Slide Presentation from the AHRQ 2008 Annual Conference
On September 8, 2008, Li Lin, Ph.D., made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (1.6 MB; Plugin Software Help).
Development of an Immersive Simulation Environment for the Study of IT Impact in the Emergency Department
Presented by Li Lin, Ph.D.
Professor of Industrial and Systems Engineering
University at Buffalo, State University of New York
AHRQ Annual Conference—September 8, 2008
- Note: AHRQ Grant U18 HS16672-02 (Patient Safety and Simulation Research): Emergency Department Simulation for Research and Training in Health Care IT.
Background: Emergency Department (ED) Status Boards
- Dry easel board ("whiteboard") centrally located and publicly available to all ED staff.
- Information (with colors, symbols, stickers):
- Caregiver (physicians, RNs).
- Medical(symptoms, status, processes, & plans).
- Admission, discharge, transfers (ADT).
- Supports coordination, communication, workflow and tracking.
- Traditional whiteboards being replaced by computerized systems and displays
- Impact of IT use to efficiency, quality of care, flexibility, communication, patient safety and staff workload remains to be studied.
- Photograph of a white board with patient tracking.
- Manual patient tracking system.
- A screen shot of an online tracking system.
- Replaced with an electronic patient tracking system.
Impact of IT Implementation
- Technology replacements.
- Rapidly designed into the system.
- Consequences on patient care and safety.
- Important to understand impact of IT solution before implementation through testing & design.
- Simulation studies can help avert safety concerns with technology implementation and prevent adverse events due to technology use.
- IT solutions can bring financial benefits, but their impact to healthcare quality, efficiency and patient safety is issue for research.
- Need to study critical human behavioral processes and performance with technology limitations.
- Simulation can facilitate study of medical professionals' behavior and performance in a controlled lab setting.
- Challenges in creating a realistic ED by simulation.
- Operational and clinical realism.
- To develop a discrete-event simulation (of operational processes) based immersive experimental environment (i.e., the Patient Tracking System Simulator) that represents an ED white board.
- To test ED staff's performance in a dynamic ED environment using IT (contrasting different workload and designs).
- Participants: ED nurses and secretaries.
- Study to assess:
- Caregivers' awareness.
- Interruptions and distractions.
- Recovery from system failures.
- Response to critical events.
The Multi-disciplinary Research Team
- University at Buffalo
- Principal Investigator (PI): Li Lin, Ph.D., Co-I: Ann Bisantz, Ph.D. (Department of Industrial & Systems Engineering).
- Co-Investigator: Jennifer Brown, M.D. (Department of Emergency Medicine).
- Ph.D. students: Priya Pennathur and Dapeng Cao (Department of Industrial & Systems Engineering).
- University of Rochester
- R. J. "Terry" Fairbanks, M.D.
- University of Florida, Jacksonville
- Robert Wears, M.D.
- Shawna Perry, M.D. (now at Medical College of Virginia).
- Meeting the challenges:
- Operational dynamics and situation awareness—industrial engineering and human factors.
- Clinical realism—ED physicians.
- ED Simulation Control Interface.
- ED-DES Initialization using historic sample data (Patient volume, types of patients, resources, time required for resource use, treatment priority).
- Control of particular simulation parameters as needed for experiment (e.g., patient arrival rate, type of patient).
- ED-EDS Discrete Event Simulation of ED Processes.
- Patient arrival process (volume, distribution of various types of patients, trauma cases, time of arrival (incl. day of week), etc.).
- Resource utilization (physicians, RNs, nurse aides, registration clerks, beds/rooms, equipment, lab/radiology, in-patient beds, etc.).
- Resource requirements (time, equipment required for treating different complaints, lab/radiology needs and time needed).
- Patient Tracking System Simulator (PTSS).
- Displays of:
- Patient demographic information.
- Vital signs.
- Triage preliminary diag.
- Attending physicians.
- Bed/room availability.
- Responsible RNS.
- ED capacity related info (No. of patients, types of complaints, etc.).
- Patient Data Flow:
- Name: Jane Doe.
- Age: 36.
- Gender: F.
- Complaint: Knee pain.
- Location: B1.
- Physician: Dr. Y.
- Large Screen Display.
- Back to Patient Data Flow.
- Name: Jane Doe.
- Age: 36.
- Gender: F.
- Complaint: Knee pain.
- Location: X-ray.
- Physician: Dr. Y.
- Resident: Dr. H.
- Tests: X-ray.
- Back to Patient Tracking System Simulator (PTSS).
- Back to ED-DES Discrete Event Simulation of ED Processes.
Simulation for Design Support
- Iterative user-centered design.
- Systematic investigation of key design parameters.
- Simulates realistic characteristics of emergency department (ED).
- Helps evaluate usability and performance measures under no-risk lab conditions.
- Provides ED staff training in use of technologies under realistic ED conditions without compromising care and safety.
- State-of-the-art computer software that mimics operational details of complex systems.
- Pac-Man-like animated simulation conveys reality in pictures.
- Consistently ranked as one of top methods for operations analysts and industrial engineers. Models in computer represent real operations and test them for performance under different conditions.
- Most useful in studying system performance—answer "WHAT IF's" before investing and making changes.
- Widely used in manufacturing, transportation, service industries, and many other applications.
Simulation of an ED
A simulation showing:
- Admittance, Discharge, Fast Track, Sub-Total/Severity.
- Patients Entered, Currently In, Total Patients Seen/ED Main, Fast Track.
- Status of Room (Bed): Idle, In Use, Blocked, Setup.
Sample ED Discrete-event Simulation Results (1)
The line graph presents the percentage of utilization based on time for edbedutilization, low, and high.
- The data for "high" during the time frame of 14-24 when it reached highs of 105%, is circled in blue.
Sample ED Discrete-event Simulation Results (2)
The line graph presents the percentage of utilization and the number of physicians based on time for edmainPhysician, low, high, and staffing.
- The data for "high" and "edmainPhysician" during the time frame of 3-9 and 14-24 when highs reached over 100% and number of Physicians were just under 3, are circled in blue.
Building the ED Patient Tracking System Simulator (PTSS)
- Patient scripts.
- Clinical information for simulated patients in the ED.
- Pseudo patient names, age, gender, chief complaints, events and orders.
- Chief complaints.
- Severity based on hospital ED-DES.
- Clinical progress information & Medical realism.
- Scripted by physicians at relevant events.
- Validation for medical realism.
- Representing a patient record.
- Integrated into an ED Event Calendar with discrete time points for an immersive simulation experiment (simulated white board)
Example Patient Script
The document image shows a typical Patient Script.
Example Event Calendar
The document image shows a typical Event Calendar.
Patient Tracking System Simulator
The screen shot shows an opened emergency room (ER) Whiteboard page.
- Charge nurses, secretaries from emergency department.
- 10 nurses, 10 secretaries.
- Display types.
- Desktop, Large screen display.
- Demand levels (patient volume).
- Two 2-hour sessions, 1 to 2 weeks apart.
- Each session.
- 2 scenarios with varying ED demand levels.
Tasks and Measures
- Typical ED paperwork.
- Phone/pager prompts to mimic real ED tasks.
- Situation awareness measures.
- Using Situation Awareness Global Assessment Technique (SAGAT, Endsley 1995).
- Information probes.
- Identifying information updates and deviations.
- System failures or "blanking out."
- Ability to respond, recover from failure.
- Audio and screen recording.
- User-system interaction issues.
- NASA-TLX (a subjective workload assessment technique).
Experiments being completed, data analysis to begin.
- Uniqueness of our study.
- Not a mannequin simulator, but simulation of ED for assessing design issues in technology use.
- Understanding interaction, human factors measures.
- Immersive ED environment useful for staff training in technology use.
- Serves as a case of technology design for complex systems, within a controlled setting.
- Framework for use of ED simulation in future studies on IT design and use in healthcare.
- Multi-disciplinary team with industrial engineering and medical expertise in developing integrated solutions.
Current as of January 2009
Development of an Immersive Simulation Environment for the Study of IT Impact in the Emergency Department. Slide Presentation from the AHRQ 2008 Annual Conference (Text Version). January 2009.
Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/annualmtg08/090808slides/Lin.htm