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Background: The current state of scientific knowledge regarding communication between emergency medicine (EM) providers indicates that communication is critical to safe and effective patient care.Objectives: In this study, we identified communication needs of EM nurses and physicians; in particular, what information should be conveyed, when, how, and to whom.Methods: Five semi-structured focus groups and one interview were conducted with nine nurses, eight attending physicians, and four residents. Questions addressed how EM personnel use and share information about patients and clinical work, what information tends to be exchanged, and what additional information would be helpful to share. Sessions were audio recorded. Transcripts were generated and analyzed using a concept mapping approach (a visual qualitative analysis technique to represent and convey synthesized knowledge).Results: Eleven concept maps were produced summarizing: information physicians needed from nurses and vice versa; methods of communication that could be utilized; barriers or obstacles to effective communication; strategies to enhance or ensure effective communication; and environmental or situational factors that impact communication.Conclusions: Our main finding of this research is that communication ensures shared awareness of patient health status, the care plan, status of plan steps and orders, and, especially, any critical changes or "surprises" regarding the health of a patient. Additionally, the research identified shared information needs; communication methods, strategies and barriers; and factors affecting successful communication, and has implications for both system and training design. Key implications for emergency nursing practice from this research are distilled in 10 'best practice' strategies for improving EM nurse-physician communication. [ABSTRACT FROM AUTHOR]

This article presents an evaluation of novel display concepts for an emergency department information system (EDIS) designed using cognitive systems engineering methods. EDISs assist emergency medicine staff with tracking patient care and ED resource allocation. Participants performed patient planning and orientation tasks using the EDIS displays and rated the display's ability to support various cognitive performance objectives along with the usability, usefulness, and predicted frequency of use for 18 system components. Mean ratings were positive for cognitive performance support objectives, usability, usefulness, and frequency of use, demonstrating the successful application of design methods to create useful and usable EDIS concepts that provide cognitive support for emergency medicine staff. Nurse and provider roles had significantly different perceptions of the usability and usefulness of certain EDIS components, suggesting that they have different information needs while working. [ABSTRACT FROM AUTHOR]

Introduction: Understanding and managing clinician workload is important for clinician (nurses, physicians and advanced practice providers) occupational health as well as patient safety. Efforts have been made to develop strategies for managing clinician workload by improving patient assignment. The goal of the current study is to use electronic health record (EHR) data to predict the amount of work that individual patients contribute to clinician workload (patient-related workload).Methods: One month of EHR data was retrieved from an emergency department (ED). A list of workload indicators and five potential workload proxies were extracted from the data. Linear regression and four machine learning classification algorithms were utilized to model the relationship between the indicators and the proxies.Results: Linear regression proved that the indicators explained a substantial amount of variance of the proxies (four out of five proxies were modeled with R2 > 0.80). Classification algorithms also showed success in classifying a patient as having high or low task demand based on data from early in the ED visit (e.g. 80 % accurate binary classification with data from the first hour).Conclusion: The main contribution of this study is demonstrating the potential of using EHR data to predict patient-related workload automatically in the ED. The predicted workload can potentially help in managing clinician workload by supporting decisions around the assignment of new patients to providers. Future work should focus on identifying the relationship between workload proxies and actual workload, as well as improving prediction performance of regression and multi-class classification. [ABSTRACT FROM AUTHOR]

'Safety-II' is a new approach to safety, which emphasizes learning proactively about how safety and efficacy are achieved in everyday frontline work. Previous research developed a new lesson-sharing tool designed based on the Safety-II approach: Resilience Engineering Tool to Improve Patient Safety (RETIPS). The tool comprises questions designed to elicit narratives of adaptations that have contributed to effectiveness in care delivery. The purpose of this study is to revise and validate the design of RETIPS. The tool was revised based on feedback of clinicians at a large multi-specialty hospital, resulting in a version customized for anesthesia residents, RETIPS-AnRes. RETIPS-AnRes was administered on a pilot-basis to anesthesia resident groups for a limited period of time. A review of the reports obtained shows a strong alignment of responses with the conceptual basis of the tool, i.e. learning about how things go well in everyday work. The exemplars include both, specific instances of successful patient care, as well as generic routines that contribute to safe and/or effective care delivery. These findings support RETIPS as a tool to operationalize the Safety-II paradigm in healthcare. Lessons and implications for implementation on a wider scale are discussed. [ABSTRACT FROM AUTHOR]

Objective: To study communicative tasks executed and related strategies used by patients, health professionals, and medical interpreters., Methods: English proficient and limited English proficient emergency department patients were observed. The content of patient-hospital staff communication was documented via pen and paper. Key themes and differences across interpreter types were established through qualitative analysis. Themes and differences across interpreter type were vetted and updated through member checking interviews., Results: 6 English proficient and 9 limited English proficient patients were observed. Key themes in communicative tasks included: establishing, maintaining, updating, and repairing understanding and rapport. All tasks were observed with English proficient and limited English proficient patients. The difference with limited English proficient patients was that medical interpreters played an active role in completing communicative tasks. Telephone-based interpreters faced challenges in facilitating communicative tasks based on thematic comparisons with in-person interpreters, including issues hearing and lost information due to the lack of visual cues., Conclusions: Professional interpreters play an important role in communication between language discordant patients and health professionals that goes beyond verbatim translation., Practical Implications: Training for interpreters and health professionals, and the design of tools for facilitating language discordant communication, should consider the role of interpreters beyond verbatim translation., Competing Interests: Declaration of Competing Interest The authors have no relevant conflicts of interest to disclose., (Copyright © 2021 Elsevier B.V. All rights reserved.)

This investigation examined the impact of speech-generating devices (SGDs) on the interaction dynamics (i.e., symmetry) of augmented speakers and their conversation partners while performing several interaction tasks. This study involved 20 dyads: 10 in which one individual had ALS and primarily used an SGD for communication while the other participant primarily used speech (AS group); and 10 in a control group comprised of individuals who used speech as a primary means of communication (OS group). Interactions between participants in the AS group were compared across four tasks (i.e., map, retell, sequencing, and personal narrative). These results were also compared to performances of participants in the OS group performing the same tasks. Task completion times, talk times, contribution types (i.e., main/repair), and contribution functions (i.e., presentation/acceptance) were used to index symmetry performance patterns across tasks for the 20 dyads. Within- and between-group comparisons were significant in differentiating the two groups in terms of the ways in which they were able to adapt to different interaction task dynamics. Findings suggest symmetry is a useful metric for identifying the constraining influence of carrying out in-person interactions with an SGD.

Objective: To characterise the use of interpreter services and other strategies used to communicate with limited English proficient (LEP) patients throughout their emergency department visit., Methods: We performed a process tracing study observing LEP patients throughout their stay in the emergency department. A single observer completed 47 hours of observation of 103 communication episodes between staff and nine patients with LEP documenting the strategy used to communicate (eg, professional interpreter, family member, own language skills) and duration of conversations for each communicative encounter with hospital staff members. Data collection occurred in a single emergency department in the eastern USA between July 2017 and February 2018., Results: The most common strategy (per communicative encounter) was for the emergency department staff to communicate with the patient in English (observed in 29.1% of encounters). Total time spent in communicating was highest using telephone-based interpreters (32.9% of total time spent communicating) and in-person interpreters (29.2% of total time spent communicating). Communicative mechanism also varied by care task/phase of care with the most use of interpreter services or Spanish proficient staff (as primary communicator) occurring during triage (100%) and the initial provider assessment (100%) and the lowest interpreter service use during ongoing evaluation and treatment tasks (24.3%)., Conclusions: Emergency department staff use various mechanisms to communicate with LEP patients throughout their length of stay. Utilisation of interpreter services was poorest during evaluation and treatment tasks, indicating that this area should be a focus for improving communication with LEP patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Hospital emergency departments (EDs) are dynamic environments, involving coordination and shared decision making by staff who care for multiple patients simultaneously. While computerized information systems have been widely adopted in such clinical environments, serious issues have been raised related to their usability and effectiveness. In particular, there is a need to support clinicians to communicate and maintain awareness of a patient's health status, and progress through the ED plan of care., Objective: This study used work-centered usability methods to evaluate an integrated patient-focused status display designed to support ED clinicians' communication and situation awareness regarding a patient's health status and progress through their ED plan of care. The display design was informed by previous studies we conducted examining the information and cognitive support requirements of ED providers and nurses., Methods: ED nurse and provider participants were presented various scenarios requiring patient-prioritization and care-planning tasks to be performed using the prototype display. Participants rated the display in terms of its cognitive support, usability, and usefulness. Participants' performance on the various tasks, and their feedback on the display design and utility, was analyzed., Results: Participants provided ratings for usability and usefulness for the display sections using a work-centered usability questionnaire-mean scores for nurses and providers were 7.56 and 6.6 (1 being lowest and 9 being highest), respectively. General usability scores, based on the System Usability Scale tool, were rated as acceptable or marginally acceptable. Similarly, participants also rated the display highly in terms of support for specific cognitive objectives., Conclusion: A novel patient-focused status display for emergency medicine was evaluated via a simulation-based study in terms of work-centered usability and usefulness. Participants' subjective ratings of usability, usefulness, and support for cognitive objectives were encouraging. These findings, including participants' qualitative feedback, provided insights for improving the design of the display., Competing Interests: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Many studies on teams report measures of team communication; however, these studies vary widely in terms of the team characteristics, situations, and tasks studied making it difficult to understand impacts on team communication more generally. The objective of this review is systematically summarize relationships between measures of team communication and team characteristics and situational contexts. A literature review was conducted searching in four electronic databases (PsycINFO, MEDLINE, Ergonomics Abstracts, and SocINDEX). Additional studies were identified by cross-referencing. Articles included for final review had reported at least one team communication measure associated with some team and/or context dimension. Ninety-nine of 727 articles met the inclusion criteria. Data extracted from articles included characteristics of the studies and teams and the nature of each of the reported team and/or context dimensions-team communication properties relationships. Some dimensions (job role, situational stressors, training strategies, cognitive artifacts, and communication media) were found to be consistently linked to changes in team communication. A synthesized diagram that describes the possible associations between eleven team and context dimensions and nine team communication measures is provided along with research needs., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

We describe the patterns and content of nurse to physician verbal conversations in three emergency departments (EDs) with electronic health records. Emergency medicine physicians and nurses were observed for 2 h periods. Researchers used paper notes to document the characteristics (e.g., partners involved, location of communication, who initiated communication) and content of nurse to physician conversations. Eighteen emergency nurses and physicians (nine each) were observed for a total of 36 h. Two hundred and fifty-five unique communication events were recorded across three emergency departments spread evenly across day, evening, and night shifts. A qualitative analysis of communication event content revealed 5 types of communication and 13 content themes. Content themes covered a broad range of topics including exchange of patient health information, management of the ED, and coordination of orders. Physician participants experienced significantly more communication events than nurse participants, while nurses initiated significantly more communication events than physicians. Most of the communication events occurred at the physician workstation followed by patient treatment areas. This study describes nature of verbal nurse to physician communication in the ED. Direct communication is still used to communicate important information, such as information about patients' status, in EDs with established electronic health records. Our results provide an overview of information exchanged in the ED which can serve as a basis for designing improved information support systems., (© Springer International Publishing AG 2017.)

Background: The effect of health information technology (HIT) on efficiency and workload among clinical and nonclinical staff has been debated, with conflicting evidence about whether electronic health records (EHRs) increase or decrease effort. None of this paper to date, however, examines the effect of interoperability quantitatively using discrete event simulation techniques., Objective: To estimate the impact of EHR systems with various levels of interoperability on day-to-day tasks and operations of ambulatory physician offices., Methods: Interviews and observations were used to collect workflow data from 12 adult primary and specialty practices. A discrete event simulation model was constructed to represent patient flows and clinical and administrative tasks of physicians and staff members., Results: High levels of EHR interoperability were associated with reduced time spent by providers on four tasks: preparing lab reports, requesting lab orders, prescribing medications, and writing referrals. The implementation of an EHR was associated with less time spent by administrators but more time spent by physicians, compared with time spent at paper-based practices. In addition, the presence of EHRs and of interoperability did not significantly affect the time usage of registered nurses or the total visit time and waiting time of patients., Conclusion: This paper suggests that the impact of using HIT on clinical and nonclinical staff work efficiency varies, however, overall it appears to improve time efficiency more for administrators than for physicians and nurses.

Root cause analysis (RCA) after adverse events in healthcare is a standard practice at many institutions. However, healthcare has failed to see a dramatic improvement in patient safety over the last decade. In order to improve the RCA process, this study used systems safety science, which is based partly on human factors engineering principles and has been applied with success in other high-risk industries like aviation. A multi-institutional dataset of 334 RCA cases and 782 solutions was analyzed using qualitative methods. A team of safety science experts developed a model of 13 RCA solutions categories through an iterative process, using semi-structured interview data from 44 frontline staff members from 7 different hospital-based unit types. These categories were placed in a model and toolkit to help guide RCA teams in developing sustainable and effective solutions to prevent future adverse events. This study was limited by its retrospective review of cases and use of interviews rather than clinical observations. In conclusion, systems safety principles were used to develop guidelines for RCA teams to promote systems-level sustainable and effective solutions for adverse events., (© 2013 American Society for Healthcare Risk Management of the American Hospital Association.)

Introduction: This article presents a simulation architecture for a patient tracking system simulator to study caregiver performance in emergency departments (EDs). The architecture integrates discrete event simulation modeling with clinical patient information. Evaluation components for electronic patient tracking system displays are also described., Methods: A simulation of an ED electronic whiteboard was developed to study situation awareness metrics. Dynamic process data from an actual ED was used to generate simulation parameters including patient arrivals at various hours, distribution of severities, times required to treat the ED patients, and ancillary turnaround times (laboratory and radiology). A team of industrial engineers and ED physicians contributed demographic and clinical information for simulator patients. ED simulation parameters were combined with clinical information resulting in an event timeline database. Event timelines were used to populate a front-end patient-tracking system display simulation., Results: The resulting patient-tracking system display simulation consists of underlying software, desktop and large-screen displays, a phone call/pager system, and typical tasks that enhance the realism of the simulation experience. The system can evaluate the impact of display parameters and ED operations on user performance., Conclusions: Modular design of the patient-tracking system display simulation helps adaptation for different studies to support various interface features and interaction types. The methodology described in this work exploits the benefits of discrete event simulation to iteratively design and test technologies such as electronic patient tracking systems and allows assessment of human performance measures.

Study Objective: We characterize and describe the communication links and patterns between and within emergency department (ED) practitioner types., Methods: This is a prospective, observational study of emergency physician and nursing staff communication patterns in an academic ED using link analysis techniques. Twenty ED staff members were observed in the pediatric and adult acute areas of the ED, including attending physicians, residents, nurses, and charge nurses. Data were recorded for each communication event, including duration, mode, partner, location, and interruptions. Because this study was intended to focus on professionally related communication between staff, social interactions and direct patient interactions were excluded. Frequency percentage and duration were calculated for each measure, and link analysis graphs were prepared to assist in interpretation of the data., Results: One thousand six hundred sixty-five total communication events were recorded during a total of 39 hours 12 minutes of observation. Face-to-face communication was the most common mode. Communication links and patterns were described and graphically represented using a link analysis technique. Communication gaps were found between ambulance providers and the providers who would ultimately take care of the patient during their ED stay. Attending physicians communicated often despite caring for separate patients, and the charge nurse seemed to be the hub for communication, linking ED personnel with non-ED staff. In the adult area, interruption rates ranged from 6.9 per hour (attending physician) to 0.5 per hour (bedside nurse), and in the pediatric area they ranged from 3.6 per hour (attending physician) to 0.3 (bedside nurse)., Conclusion: Distinct patterns are identified. These results will be helpful in designing future communication adjuncts in the ED.

We conducted four studies regarding the representation of probabilistic information. Experiments 1 through 3 compared performance on a simulated stock purchase task, in which information regarding stock profitability was probabilistic. Two variables were manipulated: display format for probabilistic information (blurred and colored icons, linguistic phrases, numeric expressions, and combinations) and specificity level (in which the number and size of discrete steps into which the probabilistic information was mapped differed). Results indicated few performance differences attributable to display format; however, performance did improve with greater specificity. Experiment 4, in which participants generated membership functions corresponding to three display formats, found a high degree of similarity in functions across formats and participants and a strong relationship between the shape of the membership function and the intended meaning of the representation. These results indicate that participants can successfully interpret nonnumeric representations of uncertainty and can use such representations in a manner similar to the way numeric expressions are used in a decision-making task. Actual or potential applications of this research include the use of graphical representations of uncertainty in systems such as command and control and situation displays.

As methods in cognitive work analysis become more widely applied, questions regarding the impact of modeling choices and similarities in modeling efforts across projects and domains are increasingly relevant. However, no explicit comparison of models of similar systems has been reported. This paper compares independently developed work domain analysis (WDA) models of two command and control environments. Similarities in model content and the types of nodes included provide evidence that WDA techniques can capture fundamental elements regarding purposes and constraints. These points of agreement provide a common starting point for developing work domain representations of military command and control systems. The comparison also revealed differences between the models. Although differences in content reflected differences in scope of coverage and level of detail, other differences corresponded to more fundamental choices in modeling approach. These included the treatment of sensors, level of integration in the model, and representation of particular abstract constraints. Examination of these more fundamental differences pointed to important degrees of freedom in how to represent a WDA and clarified the implications of these modeling choices for guiding design. Actual or potential applications of this research include aiding analysts in making work domain modeling choices as well as producing work domain models of command and control environments.

Methodologies for assessing human judgment in complex domains are important for the design of both displays that inform judgment and automated systems that suggest judgments. This paper uses the n-system lens model to evaluate the impact of displays on human judgment and to explicitly assess the similarity between human judgments and a set of potential judgment algorithms for use in automated systems. First, the need for and concepts underlying judgment analysis are outlined. Then the n-system lens model and its parameters are formally described. This model is then used to examine a previously conducted study of aircraft collision detection that had been analyzed using standard analysis of variance methods. Our analysis found the same main effects as did the earlier analysis. However, n-system lens model analysis was able to provide greater insight into the information relied upon for judgments and the impact of displays on judgment. Additionally, the analysis was able to identify attributes of human judgments that were--and were not--similar to judgments produced by automated systems. Potential applications of this research include automated aid design and operator training.