Aspects of the Proposed Work

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Aspects of the Proposed Work
Problem solving
Interaction design
Software engineering
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Patients Hospitalization Path
Intensive care unit (ICU)
Level-1 Trauma Center
Patient
CT scan
Ambulance
Operating room (OR)
Resuscitation bay
Local Hospital
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Vital signs monitor 1) Blood pressure ECG 2)
Pulse oximetry heart rate oxygen
saturation (SpO2) 3) Respiratory rate
Anesthesiologist (ANST) Assists with airway
management performs intubation
Team leader (TL) (Senior resident)Directs
resuscitation delegates work to others
Respiratory therapist (RT) Sets up ventilator
assists with intubation
Doer physician (JR) (Junior resident) Performs
tasks assigned by team leader
Primary nurse (PNR) Coordinates bedside nursing
care assists with all procedures stays with the
patient until leaves ED
Refrigerator for medications blood
EMS paramedic Briefs the team, then the scribe,
about the trauma incident
Glass-enclosed supply cabinet
Monitor for viewing X-rays
Trauma flow sheet
Physician recorder (student) Informally records
patient data treatments for physicians
post-event review
Nurse recorder (REC) Scribe records patient
data, results of tests treatments on flow
sheet. Coordinates nursing care
Attending physician (ATP) Supervises the trauma
team interfaces with major decision making
Critical care technician (CCT) Orderly obtains
sets up equipment assists with procedures takes
vital signs
Orthopedic resident (ORT) Assesses and treats
fractures
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Video cameras
Directional overhead microphones
Wall displays
Room speakers
RFID tag reader
RFID tag readers
Bluetooth headsets with close-talking microphone
Main computer with Bluetooth BS, Wi-Fi Internet
access, Speech reco engine
Tablet PC docked, with Bluetooth base
station, Wi-Fi Internet access, Speech
recognition engine
Tablet PCs or PDAs, with Bluetooth base
station, Wi-Fi Internet access, Speech
recognition engine
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Vital signs monitor 1) Blood pressure ECG 2)
Pulse oximetry heart rate oxygen
saturation (SpO2) 3) Respiratory rate
Team leader (TL) Senior resident decision maker
delegates work to others
Respiratory therapist (RT) Sets up ventilator
assists with intubation
Work bench
Oxygen outlet
Cardiac arrest cart
Chief resident (CHF) Assumes the leadership role,
if present.
Code cart with emergency resuscitation
medications and supplies
Primary nurse (PNR) Coordinates nursing
activities assists with all procedures stays
with the patient until discharged
Doer doctor (JR) Junior resident performs
assignments by Team leader
Critical care technician (CCT) Orderly obtains
sets up equipment assists with procedures takes
vital signs
Orthopedic resident (ORT) Assesses and treats
fractures
Refrigerator for blood medications
Attending physician (ATP) Supervises the trauma
team interfaces with major decision making
Trauma Assessment Flow Sheet (TAFS)
Nurse recorder (REC) Scribe records patient
data, results of tests treatments on TAFS. Uses
default charting records only exceptions
Glass-enclosed supply cabinet
Monitor for viewing X-rays
Typical room dimensions 8 ? 5 meters
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Respiratory therapist
Team leader
Chief resident
Primary nurse
Doer doctor
Critical care technician
Orthopedic resident
Attending physician
Nurse recorder
Typical room dimensions 8 ? 5 meters
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2. EMS reporting to the nurse recorder
1. EMS reporting to the trauma team
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Information Flows
Verbal
Visual
EMS staff report (?)
Vital signs monitor
Team leader
Trauma team / Providers
Patient assessment ()
Verbal
Wall charts, Broselow tape
Handwriting
Visual
Equipment, medications
Information sources
Lab tests ()
TAFS
Nurse recorder
Applied tests and treatments
Handwriting
Handwriting
Visual
X-ray images ()
Physicians descriptive record
Signed-off physicians record
CT scans (_at_)
Physician recorder
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Information Flows
Verbal
Team leader
Trauma team (Care providers)
Verbal
Handwriting
Visual, Verbal, Paper
Information sources
TAFS (Trauma Assessment Flow Sheet)
Nurse recorder
Handwriting
Handwriting
Physicians descriptive record
Signed-off physicians record
Physician recorder
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Prehospital
Oxygenation, etc.
Intake
Airway
Breathing
Circulation
Disability
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System Sequence Diagrams
EMS paramedic primary actor
Telephone operator offstage actor
EMS dispatcher supporting actor
Nurse recorder offstage actor
telephone call
answer
quadruple ?age, code, transportation-means,
estimated-arrival-time?
Time
pass on the EMS quadruple
prompt for patient status during transport
patient status during transport
pass on the patient status during transport
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Team Configuration _at_ UPenn
Respiratory Technician
Anesthesiologist (2)
Trauma Nurse
Primary Resuscitator
X-ray Technician (2)
Assistant Surgeon
Laboratory Technician
Recorder
Command Physician
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Team Configuration _at_ Liverpool
Airway Doctor
Airway Nurse
Circulation Nurse
Circulation Doctor
Orthopedic Registrar
Wardsperson
Scribe Nurse
Team Leader
Social Worker
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Team Config. _at_ UMDNJ RWJ-H
Team Leader (TL)
Respiratory Technician (RT)
Vital signs monitor
Junior Resident Fellow (JR)
Primary Nurse (PNR)
Critical Care Technician (CCT)
Orthopedic Resident (ORT)
Attending Physician (ATP)
Trauma flowsheet (TAFS)
Recording Nurse (REC)
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Typical room dimensions 8 ? 5 meters
Ceiling-mounted camera facing down to
provide view around the head of the bed
Ceiling-mounted microphone
Ceiling-mounted microphone
Wide-angle, ceiling-mounted camera slanted to
provide entire-room view
Recording nurse
Doorway
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Audio Communication System
Wall display
Marker for tracking
Bluetooth headset
Close-talking microphone
Host tablet PC with Bluetooth base station, Wi-Fi
Internet access, Speech recognition engine
Scribe
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Audio Communication System (2
Virtual marker for tracking (individualized)
Main computer with Bluetooth BS, Wi-Fi Internet
access, Speech reco engine
Bluetooth headset
Close-talking microphone
Tablet PC with Bluetooth base station, Wi-Fi
Internet access, Speech recognition engine
Scribe
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Pleur-evac chest drainage equipment
Blood pressure monitor
Bag valve mask (BVM)
Vital signs monitor
Pleural chest tube
Rapid flow fluid warmer and infuser
Endotracheal (ET) tube
ECG electrodes
Femoral cordis
Nasogastral (NG) tube
Focused abdominal sonogram for trauma (FAST)
Intraosseous infusion (used in
children)
Foley catheter
Stethoscope
Pulse oximeter
IV access cannula
Intravenous (IV) bag
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Information Flows
Information source
Channel
Receiver
Records
Verbal
EMS staff report (verbal)
Visual / Verbal
Vital sign instruments
Patient assessment Look-listen-feel,
auscultation, urine output, peritoneal lavage
Patient record
Verbal (often not communicated)
Trauma team
Verbal
Verbal
Administered medications
Handwriting
Verbal
Fluid/blood infusers
Sources of patient information
Equipment Ultrasound, ventilator, pleur-evac
chest drainage
Visual / Verbal
TAFS (Trauma Assessment Flow Sheet)
Nurse recorder
Therapeutic treatments Bleeding control,
orthopedic interventions
Verbal (often not communicated)
Handwriting
Handwriting
Paper
Blood/urine lab tests (?)
Signed-off physicians record
Visual / Verbal
X-ray images (?)
Physicians notes
Physician recorder
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Goals, Tasks, Procedures
Goals (what)
System
Increasing level of abstraction
(a)
Tasks (how)
State variables
Procedures (detail how)
(b)
Actors (Trauma team)
System (Patient)
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Checklist Mechanism of Injury
suspected severe ormultiple injuries
1

• Fall from a height (? 5m)
• Explosion
• Jammed in a car
• Ejection from the car
• Death of another passenger
• Pedestrian or cyclist hit by a car
• High-speed car or motorcycle collision

A
correction
intubated?
malposition ofendotrach. tube?
yes
yes
no
no
surgicalcricothyrotomie
airwaysobstructed?
laryngoscopypossible?
no
yes
Checklist Vital Signs
yes
no
B

• Glasgow-Coma Score ? 10
• Blood pressure ? 80 mmHg
• Respiratory rate ? 10 or ? 29
• SpO2 ? 90 (RA)

intubate
RR ? 10/min?
yes
no
C
pulsless?
consider CPR?
Checklist Type of Injury
yes

• Flail chest
• Open thorax
• Unstable pelvic fracture
• Fractures of ? 1 long bone or the lower
  extremity
• Major amputations
• Multiple rib fractures plus concomitant
  injuries

no
compression
arterialbleeding?
yes
no
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Two Problems Solved
TRAUMA BAY
Home No injury requiring monitoring or treatment
Primary survey
Secondary survey
STABLEor UNSTABLE?
DETERMINE ALL INJURIES OR POTENTIAL INJURIES
Floor Injury that needs monitoring or treatment
that cannot be done at home
initial decision
revised decision
ICU Injury that requires monitoring or treatment
that cannot be accomplished on the floor
unstable
Operating room Injury if not operated on
immediately will lead to morbidity or mortality
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Goals and Tasks (1)
State variables
Goal hierarchy of resuscitation
Mouth AND/OR nose open
Mouth, nose, and neck sight
Oropharynx unobstructed (e.g. tongue)
Level of consciousness and talk
Larynx unobstructed (e.g. epiglottis)
Breath sounds (noise)
Free airway
( Immediate threat to life )
Chest sight (wounds, bruises?)
Trachea free
Maintain perfusion
Chest movement normalcy (flail?)
Functional breathing
Adequate ventilation
Breath sounds (lateral symmetry)
Functional gas exchange
Stable circulation
Respiratory rate (RR)
Pneumo/hemo-thorax excluded or treated
Peripheral oxygen saturation (SpO2)
Overt bleeding controlled
( Potential threat to life )
Identify and treat injuries
Blood fluid balance
CO2 level in exhaled gas
Cardiac output normal
Skin color and temperature
Devise definitive care plan
External bleeding presence
Internal bleeding excluded or controlled
Systolic/diastolic blood pressure
Hemoglobin concentration gt 10 g/dl
Open wounds dressed
Heart rate / Pulse
Urine output
Patients body temperature normal
Tasks (Intervention)
Tasks (Observation)
Body temperature
Blood cellular composition
Stabilize spinal cord
Receive EMS report
Oxygenate via face mask
Setup vital sign monitoring
Abdominal sonogram
Establish two IV accesses
Draw blood for analysis
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Goals and Tasks (2)
Indicated tasks
Example observations (result of Observation tasks)
Observation tasks
Oxygenate via face mask
Visually inspect face/neck area
No visible injuries to faceneck
Intervention tasks
?
Get the patient to talk
Lucid talking
?
Listen for noise in breathing
Setup oxygen saturation monitor
Observation tasks
?
?
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Alternative Perspective Goals
Stable for ultrasound/DPL
Stable for CT
Go directly to OR
Unstable for CT
ICU
OR
Hospital floor
Home
Patient
Bad outcome
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Research Approach
Computerized Decision Support
Bottom-up Ethnographic data collection, video
tagging and analysis
Augmenting Team Communication and Information
Presentation
1.
Workload, team structure, critical decisions and
associated input parameters
Goals and subgoals, critical decisions and
associated input parameters
Monitoring Team Activities and Alerting about
Errors and Inefficiencies
2.
Top-down Cognitive work analysis of goals and
ATLS protocol
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Control Tasks (1)
Goal
Short-term memory Situation information
Observe
Intervene
Decide
?modality? ?multiplicity?
Sender
Receiver
Communication
Long-term memory Knowledge
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Control Tasks (2)
Shared goals
shortcut
Observe
Intervene
Decide
Communicate
Communicate
Team
Short-term memory Situation information
Long-term memory Knowledge
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Control Tasks Example
STEP 1
STEP 2
STEP 3
STEP 4
Observe var1
Decide
Intervene int1
Observe var3
diagnose hypovolemia ? increase blood volume
var1 blood pressure var2 oxygen
saturation var3 heart rate
var1?? var3 ?
int1 crystalloid infusion
var3
var3
var3
Actual current state
Actual current state
Actual current state
Achieved state
Goal state
Goal state
Goal state
int1
var2
var2
var2
Observed current state
Observed current state
Observed current state
var1
var1
var1
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Cognition Model
Cognitive processing
Association
Attention searchlight
Sensing
Motor Behavior
Sensing
Motor Behavior
Sensing
Motor Behavior
Prediction module
IN
OUT
Working script
Index of predicted script

• Ignore/rationalize
• Repair by alternative script
• Report mismatch

Index of predicted script
Report mismatch
Long-term memory
OUT
IN
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Models Relationship
Problem plane of problem-specific
tasks (Workflow)
Infrastructure plane of psychological processes
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Utility of X
Utility
Good outcome
do X
Test utility
Bad
DECISION Do test
prob D1
G
do Y
Utility of ?X
Threshold
B
Pr(D1)
Pr(diagnosis)
(a)
(b)
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Test
Pr(diag)
(a)
0
1
Current diagnosis
Threshold
Dont test (unnecessary)
Successive pieces of evidence
Pr(diag)
(b)
0
1
Threshold
FN TN
ln
4
(c)
??
??
0
?18
Threshold
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Task Allocation
Pending tasks ? T1, T2 Qualified tasks 1. T2
Pending tasks ? T1, T2, T7 Qualified tasks 1.
T1 (prioritized) 2. T7
Pending tasks ? T1, T2, T5 Task allocation
T1 ?? Pk T2 ?? Pi T5 ?? Pj
Given a current set of shared goals
Team member, Pi
Team member, Pj
Team leader, Pk
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Abstract Model of Teamwork
O1
I1
D1
D3
Oi
Observation i
Dj
O2
I2
Decision j
D2
Ik
DK
Intervention k
IN
OM
Comm. Link
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Scenario 1 IV Bag Low
Primary nurse
Scribe
CCT
IV bag
IV bag
D1
A1
S1
broadcast
Other team members decide to ignore
Technician
Physician
Nurse
Technician
Physician
Nurse
Comm.
Comm.
vs.
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Model Simulation
Goals Level
Tasks Level
Procedural and Communication Level
Abstract Model Simulator
Statistical Analysis
Output identified teamwork Problems/errors
Input patient scenario
Output simulation trace
System (Trauma bay)

• System state variables
• aspects of task management
• awareness
• start time
• execution duration
• performance quality
• loss
• degree of leadership
• communication intensity

Actors (Trauma team)
System (Patient)
Researchers (Our team)
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Visual Displays
Drop-down display
Wall display
Tablet PC 1
Nurse recorder
Tablet PC 2
Physician recorder
Main computer
From vital sign instruments and RFID tag readers
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Visualization rules constraints
Wall display
User interface (Data entry visualization)
Collaborative middleware
Drop-down display
Trauma protocol (ATLS etc.)
Tablet PC 1
Nurse recorder
Object tracking(RFID, vision)
User
Signal processing data analysis
To other computers
Admin user interface (for modifying rules
constraints of the protocol, visualization, and
alerting)
Tablet PC 2
Physician recorder
Shared state
From vital sign instruments and RFID tag readers
Main computer
Patient data repository
(b)
(a)
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Pending Tasks Display
SpO2 60
Airway
Breathing
Mouth / airway compromised
Disability
Circulation
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Abstract Model (1)
Goal
STM situation
Decision
Sensing
Action
LTM knowledge
Shared goals
?modality? ?n-arity?
Sender
Receiver
D
S
A
Decision
Sensing
Action
Communication
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Abstract Model
Goal
Sensing
Action
Decision
Shared goals
Sensing
Action
Decision
Communication
Communication
Receiver
Sender
Communication
S1
A1
D1
D3
Si
Sensing i
Dj
S2
A2
Decision j
D2
Ak
DK
Action k
SM
AN
Comm. Link
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Abstract Model (2)
S1
A1
R1
Si
P1
Sensor
Pj
S2
A2
Processor
R2
Ak
Actuator
PK
Rm
SM
AN
Relay
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Goals and Tasks (1)
Tasks (Sensing)
Goals of resuscitation
Mouth open OR nose open
Inspect mouth and airway
Tongue not obstructing airway
Measure respiratory rate
Trachea free
Measure blood oxygenation
Airway patency
( Immediate threat to life )
Respiratory rate gt 10 and lt 29/min
Measure CO2 level
Maintain perfusion
Breathing normalcy
Bilateral breath sounds
Check if patient can talk lucidly
Blood oxygenation (SpO2) gt 90
Listen for noisy breathing
Circulation stability
External bleeding treated
Check if patient is agitated
( Potential threat to life )
Blood pressure gt 80 mmHg
Inspect cervical spine
Identify and treat injuries
Heart rate normal (?)
Measure respiratory rate
Hemoglobin count normal (?)
Measure blood oxygenation
Do chest auscultation
Devise definitive care plan
Inspect for external bleeding
Inspect for thoracic bruises
Tasks (Action/Intervention)
Draw blood for tests/HemoCue
Measure patients temperature
Put oxygen mask
Input information
FAST detect abdomen bleeding
Establish IV access
EMS report
Foley catheter for urine output
?
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Goals and Tasks (4)
Tasks (Sensing)
Can patient talk lucidly ?
Goals
Mouth and airway unobstructed ?
Noisy breathing ?
Agitated?
Airway patency
Respiratory rate lt 10 or gt 29/min ?
Maintain perfusion
Breathing normalcy
Blood oxygenation (SpO2) lt 90 ?
Open thorax ?
Circulation stability
Flail chest ?
Hypoveolemnia (blood loss) ?
Identify injuries
Blood pressure lt 80 mmHg ?
Cervical spine injuries ?
Heart rate ?
Penetrating injuries ?
Pelvic injuries ?
Devise long-term care
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Mouth and airway uncompromised
SpO2 gt 90
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Abstract Model (2)
Cognitive processing
IN
OUT
Report if mismatch
Index of predicted script
Hierarchy layer i
Comparator
Working script
Long-term memory
OUT
IN
Perception
Behavior
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