TY - JOUR
AU1 - Calder, Lisa A
AU2 - Bhandari, Abhi
AU3 - Mastoras, George
AU4 - Day, Kathleen
AU5 - Momtahan, Kathryn
AU6 - Falconer, Matthew
AU7 - Weitzman, Brian
AU8 - Sohmer, Benjamin
AU9 - Cwinn, A Adam
AU1 - Hamstra, Stanley J
AU1 - Parush, Avi
AB - Abstract Importance Emergency resuscitation of critically ill patients can challenge team communication and situational awareness. Tools facilitating team performance may enhance patient safety. Objectives To determine resuscitation team members’ perceptions of the Situational Awareness Display's utility. Design We conducted focus groups with healthcare providers during Situational Awareness Display development. After simulations assessing the display, we conducted debriefs with participants. Setting Dual site tertiary care level 1 trauma centre in Ottawa, Canada. Participants We recruited by email physicians, nurses and respiratory therapist. Intervention Situational Awareness Display, a visual cognitive aid that provides key clinical information to enhance resuscitation team communication and situational awareness. Main outcomes and measures Themes emerging from focus groups and simulation debriefs. Three reviewers independently coded and analysed transcripts using content qualitative analysis. Results We recruited a total of 33 participants in two focus groups (n = 20) and six simulation debriefs with three 4–5 member teams (n = 13). Majority of participants (10/13) strongly endorsed the Situational Awareness Display’s utility in simulation (very or extremely useful). Focus groups and debrief themes included improved perception of patient data, comprehension of context and ability to project to future decisions. Participants described potentially positive and negative impacts on patient safety and positive impacts on provider performance and team communication. Participants expressed a need for easy data entry incorporated into clinical workflow and training on how to use the display. Conclusion Emergency resuscitation team participants felt the Situational Awareness Display has potential to improve provider performance, team communication and situational awareness, ultimately enhancing quality of care. resuscitation, team communication, situational awareness, emergency department, focus groups Introduction What is the problem? Resuscitation of critically ill patients in the emergency department can occur in potentially chaotic environments. Acutely ill patients often arrive with little notification and require urgent lifesaving interventions. Multiple healthcare team members of varying professions arrive to the emergency department at different times with different skills and communication expertise. At times, team member roles may be ill-defined. Robust team communication is often key to achieving positive patient outcomes [1, 2]. Effective teamwork requires continuous coordination, communication and information sharing among team members. By having effective teamwork processes, team situational awareness (i.e. knowing what is going on around you) is improved and maintained, thus ensuring that every team member is well aware of what is happening and who does what and when [3]. However, there are many research findings indicating obstacles to effective teamwork in the emergency department such as interruptions and distractions as well as physical environmental factors such as noise [4]. Optimizing team communication, and consequently team situational awareness, has been a recent focus in the patient safety literature. One way to address the problem of optimizing team communication and situational awareness is to develop technological cognitive aids. Display devices supporting information sharing within teams have been developed and evaluated in various domains [5–7]. The use of display devices to support collaboration and teamwork has been reported also in healthcare, but not in the setting of critical care or the adult emergency department. In the healthcare field, display devices providing patient information in a central location on the display were found to be most effective and efficient for acquiring and perceiving information relevant to situational awareness. This contrasts with process-centred displays seen in other conceptual designs [8]. Given the potential for enhancing situational awareness for resuscitation teams in the emergency department, we undertook the development of a Situational Awareness Display with a patient centred design. This visual display depicting key clinical information in real time, was designed to be mounted in the resuscitation bay to enhance team communication and situational awareness [9]. The development phase involved the determination of key information elements required for the display which are unique to the clinical resuscitation context of the emergency department. Our intent was to develop a device useful for all types of resuscitation in adult emergency medicine. Building on our concurrent research to develop this display, we used focus groups and simulation debriefs to determine emergency resuscitation team members’ perceptions of the overall utility of a Situational Awareness Display. Specifically, we also sought to ask participants their perceptions on the following four questions: (i) Is there an impact on patient safety? (ii) How does the display affect their performance in resuscitation? (iii) To what extent does the Situational Awareness Display improve team communication? (iv) What are the barriers and facilitators to implementation? Methods Study overview and setting This is a qualitative study in which we conducted focus groups with emergency department healthcare providers to facilitate the design of the Situational Awareness Display. We then tested the display in a simulation setting and conducted debriefs with participants to assess their perceptions of the Situational Awareness Display. The study was conducted at The Ottawa Hospital, a tertiary care academic and regional trauma centre located in the Canadian capital. It has a dual campus emergency department with more than 170 000 patient visits per year. The simulation portion of this study was conducted at the University of Ottawa Skills and Simulation Centre. This is the largest simulation centre in Canada and one of the largest in North America. This study was approved by the Ottawa Health Science Network Research Ethics Board. We obtained written informed consent from all participants. Study population We engaged in purposive sampling of our target population of emergency department resuscitation healthcare team members. We excluded clerks, patient care assistants, social workers and consulting physicians as these were involved in the design of the Situational Awareness Display but not the primary intended users. We excluded patients as they are typically too critically ill to be users of the Situational Awareness Display. For the focus groups, we e-mailed emergency department nurses, attending staff and resident physicians at the Civic campus of The Ottawa Hospital seeking volunteers, aiming for 6–8 participants in two focus groups. For the simulation part of the study, we developed a new group of participants by e-mailing attending staff and resident physicians, nurses and respiratory therapists from both campuses of The Ottawa Hospital emergency department. We sought to create three 5 member teams consisting of: one attending emergency physician, one emergency resident physician, two emergency nurses and one critical care respiratory therapist. Situational Awareness Display We created a Situational Awareness Display, which is a visual display, a flat screen monitor, intended to be mounted at the head of the patient’s bed in the resuscitation bay of the emergency department. A visual depiction of the Situational Awareness Display is in Fig. 1. The display depicts a central figure representing the patient on which icons can be placed to denote clinical interventions. The patient’s demographics and clinical history data elements are presented in the top left corner and the team members present are listed in the bottom left. The top right corner contains the patient’s current vital sign information as well as temporal trends. A summary of information requests and timeline of interventions is in the bottom right. The central lower part of the display depicts a visual timeline of interventions using icons. We undertook a rigorous process to design this display using stakeholder interviews, simulated resuscitation observations and live observations of resuscitations. Detailed methods and results of this conceptual design study have been published in the Journal of Biomedical Informatics and the International Journal of Emergency Medicine [9, 10]. Figure 1 View largeDownload slide Situational Awareness Display. Figure 1 View largeDownload slide Situational Awareness Display. We tested the Situational Awareness Display in a high-fidelity simulation centre, the University of Ottawa Skills and Simulation Centre, with the three teams being exposed to the display during three emergency resuscitation scenarios representing trauma, cardiac and shock resuscitations. We used a Latin square design to control for an order effect and allow each team to experience each scenario with and without the Situational Awareness Display (a total of six simulations per team). The Latin square design is a statistical approach to counterbalance sequential effects by creating a matrix where each condition is preceded by a different condition in each row [11]. Teams were briefed on the nature of the Situational Awareness Display and its purpose. They were also advised to play their roles as they would in their current clinical practices. Each team entered a simulation room designed to replicate a resuscitation bay with a high-fidelity simulation mannequin. The participants were provided a clinical stem by an investigator playing a paramedic. The teams then actively managed the patient as they would in real life with the ability to perform interventions such as intubation, chest tube insertion and bedside ultrasound. Data about the patient’s clinical state was provided either via the mannequin, a bedside vital signs monitor or a simulation technician who could receive prompts via an earpiece. If the scenario was with the Situational Awareness Display exposure, participants would also receive clinical status information via the display. A detailed description of these methods and the results of the evaluation of this display in terms of impact on observed teamwork and self-reported situational awareness are published elsewhere [9]. Data collection We organized the focus groups according to profession to encourage free dialogue and avoid potential authority gradients, i.e. one for the physicians and one for the nurses. During these sessions, participants were exposed to a conceptual design of the Situational Awareness Display. These occurred 2 months prior to the simulation portion of the study. During the simulation study, we conducted debriefs after the first two scenarios and again after all six scenarios were complete. During the resuscitation simulations, the participants engaged in patient care according to the scenario. This included patient assessments, order of investigations, treatments and performance of procedures. They were encouraged to use the Situational Awareness Display but not specifically instructed how to do so. Both the focus groups and the simulation debriefs were conducted by a trained facilitator (K.D.) using a pre-determined script with structured prompts. The researchers involved in developing the Situational Awareness Display were not the same as those who facilitated and performed the qualitative analysis. All sessions were audio-taped and field notes were taken. The audiotapes were transcribed and the data were anonymized prior to analysis. At the end of the simulation sessions, participants were asked to rate the overall utility of the Situational Awareness Display on a 5-point Likert ranking scale (1: not at all useful; 5: extremely useful). Analysis We used an inductive content analysis approach. The analysts were aware of aspects of the theoretical underpinnings of the study and the study hypothesis; however, they were not involved in the design of the Situational Awareness Display, mitigating potential biases in interpretation. Three independently trained qualitative reviewers (A.B., M.F., K.D.) read all transcripts aloud and coded together on paper copies for the focus groups, two reviewers undertook this process for the debriefs. We utilized open coding to develop theory; multiple iterations of data analysis were used to create a code book which was revised after every meeting. After 11 versions, it was felt that the codes were parsimonious and accurately reflected the data. The agreed upon codes were then applied to all transcripts. During this second wave, thematic coding was utilized from the perspective of situational awareness theory [3]. Transcripts were coded using NVivo10 software, from which we were able to extract the codes and representative quotations for each theme. Results We conducted two focus groups with the conceptual design of the Situational Awareness Display. One with 11 emergency department nurses (nine females, two males; 1–30 years clinical experience) and one with nine emergency department physicians (four females, five males; 2–30 years clinical experience). After the simulation testing of the Situational Awareness Display, we conducted two debriefs with each of the three resuscitation teams comprising of 4–5 members each. There were a total of six physicians (three attending staff, three residents; three females, three males; 4–10 years clinical experience), five nurses (three females, two males; 6–17 years clinical experience) and two respiratory therapists (one female, one male, 2–15 years clinical experience). When asked to rank the overall utility of the Situational Awareness Display, the majority of simulation participants found it very or extremely useful (10/13) and the remainder found it somewhat useful. Upon analysis of all of the transcripts from both the focus groups and debriefs, we identified themes relevant to the impact on situational awareness as well as barriers and facilitators for implementation of the display. In terms of impact on situational awareness, participants’ comments were grouped into themes of perception of patient data, comprehension of context, projection to future decisions, impact on patient safety, provider performance and team communication (Fig. 2). With respect to barriers to implementation of the display, participants described their needs for a streamlined data entry process, more extensive training prior to use and modifications in layout, content and visibility. Figure 2 View largeDownload slide Key themes from focus groups and simulation debriefs regarding the impact of a visual display in the resuscitation bay on situational awareness. Figure 2 View largeDownload slide Key themes from focus groups and simulation debriefs regarding the impact of a visual display in the resuscitation bay on situational awareness. When participants described their perceived impact of the Situational Awareness Display on situational awareness, we noted that the themes that emerged coincided with situational awareness theory. The comments could be grouped into the three key cognitive tasks that occur when acquiring situational awareness: perception, comprehension and projection [12]. Representative quotations describing these themes are presented in Table 1. Overall, participants felt the display would enhance their ability to perceive key elements of patient data, comprehend their meaning in the current clinical context and assist them project into the future either a potential deterioration of a patient or tasks that needed to be performed soon. Table 1 Representative quotations from participants on key themes related to situational awareness Theme  Participant quotation  Impact on Situational Awareness  ‘I think it allows you to have confidence in the sense of what has been done…and what needs to be done but also where we started and where we are at now, so I think lots of times you are banking all this stuff in your brain and you are trying to remember it, whereas this way you didn’t have to do that so maybe you didn’t have to cloud your brain with a bunch of information that you are trying to remember that you know you can just visually look at it.’ ~ physician, debrief  Perception of patient data  ‘say a physician comes in and says ‘what do you have for access…’ if you have the colour for IVs ‘I’ve got a 20 on the left ACF and a 16…’ and then you can say I have blood running on this one and I’ve fluids running on this one, versus looking through your charting…visually you can see it’ ~ nurse, focus group ‘I think it might be useful though to use it when you are talking to the TTL [trauma team leader]… so you could both look visually at the board and…go over things, because sometimes when you are running a scenario you might lose sight of some things that were done, like forget to mention that this intervention was done…it’s all summarized for you. You might be able to use it as a tool to better communicate what is going on with the patient’ ~ physician, focus group  Comprehension of context  ‘I know in real life scenarios when…EMS give report, they…give it to the whole team and it’s only one time but you always forget: were they hypotensive? were they hypoxic? And so having it there you can…see how your patient is responding to treatment versus when they originally came in.’ ~ nurse, debrief ‘but if you want to see the trend…during a resuscitation what time did this patient go hypotensive and then you look at the trend and then you know…it really doesn’t make much difference for you if it is 65 or 66 systolic, that doesn’t…add anything for you but it tells you ‘oh he was hypotensive at this moment, when the blood pressure spiked up again and the heart rate went up or down’ so graphic vital signs versus written vital signs…’ ~ physician, debrief  Projection to future decisions  ‘I think similarly to what was mentioned before with cardiac arrest, like timing of cycles and timing of epi [adrenaline], even if a cue for epi doesn’t come up at least you know you are looking at…’ok it has been two minutes, let’s do a pulse check’ that kind of thing, that timeline being up there when you are standing at the foot of the bed thinking ‘ok what’s next, what’s next’ that would be helpful for that situation’ ~ physician, focus group ‘I was always…wondering who have we actually called so far, so seeing ICU, Radiology, Neurosurgery and seeing those up there, I thought that was really helpful to say “ok we have notified those we need to get back and why aren’t they here”’ ~ nurse, debrief  Impact on patient safety  ‘I am just wondering because that screen is there, are people going to get so focused on the screen that they forget about the patient?’ ~ resident physician, debrief ‘There is a wonderful documentation aspect to this, that anyone after the fact will be able to use, whether it’s for patient safety, or quality assurance or reviews or teaching…you’ve got such an excellent documentation of it all in one place that you don’t have to go through 20 pages of charts trying to figure out what time the fluid was actually started’ ~ physician, focus group ‘So I think we need to [be aware of] that potential risk for miscommunication based on the fact that it’s on a board [it] is dealt with in some fashion and I think there has to be something there to double check to make sure that those things have been completed.’ ~ nurse, debrief  Impact on provider performance  ‘So I think if this reduces a lot of chit chat in the room…the volume of noise in the background will probably drop.’ ~ physician, focus group ‘It’s distractions right?…People could get themselves up to speed without taking the…person running it off the picture’ ~ nurse, debrief ‘Exactly, because most of the time during a code there is a lot of people talking, and so if you spend time telling another person, a new person the story then you kind of miss [out] on other information that is going on too, so I think the board is definitely going to help us move in a more timely fashion.’ ~physician, debrief  Impact on team communication  ‘Also whenever you have teams coming over, I really don’t want to spend time telling them everything that easily takes 2 min from my resuscitation time. Yes, it’s distracting’ ~ physician, debrief  Theme  Participant quotation  Impact on Situational Awareness  ‘I think it allows you to have confidence in the sense of what has been done…and what needs to be done but also where we started and where we are at now, so I think lots of times you are banking all this stuff in your brain and you are trying to remember it, whereas this way you didn’t have to do that so maybe you didn’t have to cloud your brain with a bunch of information that you are trying to remember that you know you can just visually look at it.’ ~ physician, debrief  Perception of patient data  ‘say a physician comes in and says ‘what do you have for access…’ if you have the colour for IVs ‘I’ve got a 20 on the left ACF and a 16…’ and then you can say I have blood running on this one and I’ve fluids running on this one, versus looking through your charting…visually you can see it’ ~ nurse, focus group ‘I think it might be useful though to use it when you are talking to the TTL [trauma team leader]… so you could both look visually at the board and…go over things, because sometimes when you are running a scenario you might lose sight of some things that were done, like forget to mention that this intervention was done…it’s all summarized for you. You might be able to use it as a tool to better communicate what is going on with the patient’ ~ physician, focus group  Comprehension of context  ‘I know in real life scenarios when…EMS give report, they…give it to the whole team and it’s only one time but you always forget: were they hypotensive? were they hypoxic? And so having it there you can…see how your patient is responding to treatment versus when they originally came in.’ ~ nurse, debrief ‘but if you want to see the trend…during a resuscitation what time did this patient go hypotensive and then you look at the trend and then you know…it really doesn’t make much difference for you if it is 65 or 66 systolic, that doesn’t…add anything for you but it tells you ‘oh he was hypotensive at this moment, when the blood pressure spiked up again and the heart rate went up or down’ so graphic vital signs versus written vital signs…’ ~ physician, debrief  Projection to future decisions  ‘I think similarly to what was mentioned before with cardiac arrest, like timing of cycles and timing of epi [adrenaline], even if a cue for epi doesn’t come up at least you know you are looking at…’ok it has been two minutes, let’s do a pulse check’ that kind of thing, that timeline being up there when you are standing at the foot of the bed thinking ‘ok what’s next, what’s next’ that would be helpful for that situation’ ~ physician, focus group ‘I was always…wondering who have we actually called so far, so seeing ICU, Radiology, Neurosurgery and seeing those up there, I thought that was really helpful to say “ok we have notified those we need to get back and why aren’t they here”’ ~ nurse, debrief  Impact on patient safety  ‘I am just wondering because that screen is there, are people going to get so focused on the screen that they forget about the patient?’ ~ resident physician, debrief ‘There is a wonderful documentation aspect to this, that anyone after the fact will be able to use, whether it’s for patient safety, or quality assurance or reviews or teaching…you’ve got such an excellent documentation of it all in one place that you don’t have to go through 20 pages of charts trying to figure out what time the fluid was actually started’ ~ physician, focus group ‘So I think we need to [be aware of] that potential risk for miscommunication based on the fact that it’s on a board [it] is dealt with in some fashion and I think there has to be something there to double check to make sure that those things have been completed.’ ~ nurse, debrief  Impact on provider performance  ‘So I think if this reduces a lot of chit chat in the room…the volume of noise in the background will probably drop.’ ~ physician, focus group ‘It’s distractions right?…People could get themselves up to speed without taking the…person running it off the picture’ ~ nurse, debrief ‘Exactly, because most of the time during a code there is a lot of people talking, and so if you spend time telling another person, a new person the story then you kind of miss [out] on other information that is going on too, so I think the board is definitely going to help us move in a more timely fashion.’ ~physician, debrief  Impact on team communication  ‘Also whenever you have teams coming over, I really don’t want to spend time telling them everything that easily takes 2 min from my resuscitation time. Yes, it’s distracting’ ~ physician, debrief  When asked about the impact of the Situational Awareness Display on patient safety, participants noted positive effects such as reducing cognitive load for the clinicians involved, using stored data for quality improvement efforts and research into patient safety concerns and having a view of vital signs trending to detect early clinical deterioration. Participants also noted potential risks to patient safety such as excessive focus on the screen rather than the patient, the risk that data on the display is not up to date or accurate and forgetting to verbally close the loop with the team. Representative quotations are displayed in Table 1. Provider performance was felt to be overall enhanced by the display according to participants. The display was described as a tool to facilitate team recaps, reduce redundancy in team communications when new team members arrived and provide a more structured organization of clinical information. Some participants felt that errors would be minimized, e.g. when transmitting key pieces of pre-hospital history or allergy status. Table 1 provides representative quotations for these themes. Nurses found the display useful, particularly for charting and envisioned its use for handover. They expressed concerns regarding the data input process and accuracy or timing of uploading information to the display. The respiratory therapists found the display less helpful due to their position at the head of the bed and the display being behind them. The physicians strongly endorsed the utility of the display for enhancing their performance and reducing cognitive load. In terms of team communication, participants viewed elements of the display useful for all members especially when arriving into a resuscitation bay, recapping progress and transitions in care. One physician participant indicated: ‘not having to repeat yourself…when the [consulting service] junior, then the senior, then the staff…comes in and you are repeating…the initial history which is…a ridiculous thing to have to spend your time talking about that that many times when there is a sick patient in front of you’. This quotation reflected the cognitive burden of emergency physicians during resuscitations which could be relieved by a cognitive tool such as the Situational Awareness Display. We explored potential barriers and facilitators to the implementation of the Situational Awareness Display in the emergency department with both the focus groups and the simulation debrief participants. Table 2 has representative quotations for these themes. Nurses and physicians both expressed concern with how the data would be entered to populate the display, as well as the accuracy and fidelity of these data. Some nurses indicated a preference for paper charting, whereas others thought electronic charting would be easier. One nurse indicated that touch screen technology for data entry could be a facilitator. Table 2 Representative quotations from participants on key themes related to display barriers and facilitators Theme  Participant quotation  Barriers  Data entry  ‘I wonder how much I would trust it if ever they made mistakes inputting the data, so if that happened to me once or twice where there was vital mistake entering it I don’t think I’d be confident using it anymore. So as a way to overcome that maybe, is there a way to make is similar to the anesthesia machines where it gets auto-populated from the vitals that are being reported’ ~ physician, focus group ‘Just because I’m old fashioned, I like to have paper…so I would still want something tangible rather than flipping through a screen, so in that case it would be the board, if maybe that…disappeared then at least you … can look back at and say ‘ok well this is here’, you still have a record of it’ ~ nurse, debrief ‘I think the limiting factor is input…it’s like any computerized…system, the limiting factor is the human involvement…so it’s a great tool but the reality is if it’s not inputted correctly,…somebody doesn’t put there is a penicillin allergy then that doesn’t really matter because it’s not going to be on the board’ ~ physician, debrief ‘And what happens if your network crashes?…our current operating environment…is really slow,…so [if] something like this was running on the same system…it’s got the same lags’ ~ nurse, focus group  Familiarity/training  ‘The biggest thing I’d mention is if we had time to look at the display and play with it for a few minutes just to focus on the display…before we started it would have been way better for us’ ~ nurse, debrief ‘Once you get used to it you might interpret it better, you might give…a quick glance instead of trying to read each line…but then again you’d…have to…know the symbols’ ~ nurse, focus group  Patient privacy  ‘I also think would there be any concern for privacy? How long would that big screen stay there? Because there is a lot of patient information, history and age and all that stuff, is that only going to be during the code that we have that? Or is that going to stay there afterwards, so we see the patient after a code still have IV lines here and there?’ ~physician, debrief  Facilitators  Data entry  ‘It truly depends on how easy [it is] to get the information in…but if it is like a touch screen where you have a scroll down, if I touch the arm it makes sense to say either an injury or an IV line.’ ~ nurse, debrief  Familiarity/training  ‘But I wonder if there would be a culture change if you have it in place for a while and the EP could say for instance ‘look at the board and if you have any questions about it, then I am happy to answer them’ but then you don’t have to spend time on the things that are already on the board’ ~ physician, focus group  Theme  Participant quotation  Barriers  Data entry  ‘I wonder how much I would trust it if ever they made mistakes inputting the data, so if that happened to me once or twice where there was vital mistake entering it I don’t think I’d be confident using it anymore. So as a way to overcome that maybe, is there a way to make is similar to the anesthesia machines where it gets auto-populated from the vitals that are being reported’ ~ physician, focus group ‘Just because I’m old fashioned, I like to have paper…so I would still want something tangible rather than flipping through a screen, so in that case it would be the board, if maybe that…disappeared then at least you … can look back at and say ‘ok well this is here’, you still have a record of it’ ~ nurse, debrief ‘I think the limiting factor is input…it’s like any computerized…system, the limiting factor is the human involvement…so it’s a great tool but the reality is if it’s not inputted correctly,…somebody doesn’t put there is a penicillin allergy then that doesn’t really matter because it’s not going to be on the board’ ~ physician, debrief ‘And what happens if your network crashes?…our current operating environment…is really slow,…so [if] something like this was running on the same system…it’s got the same lags’ ~ nurse, focus group  Familiarity/training  ‘The biggest thing I’d mention is if we had time to look at the display and play with it for a few minutes just to focus on the display…before we started it would have been way better for us’ ~ nurse, debrief ‘Once you get used to it you might interpret it better, you might give…a quick glance instead of trying to read each line…but then again you’d…have to…know the symbols’ ~ nurse, focus group  Patient privacy  ‘I also think would there be any concern for privacy? How long would that big screen stay there? Because there is a lot of patient information, history and age and all that stuff, is that only going to be during the code that we have that? Or is that going to stay there afterwards, so we see the patient after a code still have IV lines here and there?’ ~physician, debrief  Facilitators  Data entry  ‘It truly depends on how easy [it is] to get the information in…but if it is like a touch screen where you have a scroll down, if I touch the arm it makes sense to say either an injury or an IV line.’ ~ nurse, debrief  Familiarity/training  ‘But I wonder if there would be a culture change if you have it in place for a while and the EP could say for instance ‘look at the board and if you have any questions about it, then I am happy to answer them’ but then you don’t have to spend time on the things that are already on the board’ ~ physician, focus group  Although participants received limited training and orientation to the display prior to each simulation, it was intentionally minimal as the technology was intended to be intuitive. This was challenging for many participants who expressed a desire for more training. Participants understood how the board could be used but found the iconography perplexing as well as what elements were dynamic and changing as a scenario unfolded. Discussion Key findings Overall, we noted marked enthusiasm for the Situational Awareness Display from the focus groups and simulation debriefs. Key cognitive elements of situational awareness emerged naturally from the data: perception, comprehension and projection. Participants felt these cognitive tasks were enhanced by the Situational Awareness Display. Participants saw potential for enhancements in patient safety and provider performance, particularly with respect to reduced cognitive load and transitions in care. We did note a differential impact depending on participants’ roles in the resuscitation team. We observed physicians found the Situational Awareness Display most useful, closely followed by the nurses but less so by the respiratory therapists. We noted some key barriers to implementation in terms of the accuracy and speed of data entry into the display and the need for more extensive training. We are aware of technology that would facilitate the real time entry of data into the Situational Awareness Display and believe that an effective training programme can be designed and tested in the future [13]. We are unaware of any other previous studies in the clinical literature examining healthcare providers’ perceptions of the utility of a visual cognitive aid to assist with team communication in resuscitation. We are aware of a group of investigators working on a visual display concept for paediatric trauma, although we have not seen their display so are uncertain of any similarities or differences [14, 15]. Members of our group have previously developed a prototype of a visual display for the cardiac operating room although the information needs for this team are significantly different from those needed for emergency resuscitations (i.e. time on pump, time to cross-clamp) [16]. Other investigators have examined broad system strategies to enhance team situational awareness [17]. Previous authors have described effectiveness of training for situational awareness in reducing errors in the operating room or other settings but we believe this technology is novel in the adult emergency department setting [18]. Our study has several strengths. By taking a qualitative approach we were able to explore rich themes around the benefits and barriers to this technological application. By holding separate focus groups for nurses and physicians we aimed to reduce restricted participation due to authority gradients. We had a trained focus group facilitator and three independent reviewers trained in qualitative analysis. There are, however, also several limitations. During the focus groups, the principal investigator was present so there is a risk of social desirability bias in the responses. This was a single centre study and as such generalizability may be limited but we believe our participants would represent many healthcare providers in a tertiary care centre emergency department. Given that our study involved volunteers there is the risk of self-selection bias leading to responses which may be systematically different from non-volunteer healthcare providers. Finally, this study was specific to the emergency department and findings for resuscitations in other environments such as the intensive care unit and operating room may be different. Clinical and research implications We anticipate that the positive response to this technological cognitive aid will lead to further work. We foresee that this tool could be used to answer many research questions as there is an opportunity to capture and store real-time data. Our participants also volunteered future applications for the Situational Awareness Display to be used as a teaching tool to review or debrief resuscitations as well as potentially developing it into an interactive interface where clinical evidence or decision support prompts could appear. One participant suggested that having it accessible remotely could be helpful, for example, a trauma team leader looking at the Situational Awareness Display on their iPad as they came down on the elevator on route to the resuscitation. Ultimately, we foresee that this tool could be used in any setting where patients are resuscitated, with the potential to enhance team communication and patient safety. Future research would need to focus on linking existing technology for real time data entry to the Situational Awareness Display and then testing use of the display in real clinical settings. Conclusions Overall, the emergency resuscitation team participants felt the Situational Awareness Display has potential to improve provider performance, team communication and situational awareness, ultimately enhancing patient safety. Prior to implementation, key barriers of data entry and training need to be addressed. Once this occurs, the Situational Awareness Display will be tested in real-time clinical settings to determine the impact on team communication and patient care. Funding Financial support for this study was provided entirely by a grant from The Ottawa Hospital Academic Medical Organization. The funding agreement ensured the authors’ independence in designing the study, interpreting the data, writing and publishing the report. Acknowledgements Thank you to Ria De Gorter, Dr Lisa Calder’s research coordinator, for overseeing the logistics of the study. We would also like to thank Jeti Olaf, Kim Tardioli, Kevin Thomas, Alain Audette, Adam Reid, Stephanie Jones, Harender Singh and Kathy LaBelle for all of their assistance with the simulations, and our transcriptionist, Debbie Hall. Finally, we would like to thank all of the participants in the focus groups and simulations. References 1 Reader TW, Flin R, Mearns K et al.  . Developing a team performance framework for the intensive care unit. Crit Care Med  2009; 37: 1787– 93. doi:10.1097/CCM.0b013e31819f0451. Google Scholar CrossRef Search ADS PubMed  2 Risser DT, Rice MM, Salisbury ML et al.  . The potential for improved teamwork to reduce medical errors in the emergency department. The MedTeams Research Consortium. Ann Emerg Med  1999; 34: 373– 83. Google Scholar CrossRef Search ADS PubMed  3 Parush A, Campbell C, Hunter A et al.  . 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TI - Healthcare providers’ perceptions of a situational awareness display for emergency department resuscitation: a simulation qualitative study
JF - International Journal for Quality in Health Care
DO - 10.1093/intqhc/mzx159
DA - 2017-11-29
UR - https://www.deepdyve.com/lp/oxford-university-press/healthcare-providers-perceptions-of-a-situational-awareness-display-cXyrCl0qwS
SP - 16
EP - 22
VL - 30
IS - 1
DP - DeepDyve
ER -