Transcript Aspects of the Proposed Work - Decision Support for Smart Trauma

Aspects of the Proposed Work
KeyChecker
Key
code_ : long
checkKey() : boolean
1..*
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KeyStorage
getNext() : Key
getCode() : long
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validKeys
checker
Controller
numOfTrials_ : long
maxNumOfTrials_ : long
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sensor
PhotoSObsrv
isDaylight() : boolean
enterKey(k : Key)
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LightCtrl
lit_ : boolean
getLit() : boolean
setLit(v : boolean)
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lightCtrl
lockCtrl
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logger
Logger
logTransaction(k : Key)
Problem solving
Interaction design
1
LockCtrl
1
alarmCtrl
open_ : boolean
AlarmCtrl
getOpen() : boolean
setOpen(v : boolean)
soundAlarm()
Software engineering
Patient’s Hospitalization Path
Intensive care unit (ICU)
Level-1
Trauma Center
Patient
CT scan
Ambulance
?
?
?
?
Local Hospital
Resuscitation bay
Operating room (OR)
Vital signs monitor:
1) Blood pressure; ECG
2) Pulse oximetry:
heart rate + oxygen
saturation (SpO2)
3) Respiratory rate
Anesthesiologist
(ANST)
Assists with airway
management;
performs intubation
Team leader (TL)
(Senior resident)
Directs resuscitation;
delegates work to others
Respiratory therapist (RT)
Sets up ventilator; assists
with intubation
Doer physician (JR)
(Junior resident)
Performs tasks assigned
by team leader
Primary nurse (PNR)
Coordinates bedside
nursing care; assists
with all procedures;
stays with the patient
until leaves ED
Refrigerator for
medications & blood
EMS paramedic
Briefs the team, then
the scribe, about the
trauma incident
Glassenclosed
supply cabinet
Monitor for
viewing X-rays
Physician recorder
(student) Informally
records patient data
& treatments for
physician’s postevent review
Trauma flow sheet
Attending physician
(ATP)
Supervises the trauma
team; interfaces with
major decision making
Orthopedic
resident (ORT)
Assesses and
treats fractures
Critical care technician
(CCT) Orderly; obtains &
sets up equipment;
assists with procedures;
takes vital signs
Nurse recorder (REC)
Scribe; records patient
data, results of tests &
treatments on flow
sheet. Coordinates
nursing care
Video cameras
Directional overhead microphones
Wall displays
Room speakers
HR
SpO 2
ABP
110 107
94 32.1
96/56
37.2
(69)
Pulse
Tperi
Tblood
PAP
25/10
(15)
CO2
34
C.O.
5.6
RR
RFID tag reader
21
RFID tag readers
Bluetooth headsets
with close-talking
microphone
Main computer
with Bluetooth BS,
Wi-Fi Internet access,
Speech reco engine
ablet PCs or PDAs,
ith Bluetooth base station,
Wi-Fi Internet access,
peech recognition engine
Tablet PC docked,
with Bluetooth base station,
Wi-Fi Internet access,
Speech recognition engine
Vital signs monitor:
1) Blood pressure; ECG
2) Pulse oximetry: heart
rate + oxygen
saturation (SpO2)
3) Respiratory rate
Oxygen outlet
Team leader (TL)
Senior resident; decision
maker; delegates work
to others
Work bench
Respiratory
therapist (RT)
Sets up ventilator;
assists with
intubation
Cardiac
arrest cart
Chief resident (CHF)
Assumes the
leadership role, if
present.
Code cart with
emergency resuscitation
medications and
supplies
Primary nurse (PNR)
Coordinates nursing
activities; assists with
all procedures; stays
with the patient until
discharged
Doer doctor (JR)
Junior resident;
performs assignments by
Team leader
Critical care technician
(CCT) Orderly; obtains &
sets up equipment;
assists with procedures;
takes vital signs
Orthopedic
resident (ORT)
Assesses and
treats fractures
Refrigerator for
blood & medications
Attending
physician (ATP)
Supervises the
trauma team;
interfaces with
major decision
making
Trauma
Assessment Flow
Sheet (TAFS)
Glass-enclosed
supply cabinet
Monitor for
viewing X-rays
Typical room dimensions: 8  5 meters
Nurse recorder (REC)
Scribe; records patient
data, results of tests &
treatments on TAFS.
Uses default charting:
records only exceptions
l signs monitor:
Blood pressure; ECG
Pulse oximetry: heart rate
oxygen saturation (SpO2)
Respiratory rate
Oxygen outlet
Team leader (TL)
(Senior resident) Directs resuscitation;
delegates work to others
Work bench
Respiratory therapist (RT)
Sets up ventilator; assists wit
intubation
Cardiac arrest cart
ef resident (CHF)
e senior than TL; Not assigned
pecific role but, if present, often
umes the leadership role.
Code cart with emergency
resuscitation medications and
supplies
mary nurse (PNR)
ordinates bedside nursing care;
sts with all procedures; stays
the patient until leaves ED
Doer doctor (JR)
(Junior resident) Performs ta
assigned by team leader
Critical care technician
(CCT) Orderly; obtains & sets
equipment; assists with
procedures; takes vital signs
hopedic resident (ORT)
esses and treats fractures
Refrigerator for
medications & blood
ending physician (ATP)
hly experienced surgeon;
ervises resuscitation; interfaces
major decision making
Trauma assessment flow she
ss-enclosed supply cabinet
Monitor for
viewing X-rays
Typical room dimensions: 8  5 meters
Nurse recorder (REC)
Scribe; records patient data,
results of tests & treatments o
flow sheet. Coordinates nursi
care
Team leader
Respiratory therapist
Chief resident
Primary nurse
Doer doctor
Critical care
technician
Orthopedic
resident
Attending
physician
Nurse recorder
Typical room dimensions: 8  5 meters
1. EMS reporting
to the trauma team
2. EMS reporting
to the nurse
recorder
Information Flows
Verbal
EMS staff report ()
Visual
Vital signs monitor
Team leader
Trauma team / Providers
Patient assessment (†)
Information sources
Verbal
Wall charts, Broselow tape
Visual
Handwriting
Equipment, medications
TAFS
Lab tests (‡)
Nurse recorder
Applied tests and treatments
Visual
Handwriting
Handwriting
X-ray images (§)
CT scans (@)
Physician recorder
Physician’s
descriptive
record
Signed-off
physician’s
record
Information Flows
EMS staff report
Verbal
Vital signs monitor
Team leader
Information sources
Patient assessment
Trauma team (Care providers)
Verbal
Wall charts, Broselow tape
Equipment, medications
Handwriting
Visual,
Verbal,
Paper
Lab tests ()
Nurse recorder
TAFS
(Trauma Assessment Flow Sheet)
Applied tests and treatments
Handwriting
Handwriting
X-ray images (†)
CT scans (‡)
Physician recorder
Physician’s
descriptive
record
Signed-off
physician’s
record
Prehospital
Intake
Airway
Breathing
Circulation
Disability
Oxygenation, etc.
System Sequence Diagrams
EMS paramedic
EMS dispatcher
Telephone operator
Nurse recorder
«primary actor»
«supporting actor»
«offstage actor»
«offstage actor»
telephone call
answer
quadruple: age, code, transportation-means, estimated-arrival-time
Time
pass on the EMS quadruple
prompt for patient status during transport
patient status during transport
pass on the patient status during transport
Team Configuration @ UPenn
Anesthesiologist (2)
Primary
Resuscitator
Respiratory
Technician
Trauma
Nurse
X-ray
Technician (2)
Assistant
Surgeon
Laboratory
Technician
Command
Physician
Recorder
Team Configuration @ Liverpool
Airway Doctor
Airway
Nurse
Circulation
Nurse
Circulation
Doctor
Orthopedic
Registrar
Wardsperson
Social
Worker
Team
Leader
Scribe
Nurse
Team Config. @ UMDNJ RWJ-H
Vital signs
monitor
Primary
Nurse
(PNR)
Orthopedic
Resident
(ORT)
Team Leader
(TL)
Respiratory
Technician
(RT)
Junior
Resident
Fellow (JR)
Critical
Care
Technician
(CCT)
Attending
Physician
(ATP)
Trauma flowsheet (TAFS)
Recording
Nurse (REC)
Typical room dimensions: 8  5 meters
Ceiling-mounted camera
facing down to provide
view around the head of the bed
Ceiling-mounted
microphone
Ceiling-mounted
microphone
Wide-angle, ceiling-mounted camera
slanted to provide entire-room view
Recording
nurse
Doorway
Audio Communication System
Marker for
tracking
Wall
display
Bluetooth
headset
Close-talking
microphone
Controls
File Edit View Tools Configure Help
Information Preferences
Text
Audio
Video
P5
P3
Total Budget
12,082
This Session Max
2,500
Display
P11
Apply
Close
Host tablet PC
with Bluetooth base station,
Wi-Fi Internet access,
Speech recognition engine
Scribe
Audio Communication System (2
Virtual marker
for tracking
(individualized)
Main
computer
with Bluetooth BS,
Wi-Fi Internet access,
Speech reco engine
Bluetooth
headset
Close-talking
microphone
Controls
File Edit View Tools Configure Help
Information Preferences
Text
Audio
Video
P5
P3
Total Budget
12,082
This Session Max
2,500
Display
P11
Apply
Close
Tablet PC
with Bluetooth base station,
Wi-Fi Internet access,
Speech recognition engine
Scribe
Circulation
Airway
Nasal
cavity
Tongue Larynx Cricoid
Carotid
artery
Trachea
Subclavian
artery
Aorta
Thoracic
aorta
Oropharynx
Epiglottis
Esophagus
Brachial
artery
Heart
External /
Internal
jugular vein
Superior
vena cava
Brachial
vein
Inferior
vena cava
Radial
artery
Breathing
Ulnar
artery
Femoral
artery
Femoral
vein
Trachea
Right
bronchus
Popliteal
artery
Carina
Popliteal
vein
Ribs
Right
lung
Left
bronchus
Pleura
Pleural cavity
(Intrapleural space)
Left
lung
Heart
Diaphragm
Disability & Exposure (not shown)
Pleur-evac
chest
drainage
equipment
HR
SpO2
PLEUR-EVAC
Dry Suction Control
40
ABP
30 20
15
10
Bag valve mask (BVM)
CO2
Blood pressure
monitor
Endotracheal
(ET) tube
Nasogastral
(NG) tube
PAP
110 107
94 32.1
96/56
37.2
(69)
Pulse
Tperi
Tblood
25/10
(15)
34
5.6
RR
21
Vital signs monitor
Pleural
chest tube
Rapid flow
fluid warmer
and infuser
ECG
electrodes
Femoral
cordis
Focused abdominal
sonogram for trauma
(FAST)
Foley
catheter
Intraosseous
infusion (used in
children)
Stethoscope
Pulse
oximeter
Intravenous (IV) bag
C.O.
IV access
cannula
HR
SpO2
ABP
PAP
CO2
110 107
94 32.1
96/56
37.2
(69)
Pulse
Tperi
Tblood
25/10
(15)
34
C.O.
5.6
RR
21
Information Flows
Information source
Channel
Receiver
Records
Verbal
EMS staff report (verbal)
Visual / Verbal
Sources of patient information
Vital sign instruments
Patient assessment:
Look-listen-feel,
auscultation, urine output,
peritoneal lavage
Patient
record
Verbal
Trauma team
(often not communicated)
Verbal
Verbal
Administered medications
Verbal
Handwriting
Fluid/blood infusers
Equipment:
Ultrasound, ventilator,
pleur-evac chest drainage
Visual / Verbal
TAFS
(Trauma Assessment Flow Sheet)
Nurse recorder
Therapeutic treatments:
Bleeding control,
orthopedic interventions
Verbal
(often not communicated)
Handwriting
Handwriting
Paper
Blood/urine lab tests ()
X-ray images ()
Visual / Verbal
Physician recorder
Physician’s
notes
Signed-off
physician’s
record
Goals, Tasks, Procedures
(“what”)
Goals
Increasing
level of
abstraction
(a)
System
(“how”)
Tasks
State variables
Procedures (detail “how”)
varn
System
state space
Current
state
(b)
Desired
state
(goal)
var2
var1
Actors
System
(Trauma team)
(Patient)
suspected severe or
multiple injuries 1
Checklist
Mechanism of Injury
 Fall from a height ( 5m)
 Explosion
 Jammed in a car
 Ejection from the car
 Death of another passenger
 Pedestrian or cyclist hit by
a car
 High-speed car or
motorcycle collision
A
intubated?
 Glasgow-Coma Score  10
 Blood pressure  80 mmHg
 Respiratory rate  10 or  29
 SpO2  90 % (RA)
 Flail chest
 Open thorax
 Unstable pelvic fracture
 Fractures of  1 long bone
or the lower extremity
 Major amputations
 Multiple rib fractures plus
concomitant injuries
yes
correction
no
surgical
cricothyrotomie
no
yes
laryngoscopy
possible?
yes
no
B
RR  10/min?
C
Checklist
Type of Injury
malposition of
endotrach. tube?
no
airways
obstructed?
Checklist
Vital Signs
yes
yes
intubate
no
yes
pulsless?
no
arterial
bleeding?
no
yes
compression
consider CPR?
Two Problems Solved
TRAUMA BAY
Primary survey
Secondary survey
STABLE
or
UNSTABLE?
DETERMINE ALL
INJURIES OR
POTENTIAL INJURIES
initial decision
revised decision
Home
No injury requiring monitoring
or treatment
Floor
Injury that needs monitoring
or treatment that cannot be
done at home
ICU
unstable
Injury that requires
monitoring or treatment that
cannot be accomplished on
the floor
Operating room
Injury if not operated on
immediately will lead to
morbidity or mortality
Goals and Tasks (1)
Goal hierarchy of resuscitation
Free airway
( Immediate threat to life )
Maintain perfusion
Functional breathing
Stable circulation
Identify and treat injuries
Devise definitive care plan
Tasks (Observation)
Mouth AND/OR nose open
Mouth, nose, and neck sight
Oropharynx unobstructed (e.g. tongue)
Level of consciousness and talk
Larynx unobstructed (e.g. epiglottis)
Breath sounds (noise)
Trachea free
Chest sight (wounds, bruises?)
Adequate ventilation
Chest movement normalcy (flail?)
Functional gas exchange
Breath sounds (lateral symmetry)
Pneumo/hemo-thorax excluded or treated
Overt bleeding controlled
( Potential threat to life )
State variables
Respiratory rate (RR)
Peripheral oxygen saturation (SpO2)
Blood fluid balance
CO2 level in exhaled gas
Cardiac output normal
Skin color and temperature
Internal bleeding excluded or controlled
External bleeding presence
Hemoglobin concentration > 10 g/dl
Systolic/diastolic blood pressure
Open wounds dressed
Heart rate / Pulse
Patient’s body temperature normal
Urine output
Tasks (Intervention)
Body temperature
Receive EMS report
Stabilize spinal cord
Blood cellular composition
Setup vital sign monitoring
Oxygenate via face mask
Abdominal sonogram
Draw blood for analysis
Establish two IV accesses
Goals and Tasks (2)
Observation tasks
Example observations
Indicated tasks
Visually inspect face/neck area
Get the patient to talk
Listen for noise in breathing
No visible injuries to face&neck
Lucid talking
Oxygenate via face mask
?
?
Setup oxygen saturation monitor
?
?
Observation Intervention
tasks
tasks
(result of Observation tasks)
Alternative Perspective: Goals
Stable for
ultrasound/DPL
Stable
for CT
Go directly
to OR
Unstable
for CT
ICU
OR
Hospital
floor
Home
Patient
Bad
outcome
Research Approach
Computerized Decision Support
Bottom-up
Ethnographic data collection,
video tagging and analysis
Top-down
Cognitive work analysis of
goals and ATLS protocol
Workload, team structure,
critical decisions and
associated input
parameters
Goals and subgoals, critical
decisions and associated
input parameters
1.
Augmenting Team
Communication and
Information Presentation
2.
Monitoring Team
Activities and Alerting
about Errors and
Inefficiencies
Control Tasks (1)
Goal
Short-term memory: Situation information
Channel
Observe
Decide
Intervene
Long-term memory: Knowledge
Sender
modality
multiplicity
Communication
Receiver
Control Tasks (2)
shortcut
Shared
goals
Observe
Communicate
Decide
Communicate
Team
Short-term memory: Situation information
Long-term memory: Knowledge
Intervene
Control Tasks – Example
STEP 1
STEP 2
STEP 3
Observe
var1
Decide
Intervene
int1
Observe
var3
var1 = blood pressure
var2 = oxygen saturation
var3 = heart rate
diagnose
hypovolemia
 increase
blood volume
var1:
var3: 
var3
Actual
current
state
STEP 4
int1 = crystalloid infusion
var3
Actual
current
state
Goal
state
var3
Actual
current
state
Goal
state
int1
Observed
current
state
var1
var2
Observed
current
state
var1
var2
Observed
current
state
var1
Achieved
state
Goal
state var
2
Cognition Model
Cognitive
processing
Prediction
module
Association
Prediction
module
Prediction
module
Attention
searchlight
Prediction
module
Sensing
Motor Behavior
Prediction
module
Sensing
Prediction
module
Motor Behavior
Sensing
Motor Behavior
Prediction module
IN
OUT
Working
script
Index of
predicted
script
• Ignore/rationalize
• Repair by
alternative script
Long-term
memory
Index of
predicted
script
OUT
• Report mismatch
Report
mismatch
IN
Models Relationship
Problem plane of
problem-specific
tasks
(“Workflow”)
Infrastructure plane of
psychological
processes
do X
Bad
prob D1
Utility
Good
outcome
Utility
of X
Test utility
DECISION:
Do test
G
do Y
B
Utility
of X
Threshold
Pr(D1)
(a)
(b)
Pr(diagnosis)
Test
Pr(diag)
(a)
0
Current
diagnosis
Threshold
Don’t test
(unnecessary)
1
Successive pieces of evidence
Pr(diag)
(b)
0
1
Threshold
ln
FN
TN
4
(c)

18
0
Threshold

Task Allocation
Given a current
set of shared
goals:
Pending tasks:
 T1, T2
Qualified tasks:
1. T2
Team member, Pi
Pending tasks:
 T1, T2, T7
Qualified tasks:
1. T1
(prioritized
)
2. T7
Team member, Pj
Pending tasks:
 T1, T2, T5
Task allocation:
T1  Pk
T2  Pi
T5  Pj
Team leader, Pk
Abstract Model of Teamwork
O1
D1
D3
O2
I1
Oi
Observation i
I2
Dj
Decision j
Ik
Intervention k
D2
DK
OM
IN
Comm. Link
Scenario 1: IV Bag Low
Scribe
Primary
nurse
CCT
IV bag
IV bag
D1
broadcast
S1
Technician
O
Physician
Comm.
D
Nurse
Comm.
A1
I
Other team
members
decide to ignore
Technician
vs.
O
D
I
Physician
Comm.
O
D
I
Nurse
Comm.
O
D
I
Model Simulation
Goals Level
Tasks Level
Procedural and Communication Level
Input:
patient scenario
Abstract Model
Simulator
Output:
simulation trace
Statistical
Analysis
Output:
identified teamwork
Problems/errors
System
(Trauma bay)
Researchers
Actors
System
(Our team)
(Trauma team)
(Patient)
System state variables:
• aspects of task management
- awareness
- start time
- execution duration
- performance quality
- loss
• degree of leadership
• communication intensity
Visual Displays
Drop-down
display
Wall display
Tablet PC 1
Nurse recorder
Tablet PC 2
Physician recorder
Main computer
From vital sign instruments
and RFID tag readers
Tablet PC 1
rse recorder
User
Visualization rules
& constraints
Collaborative
middleware
User interface
Drop-down
display
(Data entry & visualization)
Wall display
Trauma protocol
(ATLS etc.)
Object tracking
(RFID, vision)
Signal processing
& data analysis
Tablet PC 2
sician recorder
To oth
compu
Admin user interface
From vital sign instruments
and RFID tag readers
(a)
Main computer
(for modifying rules &
constraints of the protocol,
visualization, and alerting)
Shared
state
Patient data
repository
(b)
Pending Tasks Display
SpO2 = 60 %
Mouth / airway
compromised
Abstract Model (1)
Goal
STM: situation
Sensing
Decision
Action
LTM: knowledge
Shared
goals
S
D
A
Sender
Channel
modality
n-arity
Communication
S
D
A
S
Channel
D
A
Receiver
S
Sensing
D
Decision
A
Action
Abstract Model
Goal
Sensing
Decision
Action
S
D
A
S
D
A
Shared
goals
Sensing
Communication
Decision
Sender
Channel
Receiver
Communication
Action
Communication
S1
D1
D3
S2
A1
Si
Sensing i
A2
Dj
Decision j
Ak
Action k
D2
DK
SM
AN
Comm. Link
Abstract Model (2)
S1
R1
P1
S2
A1
A2
R2
Si
Sensor
Pj
Processor
Ak
Actuator
Rm
Relay
PK
SM
AN
Goals and Tasks (1)
Goals of resuscitation
Mouth open OR nose open
Tongue not obstructing airway
Trachea free
Airway patency
( Immediate threat to life )
Respiratory rate > 10 and < 29/min
Maintain perfusion
Breathing normalcy
Bilateral breath sounds
Blood oxygenation (SpO2) > 90 %
Circulation stability
External bleeding treated
( Potential threat to life )
Identify and treat injuries
Tasks (Sensing)
Inspect mouth and airway
Measure respiratory rate
Measure blood oxygenation
Measure CO2 level
Check if patient can talk lucidly
Listen for noisy breathing
Check if patient is agitated
Blood pressure > 80 mmHg
Inspect cervical spine
Heart rate normal (?)
Measure respiratory rate
Hemoglobin count normal (?)
Measure blood oxygenation
Do chest auscultation
Devise definitive care plan
Inspect for external bleeding
Inspect for thoracic bruises
Tasks (Action/Intervention)
Input information
EMS report
Put oxygen mask
Establish IV access
?
Draw blood for tests/HemoCue
Measure patient’s temperature
FAST detect abdomen bleeding
Foley catheter for urine output
Goals and Tasks (4)
Tasks (Sensing)
Can patient talk lucidly ?
Goals
Mouth and airway unobstructed ?
Noisy breathing ?
Airway patency
Agitated?
Respiratory rate < 10 or > 29/min ?
Maintain perfusion
Breathing normalcy
Circulation stability
Blood oxygenation (SpO2) < 90 % ?
Open thorax ?
Flail chest ?
Hypoveolemnia (blood loss) ?
Identify injuries
Cervical spine injuries ?
Penetrating injuries ?
Pelvic injuries ?
Devise long-term care
Blood pressure < 80 mmHg ?
Heart rate ?
Abstract Model (2)
Cognitive
processing
OUT
IN
Report if
mismatch
Hierarchy
layer i
Index of
predicted
script
Comparator
Working
script
Long-term
memory
IN
OUT
Perception
Behavior