMC
August 2018

How Do Simulated Error Experiences Impact Attitudes Related to Error Prevention?

Simul Healthc 2016 Oct;11(5):323-333

From the School of Nursing (K.R.B.), Boise State University; Nursing Research and Education Specialist (R.L.D.), Saint Alphonsus Health System; and Patient Safety Research (M.C.W.), Saint Alphonsus Health System and Trinity Health, Boise, ID.

Introduction: The objective of this project was to determine whether simulated exposure to error situations changes attitudes in a way that may have a positive impact on error prevention behaviors.

Methods: Using a stratified quasi-randomized experiment design, we compared risk perception attitudes of a control group of nursing students who received standard error education (reviewed medication error content and watched movies about error experiences) to an experimental group of students who reviewed medication error content and participated in simulated error experiences. Dependent measures included perceived memorability of the educational experience, perceived frequency of errors, and perceived caution with respect to preventing errors.

Results: Experienced nursing students perceived the simulated error experiences to be more memorable than movies. Less experienced students perceived both simulated error experiences and movies to be highly memorable. After the intervention, compared with movie participants, simulation participants believed errors occurred more frequently. Both types of education increased the participants' intentions to be more cautious and reported caution remained higher than baseline for medication errors 6 months after the intervention.

Conclusions: This study provides limited evidence of an advantage of simulation over watching movies describing actual errors with respect to manipulating attitudes related to error prevention. Both interventions resulted in long-term impacts on perceived caution in medication administration. Simulated error experiences made participants more aware of how easily errors can occur, and the movie education made participants more aware of the devastating consequences of errors.
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http://dx.doi.org/10.1097/SIH.0000000000000174DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6154479PMC
October 2016

Toward Designing Information Display to Support Critical Care. A Qualitative Contextual Evaluation and Visioning Effort.

Appl Clin Inform 2016 10 5;7(4):912-929. Epub 2016 Oct 5.

Melanie C. Wright, PhD, Program Director, Patient Safety Research, Trinity Health and Saint Alphonsus Health System, 1055 N. Curtis Rd, Boise ID 83702, Email: Phone: 208-367-7399.

Objectives: Electronic health information overload makes it difficult for providers to quickly find and interpret information to support care decisions. The purpose of this study was to better understand how clinicians use information in critical care to support the design of improved presentation of electronic health information.

Methods: We conducted a contextual analysis and visioning project. We used an eye-tracker to record 20 clinicians' information use activities in critical care settings. We played video recordings back to clinicians in retrospective cued interviews and queried: 1) context and goals of information use, 2) impacts of current display design on use, and 3) processes related to information use. We analyzed interview transcripts using grounded theory-based content analysis techniques and identified emerging themes. From these, we conducted a visioning activity with a team of subject matter experts and identified key areas for focus of design and research for future display designs.

Results: Analyses revealed four unique critical care information use activities including new patient assessment, known patient status review, specific directed information seeking, and review and prioritization of multiple patients. Emerging themes were primarily related to a need for better representation of dynamic data such as vital signs and laboratory results, usability issues associated with reducing cognitive load and supporting efficient interaction, and processes for managing information. Visions for the future included designs that: 1) provide rapid access to new information, 2) organize by systems or problems as well as by current versus historical patient data, and 3) apply intelligence toward detecting and representing change and urgency.

Conclusions: The results from this study can be used to guide the design of future acute care electronic health information display. Additional research and collaboration is needed to refine and implement intelligent graphical user interfaces to improve clinical information organization and prioritization to support care decisions.
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http://dx.doi.org/10.4338/ACI-2016-03-RA-0033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5228134PMC
October 2016

Operating Room-to-ICU Patient Handovers: A Multidisciplinary Human-Centered Design Approach.

Jt Comm J Qual Patient Saf 2016 09;42(9):400-14

Department of Anesthesiology, Duke University Medical Center (DUMC), Durham, North Carolina, USA.

Background: Patient handovers (handoffs) following surgery have often been characterized by poor teamwork, unclear procedures, unstructured processes, and distractions. A study was conducted to apply a human-centered approach to the redesign of operating room (OR)-to-ICU patient handovers in a broad surgical ICU (SICU) population. This approach entailed (1) the study of existing practices, (2) the redesign of the handover on the basis of the input of hand over participants and evidence in the medical literature, and (3) the study of the effects of this change on processes and communication.

Methods: The Durham [North Carolina] Veterans Affairs Medical Center SICU is an 11-bed mixed surgical specialty unit. To understand the existing process for receiving postoperative patients in the SICU, ethnographic methods-a series of observations, surveys, interviews, and focus groups-were used. The handover process was redesigned to better address providers' work flow, information needs, and expectations, as well as concerns identified in the literature.

Results: Technical and communication flaws were uncovered, and the handover was redesigned to address them. For the 49 preintervention and 49 postintervention handovers, the information transfer score and number of interruptions were not significantly different. However, staff workload and team behaviors scores improved significantly, while the hand over duration was not prolonged by the new process. Handover participants were also significantly more satisfied with the new handover method.

Conclusions: An HCD approach led to improvements in the patient handover process from the OR to the ICU in a mixed adult surgical population. Although the specific handover process would unlikely be optimal in another clinical setting if replicated exactly, the HCD foundation behind the redesign process is widely applicable.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6152817PMC
http://dx.doi.org/10.1016/s1553-7250(16)42081-7DOI Listing
September 2016

Patient load effects on response time to critical arrhythmias in cardiac telemetry: a randomized trial.

Crit Care Med 2015 May;43(5):1036-42

1Department of Anesthesiology, Duke University Medical Center, Durham, NC. 2Department of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC. 3Procurement Services, Duke University, Durham, NC. 4Trauma Program, University of North Carolina Health System, Chapel Hill, NC. 5Patient Safety Research, CHE Trinity Health and Saint Alphonsus Health System, Boise, ID.

Objectives: Remotely monitored patients may be at risk for a delayed response to critical arrhythmias if the telemetry watchers who monitor them are subject to an excessive patient load. There are no guidelines or studies regarding the appropriate number of patients that a single watcher may safely and effectively monitor. Our objective was to determine the impact of increasing the number of patients monitored on response time to simulated cardiac arrest.

Design: Randomized trial.

Setting: Laboratory-based experiment.

Subjects: Forty-two remote telemetry technicians and nurses from cardiac units.

Interventions: Number of patients monitored in a simulation of cardiac telemetry monitoring work.

Measurements And Main Results: We carried out a study to compare response times to ventricular fibrillation across five patient loads: 16, 24, 32, 40, and 48 patients. The simulation replicated the work of telemetry watchers using a combination of real recorded patient electrocardiogram signals and a simulated patient experiencing ventricular fibrillation. Study participants were assigned to one of the five patient loads and completed a 4-hour monitoring session, during which they performed tasks-including event documentation and phone calls to report events-similar to real monitoring work. When the simulated patient sustained ventricular fibrillation, the time required to report this arrhythmia was recorded. As patient loads increased, there was a statistically significant increase in response times to the ventricular fibrillation. In addition, frequency of failure to meet a response time goal of less than 20 seconds was significantly higher in the 48-patient condition than in all other conditions. Task performance decreased as patient load increased.

Conclusions: As participants monitored more patients in a laboratory setting, their performance with respect to recognizing critical and noncritical events declined. This study has implications for the design of remote telemetry work and other patient monitoring tasks in critical and intermediate care units.
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http://dx.doi.org/10.1097/CCM.0000000000000923DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6226252PMC
May 2015

Standardized assessment for evaluation of team skills: validity and feasibility.

Simul Healthc 2013 Oct;8(5):292-303

From the Research Institute (M.C.W.), Saint Alphonsus Health System, Boise, ID; Trinity Institute for Health and Community Benefit (M.C.W.), Trinity Health, Livonia, MI; Department of Anesthesiology (J.M.T., N.S., G.H.,B.P.-B.) and Human Simulation and Patient Safety Center (J.M.T., N.S., G.H.), School of Medicine, Duke University, Durham, NC; NC Center for Hospital Quality and Patient Safety (L.M.), North Carolina Hospital Association, Cary, NC.

Introduction: The authors developed a Standardized Assessment for Evaluation of Team Skills (SAFE-TeamS) in which actors portray health care team members in simulated challenging teamwork scenarios. Participants are scored on scenario-specific ideal behaviors associated with assistance, conflict resolution, communication, assertion, and situation assessment. This research sought to provide evidence of the validity and feasibility of SAFE-TeamS as a tool to support the advancement of science related to team skills training.

Methods: Thirty-eight medical and nursing students were assessed using SAFE-TeamS before and after team skills training. The SAFE-TeamS pretraining and posttraining scores were compared, and participants were surveyed. Generalizability analysis was used to estimate the variance in scores associated with the following: examinee, scenario, rater, pretraining/posttraining, examinee type, rater type (actor-live vs. external rater-videotape), actor team, and scenario order.

Results: The SAFE-TeamS scores reflected improvement after training and were sensitive to individual differences. Score variance due to rater was low. Variance due to scenario was moderate. Estimates of relative reliability for 2 raters and 8 scenarios ranged from 0.6 to 0.7. With fixed scenarios and raters, 2 raters and 2 scenarios, reliability is greater than 0.8. Raters believed SAFE-TeamS assessed relevant team skills. Examinees' responses were mixed.

Conclusions: The SAFE-TeamS was sensitive to individual differences and team skill training, providing evidence for validity. It is not clear whether different scenarios measure different skills and whether the scenarios cover the necessary breadth of skills. Use of multiple scenarios will support assessment across a broader range of skills. Future research is required to determine whether assessments using SAFE-TeamS will translate to performance in clinical practice.
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http://dx.doi.org/10.1097/SIH.0b013e318290a022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6623970PMC
October 2013

A Cognitive Modeling Approach to Decision Support Tool Design for Anesthesia Provider Crisis Management.

Int J Hum Comput Interact 2013 3;29(2):55-66. Epub 2013 Jan 3.

Patient Safety Research, Trinity Health and Saint Alphonsus Health System, Boise, Idaho.

Prior research has revealed existing operating room (OR) patient monitors to provide limited support for prompt and accurate decision making by anesthesia providers during crises. Decision support tools (DSTs) developed for this purpose typically alert the anesthesia provider to existence of a problem but do not recommend a treatment plan. There is a need for a human-centered approach to the design and development of a crisis management DST. A hierarchical task analysis was conducted to identify anesthesia provider procedures in detecting, diagnosing, and treating a critical incident and a cognitive task analysis to elicit goals, decisions, and information requirements. This information was coded in a computational cognitive model using GOMS (Goals, Operators, Methods, Selection rules) Language. An OR monitor interface was prototyped to present output from the cognitive model following ecological interface design principles. A preliminary assessment of the DST was performed with anesthesiology and usability experts. The anesthesiologists indicated they would use the tool in the perioperative environment and would recommend its use by junior anesthesia providers. Future research will focus on formal validation of the DST design approach and comparison of tool output to actual anesthesia provider decisions in real or simulated crises.
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http://dx.doi.org/10.1080/10447318.2012.681220DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8510443PMC
January 2013

Can we make postoperative patient handovers safer? A systematic review of the literature.

Anesth Analg 2012 Jul 27;115(1):102-15. Epub 2012 Apr 27.

Department of Anesthesiology, Duke University Medical Center, Box 3094, Durham, NC 27710, USA.

Postoperative patient handovers are fraught with technical and communication errors and may negatively impact patient safety. We systematically reviewed the literature on handover of care from the operating room to postanesthesia or intensive care units and summarized process and communication recommendations based on these findings. From >500 papers, we identified 31 dealing with postoperative handovers. Twenty-four included recommendations for structuring the handover process or information transfer. Several recommendations were broadly supported, including (1) standardize processes (e.g., through the use of checklists and protocols); (2) complete urgent clinical tasks before the information transfer; (3) allow only patient-specific discussions during verbal handovers; (4) require that all relevant team members be present; and (5) provide training in team skills and communication. Only 4 of the studies developed an intervention and formally assessed its impact on different process measures. All 4 interventions improved metrics of effectiveness, efficiency, and perceived teamwork. Most of the papers were cross-sectional studies that identified barriers to safe, effective postoperative handovers including the incomplete transfer of information and other communication issues, inconsistent or incomplete teams, absent or inefficient execution of clinical tasks, and poor standardization. An association between poor-quality handovers and adverse events was also demonstrated. More innovative research is needed to define optimal patient handovers and to determine the effect of handover quality on patient outcomes.
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http://dx.doi.org/10.1213/ANE.0b013e318253af4bDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6152818PMC
July 2012

Usability evaluation of a personal health record.

AMIA Annu Symp Proc 2011 22;2011:1233-42. Epub 2011 Oct 22.

Duke University Medical Center, Durham, NC, USA.

The electronic personal health record (PHR) has been championed as a mediator of patient-centered care, yet its usability and utility to patients, key predictors of success, have received little attention. Human-centered design (HCD) offers validated methods for studying systems effects on users and their cognitive tasks. In HCD, user-centered activities allow potential users to shape the design of the end product and enhance its usability. We sought to evaluate the usability and functionality of HealthView, the PHR of the Duke University Health System, using HCD methods. Study participants were asked to think aloud as they carried out tasks in HealthView. They then completed surveys and interviews eliciting their reactions to the web portal. Findings were analyzed to generate redesign recommendations, which will be incorporated in a future release of HealthView.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3243224PMC
February 2013

Adaptation of a postoperative handoff communication process for children with heart disease: a quantitative study.

Am J Med Qual 2011 Sep-Oct;26(5):380-6. Epub 2011 Jun 23.

Duke University Medical Center, Durham, NC, USA.

Handoff communication is a point of vulnerability when valuable patient information can be inaccurate or omitted. An institutional protocol was implemented in 2005 to improve the handoff from the operating room to the intensive care unit after pediatric cardiac surgery. A cross-sectional study of the present process was performed to understand how users adapt a communication intervention over time. Twenty-nine handoff events were observed. Individuals required for the handoff were present at 97% of the events. Content items averaged a 53% reporting rate. Some clinical information not specified in the protocol demonstrated a higher reporting rate, such as echocardiogram results (68%) and vascular access (79%). A mean of 2.3 environmental distractions per minute of communication were noted. Participant-directed adjustments in content reporting suggest that a facilitator in process improvement is user-centered innovation. Future handoff communication interventions should reduce nonessential distractions and incorporate a discussion of the anticipated patient course.
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http://dx.doi.org/10.1177/1062860610394342DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3261576PMC
December 2011

Postoperative handoff communication: a simulation-based training method.

Simul Healthc 2010 Aug;5(4):242-7

Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA.

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http://dx.doi.org/10.1097/SIH.0b013e3181e3bd07DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6152820PMC
August 2010

Assessing teamwork in medical education and practice: relating behavioural teamwork ratings and clinical performance.

Med Teach 2009 Jan;31(1):30-8

Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.

Background: Problems with communication and team coordination are frequently linked to adverse events in medicine. However, there is little experimental evidence to support a relationship between observer ratings of teamwork skills and objective measures of clinical performance.

Aim: Our main objective was to test the hypothesis that observer ratings of team skill will correlate with objective measures of clinical performance.

Methods: Nine teams of medical students were videotaped performing two types of teamwork tasks: (1) low fidelity classroom-based patient assessment and (2) high fidelity simulated emergent care. Observers used a behaviourally anchored rating scale to rate each individual on skills representative of assertiveness, decision-making, situation assessment, leadership, and communication. A checklist-based measure was used to assess clinical team performance.

Results: Moderate to high inter-observer correlations and moderate correlations between cases established the validity of a behaviourally anchored team skill rating tool for simulated emergent care. There was moderate to high correlation between observer ratings of team skill and checklist-based measures of team performance for the simulated emergent care cases (r = 0.65, p = 0.06 and r = 0.97, p < 0.0001).

Conclusions: These results provide prospective evidence of a positive relationship between observer ratings of team skills and clinical team performance in a simulated dynamic health care task.
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http://dx.doi.org/10.1080/01421590802070853DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6557133PMC
January 2009

The impact of advanced technologies on treatment deviations in radiation treatment delivery.

Int J Radiat Oncol Biol Phys 2007 Dec;69(5):1579-86

Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA.

Purpose: To assess the impact of new technologies on deviation rates in radiation therapy (RT).

Methods And Materials: Treatment delivery deviations in RT were prospectively monitored during a time of technology upgrade. In January 2003, our department had three accelerators, none with "modern" technologies (e.g., without multileaf collimators [MLC]). In 2003 to 2004, we upgraded to five new accelerators, four with MLC, and associated advanced capabilities. The deviation rates among patients treated on "high-technology" versus "low-technology" machines (defined as those with vs. without MLC) were compared over time using the two-tailed Fisher's exact test.

Results: In 2003, there was no significant difference between the deviation rate in the "high-technology" versus "low-technology" groups (0.16% vs. 0.11%, p = 0.45). In 2005 to 2006, the deviation rate for the "high-technology" groups was lower than the "low-technology" (0.083% vs. 0.21%, p = 0.009). This difference was caused by a decline in deviations on the "high-technology" machines over time (p = 0.053), as well as an unexpected trend toward an increase in deviations over time on the "low-technology" machines (p = 0.15).

Conclusions: Advances in RT delivery systems appear to reduce the rate of treatment deviations. Deviation rates on "high-technology" machines with MLC decline over time, suggesting a learning curve after the introduction of new technologies. Associated with the adoption of "high-technology" was an unexpected increase in the deviation rate with "low-technology" approaches, which may reflect an over-reliance on tools inherent to "high-technology" machines. With the introduction of new technologies, continued diligence is needed to ensure that staff remain proficient with "low-technology" approaches.
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http://dx.doi.org/10.1016/j.ijrobp.2007.08.017DOI Listing
December 2007

Intraoperative apnea: medication error with disclosure (simulation case scenario).

Simul Healthc 2007 ;2(1):39-42

Human Simulation and Patient Safety Center and Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.

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http://dx.doi.org/10.1097/SIH.0b013e3180317c33DOI Listing
January 2009

Adaptive automation of human-machine system information-processing functions.

Hum Factors 2005 ;47(4):730-41

North Carolina State University, Department of Industrial Engineering, 328 Riddick Labs, Raleigh, NC, 27695-7906, USA.

The goal of this research was to describe the ability of human operators to interact with adaptive automation (AA) applied to various stages of complex systems information processing, defined in a model of human-automation interaction. Forty participants operated a simulation of an air traffic control task. Automated assistance was adaptively applied to information acquisition, information analysis, decision making, and action implementation aspects of the task based on operator workload states, which were measured using a secondary task. The differential effects of the forms of automation were determined and compared with a manual control condition. Results of two 20-min trials of AA or manual control revealed a significant effect of the type of automation on performance, particularly during manual control periods as part of the adaptive conditions. Humans appear to better adapt to AA applied to sensory and psychomotor information-processing functions (action implementation) than to AA applied to cognitive functions (information analysis and decision making), and AA is superior to completely manual control. Potential applications of this research include the design of automation to support air traffic controller information processing.
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http://dx.doi.org/10.1518/001872005775570989DOI Listing
June 2006

The use of high-fidelity human patient simulation as an evaluative tool in the development of clinical research protocols and procedures.

Contemp Clin Trials 2005 Dec 14;26(6):646-59. Epub 2005 Oct 14.

Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA.

Errors in clinical research can be costly, in terms of patient safety, data integrity, and data collection. Data inaccuracy in early subjects of a clinical study may be associated with problems in the design of the protocol, procedures, and data collection tools. High-fidelity patient simulation centers provide an ideal environment to apply human-centered design to clinical trial development. A draft of a complex clinical protocol was designed, evaluated and modified using a high-fidelity human patient simulator in the Duke University Human Simulation and Patient Safety Center. The process included walk-throughs, detailed modifications of the protocol and development of procedural aids. Training of monitors and coordinators provided an opportunity for observation of performance that was used to identify further improvements to the protocol. Evaluative steps were used to design the research protocol and procedures. Iterative modifications were made to the protocol and data collection tools. The success in use of human simulation in the preparation of a complex clinical drug trial suggests the benefits of human patient simulation extend beyond training and medical equipment evaluation. Human patient simulation can provide a context for informal expert evaluation of clinical protocol design and for formal "rehearsal" to evaluate the efficacy of procedures and support tools.
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http://dx.doi.org/10.1016/j.cct.2005.09.004DOI Listing
December 2005

Effects of automation of information-processing functions on teamwork.

Hum Factors 2005 ;47(1):50-66

Department of Anesthesiology, Duke University Medical Center, Box 3094, Durham, NC, 27710, USA.

We investigated the effects of automation as applied to different stages of information processing on team performance in a complex decision-making task. Forty teams of 2 individuals performed a simulated Theater Defense Task. Four automation conditions were simulated with computer assistance applied to realistic combinations of information acquisition, information analysis, and decision selection functions across two levels of task difficulty. Multiple measures of team effectiveness and team coordination were used. Results indicated different forms of automation have different effects on teamwork. Compared with a baseline condition, an increase in automation of information acquisition led to an increase in the ratio of information transferred to information requested; an increase in automation of information analysis resulted in higher team coordination ratings; and automation of decision selection led to better team effectiveness under low levels of task difficulty but at the cost of higher workload. The results support the use of early and intermediate forms of automation related to acquisition and analysis of information in the design of team tasks. Decision-making automation may provide benefits in more limited contexts. Applications of this research include the design and evaluation of automation in team environments.
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http://dx.doi.org/10.1518/0018720053653776DOI Listing
July 2005

Preliminary report on the use of high-fidelity simulation in the training of study coordinators conducting a clinical research protocol.

Anesth Analg 2004 Aug;99(2):521-7, table of contents

Department of Anesthesia, Box 3094, Duke University Medical Center, Durham, NC 27710, USA.

Training of health care research personnel is a critical component of quality assurance in clinical trials. Interactivity (such as simulation) is desirable compared with traditional methods of teaching. We hypothesized that the addition of an interactive simulation exercise to standard training methods would increase the confidence of study coordinators. A simulation exercise was developed to replicate a complex clinical trial. Eighteen study coordinators completed pre- and postexercise confidence questionnaires. Questions were targeted at key trial components using a 0-10 scale (not confident to confident) and were categorized using Bloom's Taxonomy. The primary analysis compared overall mean pre- and postexercise responses. Secondary analyses assessed affective, psychomotor, and cognitive confidence. Significance was at P < 0.05. A significant increase in overall confidence (8.64 versus 5.77; P < 0.0001) was reproduced in the subcategory analyses (affective, 8.24 versus 4.89; P < 0.0001; cognitive, 8.75 versus 6.42; P = 0.0003; psychomotor, 8.63 versus 5.26; P < 0.0001). A high level of internal consistency and reliability in question responses within domains was observed, validating the questionnaire tool. In this preliminary report, we confirmed that addition of a simulation exercise to the training of study coordinators resulted in increased confidence. Simulation exercises should be considered when training study coordinators for clinical research trials.
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http://dx.doi.org/10.1213/01.ANE.0000132694.77191.BADOI Listing
August 2004
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