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Aspects of the Proposed Work KeyChecker Key code_ : long checkKey() : boolean 1..* 1 KeyStorage getNext() : Key getCode() : long 1 validKeys checker Controller numOfTrials_ : long maxNumOfTrials_ : long 1 sensor PhotoSObsrv isDaylight() : boolean enterKey(k : Key) 1 LightCtrl lit_ : boolean getLit() : boolean setLit(v : boolean) 1 lightCtrl lockCtrl 1 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 SpO2 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 Tongue Nasal cavity 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