Presentation
Participatory Design and Simulation for Designing and Validating a Decision Pathway and Checklist for a Pediatric Emergency Department’s Resuscitation Room
SessionBuilt Environments (HE7)
DescriptionTopic/Background:
The Emergency Department (ED) Resuscitation room is a cognitively demanding and fast-paced environment where clinicians must respond rapidly, and often with incomplete information, to make life-saving medical decisions (Madani et al., 2018). This complex decision-making requires collaboration with multiple care teams, including teams from other units in the hospital. Rapid decisions become critical when a patient is in cardiac arrest with ongoing Cardiopulmonary Resuscitation (CPR), as guidelines for the initiation of Extracorporeal Membrane Oxygenation (ECMO) require cannulation within <60 minutes from arrest. The speed and quality of the team’s response impact the chances of survival, so the ED team must promptly assess ECMO candidacy and activate the appropriate response. An ECMO activation for a patient receiving ongoing CPR is referred to as Extracorporeal Cardiopulmonary Resuscitation (ECPR). Our ED’s current ECPR process prompts the Intensive Care Unit (ICU) team to present to the ED resuscitation room to evaluate the patient, and, if ECMO is indicated, move the patient to the ICU or operating room (OR) in collaboration with the ED team.
Despite being a large tertiary care pediatric hospital, ECPR in the ED is rare (activation on average occurs less than thrice a year). As an infrequent, high-acuity event, ECPR presents a cognitive challenge for healthcare staff who must recall numerous sequential steps in a life-threatening situation. When a patient is in cardiac arrest, team members must maintain situational awareness and a cohesive shared mental model of the ECMO activation process, the patient’s clinical status, and needs for patient transport. Visual aids to support cognitive recognition of steps by clinicians quickly and efficiently were deemed necessary by a Human Factors (HF) evaluation.
The use of checklists to minimize errors (slips and lapses) has been well-established in healthcare and HF literature (Gawande, 2010). At our institution, the ECMO activation process and decision-making were supported by an existing decision pathway and checklist. This pathway and checklist included steps to activate an ECMO response and to prepare a patient for transport (including equipment, medications, and personnel needed). However, the existing visual aids were challenging to follow and hindered time-sensitive decision-making. The ED’s Resuscitation Quality committee noted several occurrences of deviation from the intended ECPR workflow, so simplifying the workflow for ECPR, re-designing the visual aid to support the end-user, and minimizing visual clutter in the design to enhance cognitive recognition of actions were deemed priorities for HF interventions.
Participants and Methods:
HF work system analysis was conducted using in-person observations and unstructured interviews with staff from different roles to evaluate the efficiency of the existing decision pathway and checklist in supporting timely decision-making in cases of potential ECMO activation. The work system analysis revealed several barriers to utilizing the current visual aid in the ED resuscitation room. The aid violated the majority of Nielsen-Norman usability heuristics, had inconsistent or confusing information, and had an unclear workflow that was difficult for users to follow under time pressure. The physical location of the visual aid was also not conducive to the workflow in the ED resuscitation room.
An HF engineer (HFE) led the redesign process using a participatory iterative design approach for about nine months. The redesign process involved a multidisciplinary group that included the ED Resuscitation Quality Committee (n=15), frontline staff (n=8), HF engineers (n=2), simulation educators (n=3), and simulation participants (n=15).
Observations and Interviews were conducted with the ED clinical nurse supervisor and clinical nurse specialist to determine barriers in the current workflow for ECPR decision-making.
The “expert group” comprised members of the ED Resuscitation Quality Committee, which includes attending physicians in pediatric emergency medicine, nurse managers, improvement advisors, clinical supervisors, clinical nurse specialists, fellows, nurse practitioners, acute care technicians, and nurses. These participants were critical to identifying design needs and providing continuous feedback on design iterations.
A/B user testing with the expert group was conducted during one of the visual aid design iterations.
Formative usability testing was conducted by presenting the redesigned visual aid to 8 users (charge nurses and clinical nurse experts ) in the ED. User testing involved walking around in the ED with a prototype of the new design and recruiting potential users in the field for feedback sessions of about 5-7 minutes. This process provided feedback on the design of the visual aid, determined the ideal location for placement of the visual aid in the work environment, informed print requirements for the visual aid, determined areas of opportunities for targeted ECPR workflow education, and prompted the next iteration of changes to the pathway design.
Simulation participants comprised ED and ICU teams, including attending physicians, fellows, acute care techs, and registered nurses. A high-fidelity, “systems and process” simulation to evaluate the ECMO activation process was conducted in the ED resuscitation room utilizing the newly-designed ECPR decision pathway, and patient transport checklist. The simulation focused on recognizing and managing a patient in cardiac arrest, activating the ECMO pathway within 5 minutes of the arrest utilizing the newly redesigned visual aid, and preparing the patient for expeditious transport to the OR for ECMO cannulation.
Results and Implementation:
The HF engineer developed multiple design iterations (n=15) using feedback from the expert group throughout the process, as well as results from all human-centered methods mentioned before. Below is a description of seven of the major design iterations developed using a human-centered design approach over the 9-month duration of this project. Several other design iterations were conducted with minor changes.
Iteration 1: Developed after initial observations and interviews by the HF engineer. This iteration, along with feedback from the expert group, helped identify the need to revise two additional related visual aids in the resuscitation room.
Iteration 2: Developed based on feedback on iteration 1 and brainstorming with the expert group.
Iteration 3: Developed based on another round of feedback and brainstorming with the expert group.
Iteration 4: Developed after another set of observations and walkthrough by HF engineer.
Iteration 5: Two versions (5a and 5b) of the decision pathway were developed in response to concerns raised by an ECPR that occurred during the design process and highlighted additional gaps in the original pathway. This provided the team an opportunity to pivot the design based on the occurrence of the rare event of an ECMO activation. The expert group unanimously voted on version 5a. Formative usability testing was performed using Iteration 5a.
Iteration 6: The iteration was developed based on the results of formative user testing.
Iteration 7: The final iteration was developed based on the results of a high-fidelity simulation.
Application:
The new visual aid is grounded in Nielsen Norman usability heuristics. It is designed to foster recognition over recall, maintain consistency and standards in design, provide users with help and documentation, and foster aesthetic and minimalist design. The visual aid was recently implemented in the resuscitation room at our pediatric institution. Summative usability testing will be conducted in the coming months when the pathway and checklist are utilized for the first few times for ECPR decision-making. Summative testing is dependent on the timing of future ECMO activations.
Overview of Presentation:
This presentation will provide an overview of the different methods used in this project to maximize human-centered design, including walkthroughs, observations, A/B testing, iterative participatory design, formative usability testing, and simulation. The primary design iterations will be presented along with results from different user-testing methods. The presentation will also emphasize the role of HF, simulation, and multidisciplinary collaboration in achieving better outcomes for patients and clinicians in healthcare settings. The challenges encountered during the iterative design process will also be shared.
The Emergency Department (ED) Resuscitation room is a cognitively demanding and fast-paced environment where clinicians must respond rapidly, and often with incomplete information, to make life-saving medical decisions (Madani et al., 2018). This complex decision-making requires collaboration with multiple care teams, including teams from other units in the hospital. Rapid decisions become critical when a patient is in cardiac arrest with ongoing Cardiopulmonary Resuscitation (CPR), as guidelines for the initiation of Extracorporeal Membrane Oxygenation (ECMO) require cannulation within <60 minutes from arrest. The speed and quality of the team’s response impact the chances of survival, so the ED team must promptly assess ECMO candidacy and activate the appropriate response. An ECMO activation for a patient receiving ongoing CPR is referred to as Extracorporeal Cardiopulmonary Resuscitation (ECPR). Our ED’s current ECPR process prompts the Intensive Care Unit (ICU) team to present to the ED resuscitation room to evaluate the patient, and, if ECMO is indicated, move the patient to the ICU or operating room (OR) in collaboration with the ED team.
Despite being a large tertiary care pediatric hospital, ECPR in the ED is rare (activation on average occurs less than thrice a year). As an infrequent, high-acuity event, ECPR presents a cognitive challenge for healthcare staff who must recall numerous sequential steps in a life-threatening situation. When a patient is in cardiac arrest, team members must maintain situational awareness and a cohesive shared mental model of the ECMO activation process, the patient’s clinical status, and needs for patient transport. Visual aids to support cognitive recognition of steps by clinicians quickly and efficiently were deemed necessary by a Human Factors (HF) evaluation.
The use of checklists to minimize errors (slips and lapses) has been well-established in healthcare and HF literature (Gawande, 2010). At our institution, the ECMO activation process and decision-making were supported by an existing decision pathway and checklist. This pathway and checklist included steps to activate an ECMO response and to prepare a patient for transport (including equipment, medications, and personnel needed). However, the existing visual aids were challenging to follow and hindered time-sensitive decision-making. The ED’s Resuscitation Quality committee noted several occurrences of deviation from the intended ECPR workflow, so simplifying the workflow for ECPR, re-designing the visual aid to support the end-user, and minimizing visual clutter in the design to enhance cognitive recognition of actions were deemed priorities for HF interventions.
Participants and Methods:
HF work system analysis was conducted using in-person observations and unstructured interviews with staff from different roles to evaluate the efficiency of the existing decision pathway and checklist in supporting timely decision-making in cases of potential ECMO activation. The work system analysis revealed several barriers to utilizing the current visual aid in the ED resuscitation room. The aid violated the majority of Nielsen-Norman usability heuristics, had inconsistent or confusing information, and had an unclear workflow that was difficult for users to follow under time pressure. The physical location of the visual aid was also not conducive to the workflow in the ED resuscitation room.
An HF engineer (HFE) led the redesign process using a participatory iterative design approach for about nine months. The redesign process involved a multidisciplinary group that included the ED Resuscitation Quality Committee (n=15), frontline staff (n=8), HF engineers (n=2), simulation educators (n=3), and simulation participants (n=15).
Observations and Interviews were conducted with the ED clinical nurse supervisor and clinical nurse specialist to determine barriers in the current workflow for ECPR decision-making.
The “expert group” comprised members of the ED Resuscitation Quality Committee, which includes attending physicians in pediatric emergency medicine, nurse managers, improvement advisors, clinical supervisors, clinical nurse specialists, fellows, nurse practitioners, acute care technicians, and nurses. These participants were critical to identifying design needs and providing continuous feedback on design iterations.
A/B user testing with the expert group was conducted during one of the visual aid design iterations.
Formative usability testing was conducted by presenting the redesigned visual aid to 8 users (charge nurses and clinical nurse experts ) in the ED. User testing involved walking around in the ED with a prototype of the new design and recruiting potential users in the field for feedback sessions of about 5-7 minutes. This process provided feedback on the design of the visual aid, determined the ideal location for placement of the visual aid in the work environment, informed print requirements for the visual aid, determined areas of opportunities for targeted ECPR workflow education, and prompted the next iteration of changes to the pathway design.
Simulation participants comprised ED and ICU teams, including attending physicians, fellows, acute care techs, and registered nurses. A high-fidelity, “systems and process” simulation to evaluate the ECMO activation process was conducted in the ED resuscitation room utilizing the newly-designed ECPR decision pathway, and patient transport checklist. The simulation focused on recognizing and managing a patient in cardiac arrest, activating the ECMO pathway within 5 minutes of the arrest utilizing the newly redesigned visual aid, and preparing the patient for expeditious transport to the OR for ECMO cannulation.
Results and Implementation:
The HF engineer developed multiple design iterations (n=15) using feedback from the expert group throughout the process, as well as results from all human-centered methods mentioned before. Below is a description of seven of the major design iterations developed using a human-centered design approach over the 9-month duration of this project. Several other design iterations were conducted with minor changes.
Iteration 1: Developed after initial observations and interviews by the HF engineer. This iteration, along with feedback from the expert group, helped identify the need to revise two additional related visual aids in the resuscitation room.
Iteration 2: Developed based on feedback on iteration 1 and brainstorming with the expert group.
Iteration 3: Developed based on another round of feedback and brainstorming with the expert group.
Iteration 4: Developed after another set of observations and walkthrough by HF engineer.
Iteration 5: Two versions (5a and 5b) of the decision pathway were developed in response to concerns raised by an ECPR that occurred during the design process and highlighted additional gaps in the original pathway. This provided the team an opportunity to pivot the design based on the occurrence of the rare event of an ECMO activation. The expert group unanimously voted on version 5a. Formative usability testing was performed using Iteration 5a.
Iteration 6: The iteration was developed based on the results of formative user testing.
Iteration 7: The final iteration was developed based on the results of a high-fidelity simulation.
Application:
The new visual aid is grounded in Nielsen Norman usability heuristics. It is designed to foster recognition over recall, maintain consistency and standards in design, provide users with help and documentation, and foster aesthetic and minimalist design. The visual aid was recently implemented in the resuscitation room at our pediatric institution. Summative usability testing will be conducted in the coming months when the pathway and checklist are utilized for the first few times for ECPR decision-making. Summative testing is dependent on the timing of future ECMO activations.
Overview of Presentation:
This presentation will provide an overview of the different methods used in this project to maximize human-centered design, including walkthroughs, observations, A/B testing, iterative participatory design, formative usability testing, and simulation. The primary design iterations will be presented along with results from different user-testing methods. The presentation will also emphasize the role of HF, simulation, and multidisciplinary collaboration in achieving better outcomes for patients and clinicians in healthcare settings. The challenges encountered during the iterative design process will also be shared.
Authors
Event Type
Oral Presentations
TimeTuesday, April 14:10pm - 4:30pm EDT
LocationHarbour C
Hospital Environments (HE)