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Adaptive Behaviors of Experts in Following Standard Protocol in Trauma Management: Implications for Developing Flexible Guidelines

AMIA Annual Symposium 2012
by

Mithra Vankipuram

on 5 November 2012

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Transcript of Adaptive Behaviors of Experts in Following Standard Protocol in Trauma Management: Implications for Developing Flexible Guidelines

Typical Trauma Unit
Highly dynamic environment
Diverse teams
Time-critical events
Can become chaotic very quickly
Chronic exposure to clusters of events

Multiple Information Source
Pre-arrival patient information
Trauma workflow sheets
Patient vital signs monitor, x-ray and CT scans & diagnostic tools to analyze blood and urine samples Mixed Methodology Framework for Data Collection Quantitative Data using RFID Tags Methods Data Collection Qualitative methods (observations and interviews)
Quantitative methods (RFID tags) Used RFID tags to capture 100 samples of 15 different movement-based activities
Hidden Markov Modeling (HMM) used to develop computational activity models
Avg. recognition accuracy on test samples was 87.5% (min: 84.5% and max: 90.5%)
Qualitative analysis (classification) of activities needed to support quantitative methods Recognition accuracy for tested-movement based activities Cognition and Expertise Are all deviations errors? Experts use well developed knowledge base and superior reasoning strategies for clinical decision making - Patel et al.
Experts most often use a top-down heuristic in a familiar domain - Patel and Groen
Expert clinicians generate higher-level problem representations as compared to residents or medical students Previous Work Key Research Questions How often do the clinicians deviate from guidelines?
What types of deviations are made?
How do these types of deviations vary with the experience (level and type) of the members of the clinical team? Previous Work Key Findings
An average of 9.1 (± 2.14) made in 10 trauma cases observed
Experts (attending and PGY4/5 residents) made more innovations than novices (PGY2/3 residents)
Novices made more errors compared to any other group

Limitation
Terminology based on patient outcome may be hard to track
Sample size could be larger to assess consistency of results Adaptive Behaviors Shetty et al. assessed performance of teams in cardiac resuscitation
Outcomes in critical care affected by flexible leadership, two-way communication and number of tasks performed
Adherence to sequence of protocol was not characteristic of a successful team Frequency of team behaviors in the successful and the unsuccessful teams
Outcome determined by patient survival
A: Good Outcome; B: Bad Outcome

Attempts to Obtain Pat. Information (AO-PI); Providing Patient Status (PPS); Provide Task Status (PTS); Reminders(R); Clarifications (CL); Confirmations (CO); Non-leader Providing Suggestions (NL-PS) for Intervention; Leader assigning tasks to members of the team (L-AT) Deviations were classified as Errors: potentially impacts patients and their treatment outcome negatively
Innovations: May positively affect the patient’s outcome
Proactive: Actions performed ahead of need
Reactive: Steps in reaction to patient-specific actions NOTES
Clearly marking every deviation as an error is not an adequate strategy.
Protocols and standards are based on observations and evidence gathered from practices. New information and novel findings from practice need to be incorporated into the guidelines and protocols. Deviation Classification Proactive Deviations A proactive deviation occurs when
An activity is performed (without compromising patient care) in anticipation of a future requirement (or lack thereof) when treating a patient (or)
An activity (which may be out of the bounds of an individual’s role in the trauma team) is performed in order to correct or prevent an error

Examples of proactive deviations encountered in our study
Technician sets up x-ray board for a chest scan prior to trauma arrival
A trauma nurse calls the radiology unit to let them know that the technician would not be required as the scans were already taken
The trauma nurse reminds a junior resident that c-spine results have to be received prior to removal of the spine Innovations as Deviations Innovations are defined as deviations that
Potentially benefit the individual, team or patient
By bringing a novel perspective to the situation at hand

Examples of innovations encountered in our study,
In the absence of an appropriate translator the attending surgeon requested a family member to support the team by communicating with the patient communication
The trauma nurse provided a patient a hand mirror to alleviate nervousness about extent of injuries Reactive Deviations Reactive deviations occur when an activity is performed
In reaction to an unanticipated event (or)
Change in patient condition, diagnosis process or treatment plans

Examples of reactive deviations found in this study
A patient was violently reacting to pain and needed to be held down by the trauma team in order to complete primary survey and intubate patient.
The results of the x-ray ordered were inconclusive. As a result, the resident ordered an angiogram.
A patient concerned about his facial injuries requested a plastics consult. The treatment plan had to be altered to accommodate the patient’s request. Other Deviation Terminology Deviations can be classified based on whether they occurred due to an individual or team decision

Process related: How the guideline is implemented
Example: Log roll not being performed correctly or an x-ray being ordered after the secondary survey

Procedure related: How a specific medical intervention is performed
Example: Clinician making an error in stapling a wound

Care-delivery related: How care interventions are provided to the patient
Example: Providing a mirror to a patient concerned by facial injuries or providing medications for a patient in pain Experiment Methodology Step 1: Observations of 30 trauma cases, with 15 cases led by PGY 4/5 (senior) residents and 15 cases led by PGY 2/3 (junior) residents was gathered
Step 2: A rater compared each observation case to the steps in the ATLS guideline to identify deviations
Step 3: Deviations are then classified based on terminology scheme developed Deviation Type and Leader Expertise Significant association between trauma leader expertise and deviations (Chi-sq = 9.93, df = 3, p = 0.0192)

More errors and reactive deviations in cases led by junior residents

More innovations in cases led by a senior resident

Trauma leaders with more experience are able to adapt to the dynamic environment will minimizing errors Deviation Type and Leader Expertise Significant association between trauma leader expertise and deviations (Chi-sq = 9.89, df = 3, p=0.0194)

Cases led by junior residents had fewer care delivery and team deviations
Junior resident’s cases biased toward procedure related deviations

Lack of experience at the helm could affect communication channels
Senior residents having mastered procedures, can focus on developing other skills, such as communication Deviation Type and Phases of Trauma Significant relationship between deviation and phase of trauma standard (Chi-sq = 63.09, df = 12, p<0.0001)

Process-related deviations higher when x-ray and diagnostic tests are ordered (52% in Phase 2)

Certain steps in trauma treatment may be more adaptable than others

Monitoring deviations in critical steps can provide information to direct guideline updates Deviation Type and Clinician Role Significant relationship between deviations and clinician role (Chi-sq = 69.83, df = 12, p<0.0001)

Expert clinicians (senior residents, attendings and trauma nurses) made more innovations when compared to junior residents

Junior residents made more errors than any other group

Support the results reported in previous study Deviation Type and Clinician Role Significant relationship between deviations and clinician role (Chi-sq = 69.83, df = 12, p<0.0001)

Resident’s deviations are mostly process related, trauma nurses lead the group in number of deviations in care delivery and at the team level.

Trauma nurses often act as an information hub, connecting technicians to residents and residents to attending surgeons. Results Summary Expertise of Trauma Team Leader
Trauma leaders with more experience are able to adapt to the dynamic environment will minimizing errors
Lack of experience at the helm could be affecting communication channels
Critical Steps of Trauma Standards
The primary survey is protocol driven, while the secondary survey and definitive care are more flexible
Certain steps in trauma treatment may be more adaptable than others
Role of Clinician in Trauma Team
Trauma nurses often act as an information hub, connecting technicians to residents and residents to attending surgeons.
Expert clinicians (senior residents, attendings and trauma nurses) made more innovations when compared to junior residents Assessment of Inter-rater Reliability Methods
Two raters (with clinical environments experience) trained on deviations from 5 trauma cases
After training, they classified deviations from 10 trauma cases.

Key Findings
Substantial inter-rater reliability for schema 1 and schema 2
Insufficient samples to assess reliability of classification for schema 3
Inter-rater reliability with original classification between ranged between moderate to excellent for classification schemas Experts do make errors, but are adept at correcting them before negative consequences occur
Expertise is critical to formation of adaptive teams
Adds to emerging knowledge about medical error and expertise

Deviations classification developed is generic.
Schema developed can be extended to other environments (with similar time pressures and complexity)
Provides a methodology for assessing adaptive behaviors in a complex system Acknowledgments “Cognitive Complexity and Error”
James S. McDonnell Foundation Grant
to Vimla L. Patel

Banner Good Samaritan Medical Center
Vafa Ghaemmaghami, Denise Drumm-Gurnee and clinicians from Banner Trauma

Kanav Kahol and Thomas Kannampallil Mithra Vankipuram, PhD Clinical Environments and Complex Adaptive Systems Introduction Nature of clinical environments
Complex
Dynamic
Interactive

Errors may occur due to,
Lack of communication
Poor decision making
Dynamically altering goals Intensive Care Trauma Emergency Department "a collection of individual agents with freedom to act in ways that are not always predictable, and whose actions are interconnected so that one agent's actions, changes the context for other agents" – Plesk and Greenhalgh, 2001 Complex Adaptive Systems Adaptive Behaviors of Experts in Following Standard Protocol in Trauma Management: Implications for Developing Flexible Guidelines Critical Care Units
Multiple individuals (patients, physicians, nurses and technicians)
Distributed cognitive processes
Complex interactions
Random events Key Challenges Challenges and Goals Clinicians may need to deviate to adapt to dynamic environments
Researchers may be limited by the tools used to study these systems INTRODUCTION Critical Care Environments and Complex Adaptive Systems RFID Activity Modeling Next Steps? Analysis of Deviations from Standards Active and Passive RFID Technology Dissertation Error in Critical Care 2008 2009-2010 2008 2010 - 2012 Errors or Innovation? 2012 Trauma Critical Care as a Complex System Typical Workflow in Trauma RESEARCH TIMELINE 2008 2009 2010 2011 2012 Graduated with M.S. Computer Science Joined "Cognitive Complexity and Error" Project Vankipuram M, “Modeling Interactions in Clinical Environments”, James S. McDonnell Foundation Annual Conference, (2008). PRESENTATION Vankipuram M, Kahol K, Cohen T, Patel VL, “Visualization and Analysis of Medical Errors in Immersive Virtual Environments”, presented at Medicine Meets Virtual Reality, (2009).
[Awarded Best Poster] POSTER CONFERENCE Vankipuram M, Kahol K, Cohen T, Patel V, “Visualization and Analysis of Activities in Critical Care Environments”, AMIA Annual Symposium Proceedings, (2009); 662–6. PRESENTATION
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POSTER Vankipuram M, “Error in Critical Care”, presented at the Medical Simulation and Robotics Doctoral Consortium, (2010).
.
Vankipuram M, “Real Event Driven Simulations for Competency Skills Training”, presented at Annual BMI Spring Symposium, Arizona State University, (2010) [Awarded Best Student Poster]. PRESENTATION Vankipuram M, “Errors and Innovations”, James S. McDonnell Foundation Annual Conference, (2010). POSTER Vankipuram M, “Modeling Innovations in Critical Care Environments”, presented at the Annual BMI Spring Symposium, Arizona State University, (2011) [Awarded 2nd Place for Best Student Poster]. JOURNAL PAPERS Kahol K, Vankipuram M, Patel VL, Smith ML, “Deviations from Protocol in a Complex Trauma Environment: Errors or Innovations?”, J Biomedical Informatics, (2011); 44(3): 425-31.
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Vankipuram M, Kahol K, Cohen T, Patel VL, “Toward Automated Workflow Analysis and Visualization in Clinical Environments”, J Biomedical Informatics, (2011); 44(3): 432-40. CONFERENCE SUBMISSION
.
PRESENTATION Vankipuram M, Ghaemmaghami V, Patel VL, “Adaptive Behaviors of Experts in Following Standard Protocol in Trauma Management: Implications for Developing Flexible Guidelines”, submitted to AMIA Annual Symposium, (2012).
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Vankipuram M, “Adherence to Standards in Complex Environments”, James S. McDonnell Foundation Annual Conference, (2012). Ph.D. Oral Examination Ph.D. Comprehensive and Proposal Defense Ph.D. Dissertation Defense UNDERSTANDING ADAPTIVE BEHAVIORS IN COMPLEX CLINICAL ENVIRONMENTS ACKNOWLEDGEMENTS Mithra Vankipuram
Dissertation Topic ARE ALL DEVIATIONS ERRORS? EXPERIMENTS Errors as Deviations An error is defined as a deviation from the standard, if,
It violated a prescribed order of activities with a negative impact on workflow
Resulted (directly or indirectly) in compromising patient care (or)
Resulted in an activity being repeated due to failure in execution or a loss of information

Examples of errors encountered our study,
A resident completed the secondary survey prior to ordering chest/abdomen/pelvis x-rays
A junior resident attempted to remove the spine board before the patient’s spine was cleared (confirmed not be injured) Deviations Errors Innovations Proactive Reactive Individual: Process Classification Schema Tabulation Deviations and Expertise of Team Leader Deviation Type and Phases of Trauma Significant relationship between deviation and phase of trauma standard (Chi-sq = 63.09, df = 12, p<0.0001)

More deviations occur in the phases following trauma preparation and primary survey

Errors occur throughout, while innovations only after primary survey

Primary survey is protocol driven, while the secondary survey and definitive care are more flexible Deviations and Phases of Trauma Standard Deviations and Role of Clinician OTHER RESULTS Clinician Role and Leader Expertise Significant relationship between deviations made by specific clinicians and clinician role (p<0.0001)

Attending make more deviations (are more involved) in cases led by a junior resident Phase of Trauma and Clinician Role Significant relationship between deviations made at a particular trauma phase and clinician role and members involved (p<0.0001)

Attendings make very few deviations in Primary Survey, while nurses make several deviations in Definitive Care Schema 1 and Schema 2 Significant relationship between deviations classified with schema 1 and schema 2 (p=0.0002)

None of the care-delivery deviations were errors

Further data is need to examine relationships between these variables Clinician Role and Leader Expertise Phase of Trauma and Clinician Role Schema 1 and Schema 2 Assessment of Inter-rater Reliability Classification of deviations is a subjective process.

Example: Attending asking a nurse if there is a (disease-specific) protocol to follow, after it was discovered that the patient may be infected.

Deviation: Proactive
Rationale: As the attending went out of the bounds of his role in requesting the information (possibly in anticipation of steps to follow).

Deviation: Innovation
Rationale: If thought of as a novel task addition that greatly improves patient and team safety it is an innovation.

Deviation: Reactive
Rationale: Common task addition in reaction to the patient being infected (a random event).

Rubric for novelty and effect of deviation is needed to standardize the process further. REPLICABILITY Assessment of Completeness of Classification Methods
Observe trauma cases for 3 weeks in Banner's Level 1 Trauma center
Every 10 cases, assess if new cases add to existing classification. If yes, continue data collection. If not, end study.

Study Status
As of 06/04/2012, 10 Trauma cases were observed.
Results will be submitted for a publication after analysis. PRACTICAL IMPLICATIONS SCIENTIFIC IMPLICATIONS The Big Picture While adherence to protocols and standards is important for novice practitioners to reduce medical errors and ensure patient safety, there is strong need for training novices in coping with complexity
Need for educational tools for training
(For example though simulation and retrospective analysis of trauma cases)

Complex environments (such as trauma) cannot be treated as zero-tolerance environments.
Need for policy/outlook change How does classification integrate with tag data? Temporal relationship between deviations in a trauma? Relationship between types of deviations? What are the types of team generated deviations? Generalizability of classification to other critical care settings? Do deviations vary in magnitude of importance? Services and Solutions Research Lab, HP Labs
Hewlett-Packard Company
Palo Alto, CA Vafa Ghaemmaghami, MD, FACS Vimla L. Patel, PhD, DSc Banner Good Samaritan Medical Center (Trauma)
Phoenix, AZ Center for Cognitive Studies in Medicine and Public Health
New York Academy of Medicine
New York, NY Individual: Procedure Individual: Care Delivery Team Type of Deviation Initiated By Types of deviations based on consequence to workflow compared against leader expertise
ERR: Error, INN: Innovation, PRO: Proactive deviations, REAC: Reactive deviations Types of deviations based on level of occurrence compared against leader expertise
PRS: Process, PROC: Procedure, CD: Care
delivery, TM: Team Key phases in trauma standard are
compared to deviations classified by impact on workflow
Phases compared include 1: Trauma Preparation, Primary Survey and Resuscitation, 2: X-ray and
Diagnostic Studies, 3: Secondary Survey, 4: Tertiary Survey and Definitive Care Key phases in trauma standard are
compared to deviations classified by level of
occurrence
Phases compared include 1: Trauma Preparation, Primary Survey and Resuscitation, 2: X-ray and
Diagnostic Studies, 3: Secondary Survey, 4: Tertiary Survey and Definitive Care Types of deviations based on impact on workflow compared role of clinician in trauma team
Roles include JR: Junior Resident (PGY1/2), SR: Senior Resident (PGY4/5), ATT: Attending, NUR: Trauma Nurses, TECH: Technicians Types of deviations based on level of occurrence are compared role of clinician in trauma team
Roles include JR: Junior Resident (PGY1/2), SR: Senior Resident (PGY4/5), ATT: Attending, NUR: Trauma Nurses, TECH: Technicians Thank You Questions? Research Goals Development of tools and methods for studying activities in trauma
Development of a generalizable classification of adaptations that occur in trauma Quantitative methods Radio frequency identification tags used to track encounters
Features tracked included tag ID, time, date and received signal strength (RSSI) value
Proximity information used as a proxy for interaction Measuring movement-
based activities Presentation available at:
bit.ly/VrKjRM
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