1
|
Wooldridge AR, Carayon P, Hoonakker P, Hose BZ, Shaffer DW, Brazelton T, Eithun B, Rusy D, Ross J, Kohler J, Kelly MM, Springman S, Gurses AP. Team Cognition in Handoffs: Relating System Factors, Team Cognition Functions and Outcomes in Two Handoff Processes. Hum Factors 2024; 66:271-293. [PMID: 35658721 PMCID: PMC11022309 DOI: 10.1177/00187208221086342] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE This study investigates how team cognition occurs in care transitions from operating room (OR) to intensive care unit (ICU). We then seek to understand how the sociotechnical system and team cognition are related. BACKGROUND Effective handoffs are critical to ensuring patient safety and have been the subject of many improvement efforts. However, the types of team-level cognitive processing during handoffs have not been explored, nor is it clear how the sociotechnical system shapes team cognition. METHOD We conducted this study in an academic, Level 1 trauma center in the Midwestern United States. Twenty-eight physicians (surgery, anesthesia, pediatric critical care) and nurses (OR, ICU) participated in semi-structured interviews. We performed qualitative content analysis and epistemic network analysis to understand the relationships between system factors, team cognition in handoffs and outcomes. RESULTS Participants described three team cognition functions in handoffs-(1) information exchange, (2) assessment, and (3) planning and decision making; information exchange was mentioned most. Work system factors influenced team cognition. Inter-professional handoffs facilitated information exchange but included large teams with diverse backgrounds communicating, which can be inefficient. Intra-professional handoffs decreased team size and role diversity, which may simplify communication but increase information loss. Participants in inter-professional handoffs reflected on outcomes significantly more in relation to system factors and team cognition (p < 0.001), while participants in intra-professional handoffs discussed handoffs as a task. CONCLUSION Handoffs include team cognition, which was influenced by work system design. Opportunities for handoff improvement include a flexibly standardized process and supportive tools/technologies. We recommend incorporating perspectives of the patient and family in future work.
Collapse
Affiliation(s)
- Abigail R. Wooldridge
- Department of Industrial and Enterprise Systems Engineering, University of Illinois at Urbana-Champaign
| | - Pascale Carayon
- Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin–Madison
- Department of Industrial and Systems Engineering, University of Wisconsin – Madison
| | - Peter Hoonakker
- Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin–Madison
| | - Bat-Zion Hose
- Department of Anesthesiology and Critical Care at the Perelman School of Medicine, University of Pennsylvania
| | | | - Tom Brazelton
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Ben Eithun
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Deborah Rusy
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Joshua Ross
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Michelle M. Kelly
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Scott Springman
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Ayse P. Gurses
- Center for Health Care Human Factors, Armstrong Institute for Patient Safety and Quality, Schools of Medicine, Bloomberg School of Public Health and Whiting School of Engineering, Johns Hopkins University, Baltimore, MD
| |
Collapse
|
2
|
Amlong C, Rusy D, Sanders RD, Lake W, Raz A. Dexmedetomidine depresses neuronal activity in the subthalamic nucleus during deep brain stimulation electrode implantation surgery. BJA Open 2022; 3:100088. [PMID: 37588575 PMCID: PMC10430856 DOI: 10.1016/j.bjao.2022.100088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 08/03/2022] [Indexed: 08/18/2023]
Abstract
Background Micro-electrode recordings are often necessary during electrode implantation for deep brain stimulation of the subthalamic nucleus. Dexmedetomidine may be a useful sedative for these procedures, but there is limited information regarding its effect on neural activity in the subthalamic nucleus and on micro-electrode recording quality. Methods We recorded neural activity in five patients undergoing deep brain stimulation implantation to the subthalamic nucleus. Activity was recorded after subthalamic nucleus identification while patients received dexmedetomidine sedation (loading - 1 μg kg-1 over 10-15 min, maintenance - 0.7 μg kg-1 h-1). We compared the root-mean square (RMS) and beta band (13-30 Hz) oscillation power of multi-unit activity recorded by microelectrode before, during and after recovery from dexmedetomidine sedation. RMS was normalised to values recorded in the white matter. Results Multi-unit activity decreased during sedation in all five patients. Mean normalised RMS decreased from 2.8 (1.5) to 1.6 (1.1) during sedation (43% drop, p = 0.056). Beta band power dropped by 48.4%, but this was not significant (p = 0.15). Normalised RMS values failed to return to baseline levels during the time allocated for the study (30 min). Conclusions In this small sample, we demonstrate that dexmedetomidine decreases neuronal firing in the subthalamic nucleus as expressed in the RMS of the multi-unit activity. As multi-unit activity is a factor in determining the subthalamic nucleus borders during micro-electrode recordings, dexmedetomidine should be used with caution for sedation during these procedures. Clinical trial number NCT01721460.
Collapse
Affiliation(s)
- Corey Amlong
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Deborah Rusy
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Robert D. Sanders
- University of Sydney, Sydney, Australia
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Wendell Lake
- Department of Neurosurgery, University of Wisconsin, Madison, WI, USA
| | - Aeyal Raz
- Department of Anesthesiology, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion – Israel Institute of Technology, Haifa, Israel
| |
Collapse
|
3
|
Wooldridge AR, Carayon P, Hoonakker P, Hose BZ, Schroeer K, Brazelton T, Eithun B, Rusy D, Ross J, Kohler J, Kelly MM, Dean S, Springman S, Rahal R, Gurses AP. Care transition of trauma patients: Processes with articulation work before and after handoff. Appl Ergon 2022; 98:103606. [PMID: 34638036 PMCID: PMC10373374 DOI: 10.1016/j.apergo.2021.103606] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/23/2021] [Accepted: 10/05/2021] [Indexed: 06/13/2023]
Abstract
While care transitions influence quality of care, less work studies transitions between hospital units. We studied care transitions from the operating room (OR) to pediatric and adult intensive critical care units (ICU) using Systems Engineering Initiative for Patient Safety (SEIPS)-based process modeling. We interviewed twenty-nine physicians (surgery, anesthesia, pediatric critical care) and nurses (OR, ICU) and administered the AHRQ Hospital Survey on Patient Safety Culture items about handoffs, care transitions and teamwork. Care transitions are complex, spatio-temporal processes and involve work during the transition (i.e., handoff and transport) and preparation and follow up activities (i.e., articulation work). Physicians defined the transition as starting earlier and ending later than nurses. Clinicians in the OR to adult ICU transition without a team handoff reported significantly less information loss and better cooperation, despite positive interview data. A team handoff and supporting articulation work should increase awareness, improving quality and safety of care transitions.
Collapse
Affiliation(s)
- Abigail R Wooldridge
- Department of Industrial and Enterprise Systems Engineering, University of Illinois at Urbana-Champaign, Urbana, IL, USA.
| | - Pascale Carayon
- Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin, Madison, USA; Department of Industrial and Systems Engineering, University of Wisconsin, Madison, USA
| | - Peter Hoonakker
- Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin, Madison, USA
| | - Bat-Zion Hose
- Department of Anesthesiology and Critical Care at the Perelman School of Medicine, University of Pennsylvania, USA
| | - Katherine Schroeer
- Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin, Madison, USA; Department of Industrial and Systems Engineering, University of Wisconsin, Madison, USA
| | - Tom Brazelton
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ben Eithun
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Deborah Rusy
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Joshua Ross
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | - Michelle M Kelly
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Shannon Dean
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Scott Springman
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Rima Rahal
- Vituity, Mercy General Hospital and Sutter Medical Center, Sacramento, CA, USA
| | - Ayse P Gurses
- Center for Health Care Human Factors, Armstrong Institute for Patient Safety and Quality, Schools of Medicine, Bloomberg School of Public Health and Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
4
|
Wooldridge AR, Carayon P, Hoonakker P, Hose BZ, Eithun B, Brazelton T, Ross J, Kohler JE, Kelly MM, Dean SM, Rusy D, Gurses AP. Work system barriers and facilitators in inpatient care transitions of pediatric trauma patients. Appl Ergon 2020; 85:103059. [PMID: 32174347 PMCID: PMC7309517 DOI: 10.1016/j.apergo.2020.103059] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 11/13/2019] [Accepted: 01/13/2020] [Indexed: 06/02/2023]
Abstract
Hospital-based care of pediatric trauma patients includes transitions between units that are critical for quality of care and patient safety. Using a macroergonomics approach, we identify work system barriers and facilitators in care transitions. We interviewed eighteen healthcare professionals involved in transitions from emergency department (ED) to operating room (OR), OR to pediatric intensive care unit (PICU) and ED to PICU. We applied the Systems Engineering Initiative for Patient Safety (SEIPS) process modeling method and identified nine dimensions of barriers and facilitators - anticipation, ED decision making, interacting with family, physical environment, role ambiguity, staffing/resources, team cognition, technology and characteristic of trauma care. For example, handoffs involving all healthcare professionals in the OR to PICU transition created a shared understanding of the patient, but sometimes included distractions. Understanding barriers and facilitators can guide future improvements, e.g., designing a team display to support team cognition of healthcare professionals in the care transitions.
Collapse
Affiliation(s)
- Abigail R Wooldridge
- Department of Industrial and Enterprise Systems Engineering, University of Illinois at Urbana-Champaign, Urbana, IL, USA.
| | - Pascale Carayon
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA; Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Peter Hoonakker
- Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Bat-Zion Hose
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA; Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Benjamin Eithun
- American Family Children's Hospital, University of Wisconsin School of Medicine and Public Health, School of Nursing, University of Wisconsin-Madison, Madison, WI, USA
| | - Thomas Brazelton
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Joshua Ross
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jonathan E Kohler
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Michelle M Kelly
- Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA; Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Shannon M Dean
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Deborah Rusy
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ayse P Gurses
- Center for Health Care Human Factors, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD, USA; Division of Health Sciences Informatics, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Bloomberg School of Public Health and Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
5
|
Wooldridge A, Carayon P, Hoonakker P, Hose BZ, Ross J, Kohler JE, Brazelton T, Eithun B, Kelly MM, Dean SM, Rusy D, Durojaiye A, Gurses AP. Complexity of the pediatric trauma care process: Implications for multi-level awareness. Cogn Technol Work 2019; 21:397-416. [PMID: 31485191 PMCID: PMC6724740 DOI: 10.1007/s10111-018-0520-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 08/23/2018] [Indexed: 06/02/2023]
Abstract
Trauma is the leading cause of disability and death in children and young adults in the US. While much is known about the medical aspects of inpatient pediatric trauma care, not much is known about the processes and roles involved in in-hospital care. Using human factors engineering (HFE) methods, we combine interview, archival document and trauma registry data to describe how intra-hospital care transitions affect process and team complexity. Specifically, we identify the 53 roles directly involved in patient care in each hospital unit and describe the 3324 total transitions between hospital units and the 69 unique pathways, from arrival to discharge, experienced by pediatric trauma patients. We continue the argument to shift from eliminating complexity to coping with it and propose supporting three levels of awareness to enhance the resilience and adaptation necessary for patient safety in health care, i.e. safety in complex systems. We discuss three levels of awareness (individual, team and organizational) and describe challenges and potential sociotechnical solutions for each. For example, one challenge to individual awareness is high time pressure. A potential solution is clinical decision support of information perception, integration and decision making. A challenge to team awareness is inadequate "non-technical" skills, e.g., leadership, communication, role clarity; simulation or another form of training could improve these. The complex, distributed nature of this process is a challenge to organizational awareness; a potential solution is to develop awareness of the process and the roles and interdependencies within it, by using process modeling or simulation.
Collapse
Affiliation(s)
- Abigail Wooldridge
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, 1513 University Avenue, 3270 Mechanical Engineering Building, Madison WI 53706, USA
| | - Pascale Carayon
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, 1513 University Avenue, 3270 Mechanical Engineering Building, Madison WI 53706, USA
| | - Peter Hoonakker
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, 1550 Engineering Drive, 3135 Engineering Centers Building, Madison WI 53706, USA
| | - Bat-Zion Hose
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, 1513 University Avenue, 3270 Mechanical Engineering Building, Madison WI 53706, USA
| | - Joshua Ross
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, 800 University Bay Drive, Suite 310, MC 9123, Madison WI 53705, USA
| | - Jonathan E Kohler
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Department of Surgery Administration MC: 7375, Madison WI 53792, USA
| | - Thomas Brazelton
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, 600 Highland Avenue, Madison WI 53793, USA
| | - Benjamin Eithun
- American Family Children's Hospital, University of Wisconsin School of Medicine and Public Health, 1675 Highland Avenue, Madison WI 53792, USA
| | - Michelle M Kelly
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, 1550 Engineering Drive, 3135 Engineering Centers Building, Madison WI 53706, USA
| | - Shannon M Dean
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, 600 Highland Avenue, Madison WI 53793, USA
| | - Deborah Rusy
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Ashimiyu Durojaiye
- Center for Health Care Human Factors, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, 750 East Pratt Street, 15 Floor, Baltimore MD 21202, USA, Division of Health Sciences Informatics, School of Medicine, Johns Hopkins University, 2024 East Monument Street, S1-200, Baltimore MD 21205, USA
| | - Ayse P Gurses
- Center for Health Care Human Factors, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, 750 East Pratt Street, 15 Floor, Baltimore MD 21202, USA, Division of Health Sciences Informatics, School of Medicine, Johns Hopkins University, 2024 East Monument Street, S1-200, Baltimore MD 21205, USA
| |
Collapse
|
6
|
Abstract
BACKGROUND An electroencephalogram (EEG) monitoring device, recently developed by Nicolet Biomedical, analyzes both high and low EEG frequencies. A processed derivative is obtained and displayed graphically and numerically on a monitor and may be used during anesthesia to indicate anesthetic "depth." However, radio-frequency interference from electrical equipment typically used in the operating room has the potential to interfere with the analysis of the high frequency components of the EEG. OBJECTIVE The objective of this study was to determine the ability of the Nicolet EEG monitoring device to function satisfactorily and effectively in the operating arena when used for anesthetized patients. METHODS A total of 40 patients undergoing surgery with general anesthesia were monitored using a prototype, processed EEG monitoring device. The device was used beginning prior to induction and continuing until emergence from anesthesia. RESULTS Analysis was performed on 38 of the 40 patients. Brief interruption of the derived EEG Index occurred during use of the monopolar electrosurgical unit (ESU) as well as during stimulation of the facial nerve (used to monitor pharmacologic muscle relaxation). Derived EEG Index interruption was also noted during some movements of the patient's head or the EEG electrode wires. Changes in the derived EEG Index value accompanied changes in inhaled concentration of anesthetics and, in one patient, change in the derived EEG Index preceded patient movement that was not heralded by the typical cardiovascular indications of "light" anesthesia. CONCLUSIONS The derived EEG Index monitoring system evaluated in this study functioned satisfactorily in the operating room setting in patients undergoing general anesthesia. Interference from ESU, facial nerve stimulation, and movement of the electrode wires caused brief interruptions of the derived EEG Index display and did not affect its utility in monitoring brain activity during anesthesia.
Collapse
Affiliation(s)
- Karl Willmann
- Department of Anesthesia, University of Wisconsin Hospital and Clinics, Madison, Wisconsin 53792, USA.
| | | | | | | |
Collapse
|
7
|
|
8
|
Hogan KJ, Rusy D, Springman SR. Difficult laryngoscopy and diabetes mellitus. Anesth Analg 1989; 69:419-20. [PMID: 2672897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
|
9
|
Hogan KJ, Rusy D, Springman SR. Difficult Laryngoscopy and Diabetes Mellitus. Anesth Analg 1989. [DOI: 10.1213/00000539-198909000-00046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
10
|
|
11
|
Hogan K, Rusy D, Springman SR. Difficult laryngoscopy and diabetes mellitus. Anesth Analg 1988; 67:1162-5. [PMID: 3057934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The incidence of difficult laryngoscopy was determined retrospectively in 40 diabetic patients having pancreas transplantations and in 75 diabetic and 112 nondiabetic patients having kidney transplantations. Diabetes was associated with a significant increase in the proportion of patients having difficult laryngoscopies in patients having renal transplants: 0.027 in patients without diabetes; 0.320 in patients with diabetes. The incidence of difficult laryngoscopy in diabetic recipients of cadaveric kidneys (0.419) was not significantly different from that in diabetic recipients of pancreas transplants (0.40), but significantly higher than that in diabetics given kidneys from living donors (0.187). Although cadaveric recipients were older than recipients of kidneys from living donors (40.8 v. 31.6 years), age at the time of transplantation was not a significant predictor of difficulty in laryngoscopy. Groups were otherwise matched for clinical, morphologic, hematologic, and biochemical indices. Diabetic stiff joint syndrome (SJS), which predisposes a subset of Type I diabetic patients to rapidly progressive microvascular disease and subsequent need for renal and/or pancreas transplantation, may lead to difficult laryngoscopy because of involvement of the atlanto-occipital joint.
Collapse
Affiliation(s)
- K Hogan
- Department of Anesthesiology, University of Wisconsin, Madison 53792
| | | | | |
Collapse
|