Effect of monitor positioning on visual attention and situation awareness during neonatal resuscitation: a randomised simulation study

Effects of a respiratory function indicator light on visual attention and ventilation quality during neonatal resuscitation: a randomised controlled crossover simulation trial

OBJECTIVES

To investigate the effectiveness of placing an indicator light indicating inadequate ventilation near the face mask during positive-pressure ventilation with respiratory function monitors (RFMs) in neonatal resuscitation. The study is a three-group, randomised, controlled, crossover simulation trial.

METHODS

Paediatrics residents, neonatology fellows, and attending neonatologists at a single neonatal intensive care unit. A ventilation simulation with a manikin was performed three times consecutively using the same scenario with three different ventilation evaluation methods (A) RFM plus indicator light and conventional methods (heart rate and chest rise) (B) RFM and conventional methods, and (C) conventional methods alone.

RESULTS

The ratio of gaze duration on the manikin to the total trial duration was recorded using an eye-tracking device. The proportion of trials with adequate ventilation (expiratory tidal volume [VTe], 4-10 mL/kg; peak inspiratory pressure <30 cm H2O; leak <40 %) was determined. After excluding incomplete data, 63 simulations (22 participants) were analysed. The ratios of the gaze duration on the manikin to the total trial duration were significantly different among settings A (0.60 [95 % confidence interval: 0.52-0.67] s/s), B (0.51 [0.43-0.59] s/s), and C (0.80 [0.76-0.84] s/s). Ventilation with adequate VTe and less leakage was more frequent in settings A and B than in setting C (adequate VTe: A, 91 %; B, 91 %; and C, 83 %; less leak: A, 76 %; B, 78 %; and C, 57 %).

CONCLUSIONS

An indicator light close to the facemask with an RFM directed the eyesight towards the manikin without compromising the ventilation quality during the simulation of neonatal resuscitation.

Quantifying Workload and Stress in Intensive Care Unit Nurses: Preliminary Evaluation Using Continuous Eye-Tracking

OBJECTIVE

(1) To assess mental workloads of intensive care unit (ICU) nurses in 12-hour working shifts (days and nights) using eye movement data; (2) to explore the impact of stress on the ocular metrics of nurses performing patient care in the ICU.

BACKGROUND

Prior studies have employed workload scoring systems or accelerometer data to assess ICU nurses' workload. This is the first naturalistic attempt to explore nurses' mental workload using eye movement data.

METHODS

Tobii Pro Glasses 2 eye-tracking and Empatica E4 devices were used to collect eye movement and physiological data from 15 nurses during 12-hour shifts (252 observation hours). We used mixed-effect models and an ordinal regression model with a random effect to analyze the changes in eye movement metrics during high stress episodes.

RESULTS

While the cadence and characteristics of nurse workload can vary between day shift and night shift, no significant difference in eye movement values was detected. However, eye movement metrics showed that the initial handoff period of nursing shifts has a higher mental workload compared with other times. Analysis of ocular metrics showed that stress is positively associated with an increase in number of eye fixations and gaze entropy, but negatively correlated with the duration of saccades and pupil diameter.

CONCLUSION

Eye-tracking technology can be used to assess the temporal variation of stress and associated changes with mental workload in the ICU environment. A real-time system could be developed for monitoring stress and workload for intervention development.

Use of eye-tracking to evaluate human factors in accessing neonatal resuscitation equipment and medications for advanced resuscitation: A simulation study

Introduction

Emergency neonatal resuscitation equipment is often organized into "code carts". Simulation studies previously examined human factors of neonatal code carts and equipment; however, visual attention analysis with eye-tracking might further inform equipment design.

Objectives

To evaluate human factors of neonatal resuscitation equipment by: (1) comparing epinephrine preparation speed from adult pre-filled syringe vs. medication vial, (2) comparing equipment retrieval times from two carts and (3) utilizing eye-tracking to study visual attention and user experience.

Methods

We conducted a 2-site randomized cross-over simulation study. Site 1 is a perinatal NICU with carts focused on airway management. Site 2 is a surgical NICU with carts improved with compartments and task-based kits. Participants were fitted with eye-tracking glasses then randomized to prepare two epinephrine doses using two methods, starting with an adult epinephrine prefilled syringe or a multiple access vial. Participants then obtained items for 7 tasks from their local cart. Post-simulation, participants completed surveys and semi-structured interviews while viewing eye-tracked video of their performance. Epinephrine preparation times were compared between the two methods. Equipment retrieval times and survey responses were compared between sites. Eye-tracking was analyzed for areas of interest (AOIs) and gaze shifts between AOIs. Interviews were subject to thematic analysis.

Results

Forty HCPs participated (20/site). It was faster to draw the first epinephrine dose using the medication vial (29.9s vs. 47.6s, p < 0.001). Time to draw the second dose was similar (21.2s vs. 19s, p = 0.563). It was faster to obtain equipment from the Perinatal cart (164.4s v 228.9s, p < 0.027). Participants at both sites found their carts easy to use. Participants looked at many AOIs (54 for Perinatal vs. 76 for Surgical carts, p < 0.001) with 1 gaze shifts/second for both.Themes for epinephrine preparation include: Facilitators and Threats to Performance, and Discrepancies due to Stimulation Conditions. Themes for code carts include: Facilitators and Threats to Performance, Orienting with Prescan, and Suggestions for Improvement. Suggested cart improvements include: adding prompts, task-based grouping, and positioning small equipment more visibly. Task-based kits were welcomed, but more orientation is needed.

Conclusions

Eye-tracked simulations provided human factors assessment of emergency neonatal code carts and epinephrine preparation.

The Validity of the SEEV Model as a Process Measure of Situation Awareness: The Example of a Simulated Endotracheal Intubation

OBJECTIVE

In the context of anesthesiology, we investigated whether the salience effort expectancy value (SEEV) model fit is associated with situation awareness and perception scores.

BACKGROUND

The distribution of visual attention is important for situation awareness-that is, understanding what is going on-in safety-critical domains. Although the SEEV model has been suggested as a process situation awareness measure, the validity of the model as a predictor of situation awareness has not been tested.

METHOD

In a medical simulation, 31 senior and 30 junior anesthesiologists wore a mobile eye tracker and induced general anesthesia into a simulated patient. When inserting a breathing tube into the mannequin's trachea (endotracheal intubation), the scenario included several clinically relevant events for situation awareness and general events in the environment. Both were assessed using direct awareness measures.

RESULTS

The overall SEEV model fit was good with no difference between junior and senior anesthesiologists. Overall, the situation awareness scores were low. As expected, the SEEV model fits showed significant positive correlations with situation awareness level 1 scores.

CONCLUSION

The SEEV model seems to be suitable as a process situation awareness measure to predict and investigate the perception of changes in the environment (situation awareness level 1). The situation awareness scores indicated that anesthesiologists seem not to perceive the environment well during endotracheal intubation.

APPLICATION

The SEEV model fit can be used to capture and assess situation awareness level 1. During endotracheal intubation, anesthesiologists should be supported by technology or staff to notice changes in the environment.

Respiratory function monitoring to improve the outcomes following neonatal resuscitation: a systematic review and meta-analysis

IMPORTANCE

Animal and observational human studies report that delivery of excessive tidal volume (V_T) at birth is associated with lung and brain injury. Using a respiratory function monitor (RFM) to guide V_T delivery might reduce injury and improve outcomes.

OBJECTIVE

To determine whether use of an RFM in addition to clinical assessment versus clinical assessment alone during mask ventilation in the delivery room reduces in-hospital mortality and morbidity of infants <37 weeks' gestation.

STUDY SELECTION

Randomised controlled trials (RCTs) comparing RFM in addition to clinical assessment versus clinical assessment alone during mask ventilation in the delivery room of infants born <37 weeks' gestation.

DATA ANALYSIS

Risk of bias was assessed using Covidence Collaboration tool and pooled into a meta-analysis using a random-effects model. The primary outcome was death prior to discharge.

MAIN OUTCOME

Death before hospital discharge.

RESULTS

Three RCTs enrolling 443 infants were combined in a meta-analysis. The pooled analysis showed no difference in rates of death before discharge with an RFM versus no RFM, relative risk (RR) 95% (CI) 0.98 (0.64 to 1.48). The pooled analysis suggested a significant reduction for brain injury (a combination of intraventricular haemorrhage and periventricular leucomalacia) (RR 0.65 (0.48 to 0.89), p=0.006) and for intraventricular haemorrhage (RR 0.69 (0.50 to 0.96), p=0.03) in infants receiving positive pressure ventilation with an RFM versus no RFM.

CONCLUSION

In infants <37 weeks, an RFM in addition to clinical assessment compared with clinical assessment during mask ventilation resulted in similar in-hospital mortality, significant reduction for any brain injury and intraventricular haemorrhage. Further trials are required to determine whether RFMs should be routinely available for neonatal resuscitation.

Using eye-tracking augmented cognitive task analysis to explore healthcare professionals' cognition during neonatal resuscitation

AIM

We aimed to describe the cognitive processes of healthcare providers participating as airway leads in delivery room neonatal resuscitations using eye-tracking assisted debriefing to facilitate recall and provide situational context.

METHODS

Delivery room neonatal resuscitations were recorded using eye-tracking glasses worn by participants who acted as airway leads. These glasses analyze eye-movements to produce an audio-visual recording approximating what was "seen" by the participant and marking their visual attention. Participants then reviewed and debriefed their recordings. Debriefing involved a retrospective think-aloud prompted by eye-tracked recordings and an integrated semi-structured interview. Debriefing sessions were transcribed and subjected to thematic analysis.

RESULTS

Eight healthcare providers participated in 10 interviews; two providers participated twice in two separate resuscitations. Most visual attention was directed at the infant (62%), with 16% directed to monitors/gauges, 3% to team members. Five major themes emerged including situation awareness, performance, working in teams, addressing threats to performance, and perception of eye-tracking. Information processing was complex and involved top-down and bottom-up processing of environmental stimuli, integration of knowledge/experience, and anticipation of patient response. Despite the focus on individual cognition, interpersonal interactions and teamwork emerged as key aspects of resuscitation performance. Potential threats to performance include equipment issues, mental stress, distractions, and parental presence. Eye-tracking recordings were well-received by the participants.

CONCLUSION

Retrospective think-aloud prompted by point-of-view eye-tracked recordings is a useful means of examining cognition of healthcare providers during neonatal resuscitation. Themes identified in this project aligned with existing models of clinical reasoning.