Improving information transfer

The Centre of Research Excellence in Patient Safety will examine attributes of communication that will either facilitate or produce barriers to delivering safe care. Techniques such as simulation and video taping of clinical encounters will be used in conjunction with human factors engineering concepts as tools to assist in understanding how adverse incidents occur. The use of real-life and simulated situations will test the transition of theory into practice.

Trauma Reception and Resuscitation Project

Investigators: Nathan Farrow, Mark Fitzgerald
Background: The Trauma Reception & Resuscitation (TR&R) Project tested the hypothesis that the implementation of real-time, computer-prompted algorithms in the first half hour of major trauma management would result in a measurable reduction in management errors. An interventional study employing a randomised controlled trial was used to measure the effect of real-time, computer prompted, evidence-based algorithms on algorithm deviation and error occurrence during trauma resuscitation. Computer assisted video audit allowed objective identification of algorithm deviation and error. Data analysis demonstrated that real-time decision support improved protocol compliance and significantly decreased errors of omission during the initial resuscitation of major trauma patients.
Aims: The TAC funded Trauma Reception & Resuscitation (TR&R) Project tested the hypothesis that the implementation of real-time, computer-prompted algorithms in the first half hour of major trauma management would result in a measurable reduction in management errors.
Methods: This was an interventional study 0f 1187 severely injured patients employing a randomised controlled trial was used to measure the effect of real-time, computer prompted, evidence-based algorithms on algorithm deviation and error occurrence during trauma resuscitation. Computer assisted video audit allowed objective identification of algorithm deviation and error.
Results: Computer aided decision support for Medical and Nursing Trauma Teams improved protocol compliance and significantly decreased errors of omission during the initial resuscitation of major trauma patients. This is a ‘world first’ study that demonstrates that computer-aided decision support reduces errors during the initial resuscitation of major trauma patients. Introduction of this technology is expected to reduce morbidity and mortality of the severely injured. Shock management errors reduced by 26% and the need for blood transfusion was significantly reduced (p<0.0001).
Status: Completed

Publications:

Lee G, Farrow N, Fitzgerald M, Cameron P, Bystrzycki A, Gocentas R, McNeil J. Innovative technology to improve trauma patient outcomes – the trauma reception and resuscitation project. Australasian Emergency Nursing Journal 2005; 8(3) 122-3.

Mark Fitzgerald, Rob Gocentas, Linas Dziukas, Peter Cameron, Colin Mackenzie, Nathan Farrow. Using video audit to improve trauma resuscitation – time for a new approach. Can J Surg, June 2006;49(3):208-11.

Mark Fitzgerald, Adam Bystrzycki, Nathan Farrow, Peter Cameron, Thomas Kossmann, Michael Sugrue, Colin Mackenzie. Trauma Reception & Resuscitation. ANZ J Surg, 2006:76(8):725 -28.

Mitra B, Mori A, Cameron P, Fitzgerald M, Street A, Bailey M. Massive Transfusion and Trauma Resuscitation. Injury. 2007 Sep;38(9):1023-9.

Colin F. Mackenzie, Yan Xiao, Fu-Ming Hu, Jacob Seagull, Mark Fitzgerald. Video as a Tool for Improving Tracheal Intubation Tasks for Emergency Medical and Trauma Care. Ann Em Med. 2007 Oct;50(4):436-442.

Fitzgerald M, Mackenzie C F, Marasco S, Hoyle R, Kossmann T. Pleural Decompression and Drainage during Trauma Reception and Resuscitation. Injury 2008 Jan:39;9-20.

Mark Fitzgerald, Nathan Farrow, Pamela Scicluna, Angela Murray, Yan Xiao, Colin F. Mackenzie. 'Challenges to Real-Time Decision Support in Health Care', Chapter in - Henriksen K, Battles JB, Keyes MA, Grady ML, editors. Advances in patient safety: New directions and alternative approaches. Vol. 2. Culture and Redesign. AHRQ Publication No. 08-0034-2. Rockville, MD: Agency for Healthcare Research and Quality; August 2008

Enhancing communication transfer between the Ambulance Service and the Emergency Department

Investigators:Patrick I, Evans SM, Fitzgerald M, Cameron PA, McCabe N.
Project Coordinator:Dr Sue Evans
Background:Communication errors are costly, both in human and economic cost. Clinical handover provides a particularly vulnerable period for communication errors. The transfer of information between paramedics and the trauma team in the receiving hospital offers unique challenges to achieving effective handover. There is often little time to document extensive information about the patient’s condition in transit to hospital resulting in substantial dependence on memory by paramedics when providing a verbal handover. The complex nature of trauma events and the time critical nature of transmitting information to multiple people with many interruptions, coupled by the need for receiving trauma teams to rely on memory when paper documentation is not present increases risk that information will be lost or misinterpreted.In recognition of the need to transmit information succinctly and methodically paramedics are taught to handover using a format known as MIST. We do not know (a) whether the MIST format is used effectively and meets the needs of the receiving trauma team; or (b) the extent to which information loss occurs when information is handed over from paramedics to trauma team members, in an Australian context. Evidence demonstrates that early transmission of critical information through mobile networks improves communication between paramedics and treating medical teams and results in patients receiving more timely treatment on arrival in the ED The VACIS has been developed as an electronic medical record for use by paramedics in Australia. Work is underway to enable information to be transmitted in advance by paramedics to receiving hospital IT systems. However, currently no work has been done to evaluate what information would best assist clinicians in receiving hospital provide better patient care and how this can most effectively be done by paramedics.
Aims:This project will advance trauma care and practice by:

Assessing current practice with regard to handover of information between paramedics and the trauma team. The educational benefit of this project is significant. Currently the quality of the handover process between paramedics and the trauma team is not well evaluated. No published studies have been undertaken in an Australian context to identify whether verbal handover is performed consistently and effectively.

Providing a framework to assist paramedics in ensuring that there is congruence between what paramedics believe should be handed over and what trauma team members want to know.

Informing a body of work which will ensure that vital information is transmitted in a timely manner and displayed in the receiving hospital trauma bay so that it can be accessed by all members of the trauma team and used to enhance decision making. Currently if members of the trauma team are not present when verbal handover is provided by paramedics, information relating to pre-hospital care might not be accessible until the full written report is provided by the paramedics. This occurs, on average, 20 minutes after arrival in the hospital. Even when trauma team members are present at the time of handover, much of the information transmitted verbally is not retained by the trauma team. Only 36% of information being handed over verbally by the paramedic is recalled by the treating physician. The more severe the trauma, the less likely it is that recall of information will occur. Physicians are more likely to recall details of the crash scene (46%), than they are of the patients’ health status (34%) or information about their pre-hospital management (30%).

Informing a body of work which is designed to improve coordination of care in the ED. It is hypothesized that real-time transmission of data will increase situational awareness of the patient’s condition on arrival in the ED. This has potential to improve coordination of care. This has been demonstrated in the University of Maryland Medical Center, where wireless transmission of data to the ED resulted in better coordination of care and decreased need for labour-intensive voice communication.

Clinical Handover – Obstetrics and Gynaecology

Project Coordinator: Dr Georgiana Chin
Investigators: Professor Peter Cameron, Dr Louise Kornman; Dr Narelle Warren
Aims: This project will identify the key requirements for effective and safe clinical handover and to develop an intervention to improve the process of clinical handover.
Method:This project will be undertaken in the obstetrics and gynaecology setting and will advance current knowledge of how to effectively improve communication of critical information between staff. While this study will be implemented in the obstetric and gynaecology environment, it is anticipated that the findings will have elements which have general application to other areas of clinical practice. The project involves literature review, audit in incident report data and stakeholder survey through paper survey, interview and focus groups. The information that is obtained from this study is to assist in better understanding of clinical handover through the identification of the factors that both provide risk of adverse outcomes and protective features that are present and protect the quality and safety of health care associated with clinical handovers.
Results: Pending
Status: Data entry and analysis
Publications: Pending
Students: Georgina Chin
Contact: Georgina Chin - georgiana.chin@med.monash.edu.au

Managing interruptions and distractions in anaesthesia practice

Project Coordinator:Penelope Sanderson
Investigators: Tobias Grundgeiger (PhD student), Prof. Penelope Sanderson (supervisor)
Background:Interruptions are frequent in healthcare settings. Although researchers are concerned about disruptive effects of interruptions, such as forgetting to return to an unfinished interrupted task, there are no theoretically-guided studies that explore what facilitates or hinders task resumption. Therefore, empirically tested recommendations to prevent disruptive effects of interruptions are not available for healthcare settings.
Aims:The general aim is to generate theoretically-based and empirically-tested recommendations on how to ease or prevent cognitive demands caused by distractions and interruptions. The first study investigated which factors facilitate or compromise task resumption. A second study is planned to test interventions.
Method: The first part of the project was a literature review of studies on distractions and interruptions in healthcare settings (Grundgeiger & Sanderson, 2009). The second part was an observational study in an intensive care unit using a mobile eye tracker (Grundgeiger, Sanderson McDougall, & Venkatesh, in press-a; in press-b; submitted). The third part is about testing interventions in field settings or simulated environments.
Results: The current literature on distractions and interruptions is mostly descriptive and only three studies report that people forget tasks due to interruptions (Grundgeiger & Sanderson, 2009). The result of the eye tracking study indicates that longer interruptions and physical changes of the context due to interruptions make it harder to resume interrupted task (Grundgeiger et al., submitted). In addition, nurses used a variety of behavioural strategies to prevent memory demands of interruptions.
Status: ongoing
Staff: Tobias Grundgeiger, Penelope Sanderson
Student/s: Tobias Grundgeiger
Contact Person:Tobias Grundgeiger; tobiasg@psy.uq.edu.au

Publications

Grundgeiger, T., Sanderson, P., MacDougall, H. G., & Venkatesh, B. (submitted). Interruptions in the wild: Predicting resumption times and assessing distributed support. Manuscript submitted for publication.

Grundgeiger, T., & Sanderson, P. (2009). Interruptions in healthcare: Theoretical views. International Journal of Medical Informatics, 78, 293-307. [abstract] [Full paper: doi:10.1016/j.ijmedinf.2008.10.001]

Liu, D., Grundgeiger, T., Sanderson, P. M., Jenkins, S., & Leane, T. (2009). Interruptions and blood transfusion checks: Lessons from the simulated operating room. Anesthesia and Analgesia, 108(1), 219-222. [pdf]

Optimizing Trauma Team Performance (OTTP)

Project Coordinator: Shelly Jeffcott
Investigators: Peter Cameron, Shelly Jeffcott, Mark Fitzgerald, Nathan Farrow, Stuart Marshall
Background: Recent acknowledgement of the importance of “non technical” skills, like decision making and leadership, has resulted in a proliferation of team training in both real and simulated healthcare settings. However, there remain many unknowns regarding ideal team interactions in high-risk settings such as trauma.
Aims: To measure and investigate how team communication and coordination contribute to overall team effectiveness in the trauma resuscitation setting. To inform the development of training and education programs to improve team performance across the Victorian State Trauma System (VSTS)
Method: Methods include (1) video audit of 50-100 videos of the first 30 minutes of trauma resuscitation; (2) interviews and focus groups with a range of trauma professionals; and, (3) the linking of team scores as measured through the video audit with patient outcomes as collected through the Victorian State Trauma Outcomes Measurement Registry (VSTORM).
Results: Pending
Status: Design / Implementation
Staff: Shelly Jeffcott
Publications: Jeffcott S., Mackenzie C. (2008). Measuring team performance in healthcare: Review of research and implications for patient safety. Journal of Critical Care, 23(2), 188-196.
Student/s: N/A
Contact Person: Shelly Jeffcott, shelly.jeffcott@med.monash.edu.au