Eye-tracking reveals how observation chart design features affect the detection of patient deterioration: An experimental study

Examining Care Planning Efficiency and Clinical Decision Support Adoption in a System Tailoring to Nurses' Graph Literacy: National, Web-Based Randomized Controlled Trial

BACKGROUND

The proliferation of health care data in electronic health records (EHRs) is fueling the need for clinical decision support (CDS) that ensures accuracy and reduces cognitive processing and documentation burden. The CDS format can play a key role in achieving the desired outcomes. Building on our laboratory-based pilot study with 60 registered nurses (RNs) from 1 Midwest US metropolitan area indicating the importance of graph literacy (GL), we conducted a fully powered, innovative, national, and web-based randomized controlled trial with 203 RNs.

OBJECTIVE

This study aimed to compare care planning time (CPT) and the adoption of evidence-based CDS recommendations by RNs randomly assigned to 1 of 4 CDS format groups: text only (TO), text+table (TT), text+graph (TG), and tailored (based on the RN's GL score). We hypothesized that the tailored CDS group will have faster CPT (primary) and higher adoption rates (secondary) than the 3 nontailored CDS groups.

METHODS

Eligible RNs employed in an adult hospital unit within the past 2 years were recruited randomly from 10 State Board of Nursing lists representing the 5 regions of the United States (Northeast, Southeast, Midwest, Southwest, and West) to participate in a randomized controlled trial. RNs were randomly assigned to 1 of 4 CDS format groups-TO, TT, TG, and tailored (based on the RN's GL score)-and interacted with the intervention on their PCs. Regression analysis was performed to estimate the effect of tailoring and the association between CPT and RN characteristics.

RESULTS

The differences between the tailored (n=46) and nontailored (TO, n=55; TT, n=54; and TG, n=48) CDS groups were not significant for either the CPT or the CDS adoption rate. RNs with low GL had longer CPT interacting with the TG CDS format than the TO CDS format (P=.01). The CPT in the TG CDS format was associated with age (P=.02), GL (P=.02), and comfort with EHRs (P=.047). Comfort with EHRs was also associated with CPT in the TT CDS format (P<.001).

CONCLUSIONS

Although tailoring based on GL did not improve CPT or adoption, the study reinforced previous pilot findings that low GL is associated with longer CPT when graphs were included in care planning CDS. Higher GL, younger age, and comfort with EHRs were associated with shorter CPT. These findings are robust based on our new innovative testing strategy in which a diverse national sample of RN participants (randomly derived from 10 State Board of Nursing lists) interacted on the web with the intervention on their PCs. Future studies applying our innovative methodology are recommended to cost-effectively enhance the understanding of how the RN's GL, combined with additional factors, can inform the development of efficient CDS for care planning and other EHR components before use in practice.

Advantages of graphical nutrition facts label: faster attention capture and improved healthiness judgement

Consumers have to rely on the traditional back-of-package nutrition facts label (NFL) to obtain nutrition information in many countries. However, traditional NFLs have been criticised for their poor visualisation and low efficiency. This study redesigned back-of-package NFLs integrated with bar graphs (black or coloured) to visually indicate nutrient reference values (NRVs). Two eye movement studies were performed to evaluate the ergonomic advantages of the graphical NFLs. Our findings suggested that the newly designed NFLs led to faster and better healthiness evaluation performance. The newly designed graphical labels led to a shorter time to first fixation duration and offered a higher percentage of fixation time in the nutrient reference values region compared with that observed using traditional text labels. Nowadays, many chronic diseases are associated with poor eating habits, therefore, the importance of visualisation design to nudge healthier food choices could be paid more attention to by policymakers and food manufacturers.Practitioner summary: To improve the ergonomic design of traditional nutrition facts panel (NFL), this study assessed a newly designed graphical NFL. The results showed that graphical NFL captured consumers' attention faster and improved their healthiness judgement. Moreover, a brief nutrition education can improve consumers' attention and understanding of nutrition information.

Looking beyond the laboratory: Exploring behavioral and eye-fixation patterns in individuals with severe mental illness during a real-life supermarket task

Individuals with severe mental illnesses (SMI) often have difficulty performing daily activities that require intact executive functions, such as grocery shopping. Performance-based evaluations are valuable but lack the subjects' viewpoints during task performance. This study aims to combine performance-based observation and cognitive science methods to provide insights regarding real-life behavior and problem-solving in populations with SMI. In this correlational-research study, 42 participants (10 in the SMI group and 32 in the control group) performed the Test of Grocery Shopping Skills (TOGSS) while wearing an eye-tracking device. We hypothesized that patterns in task planning, task-time use, and attention allocation to written information relevant to the task would differ between the groups during the task. The results showed between-group differences in both TOGSS efficiency outcomes (time and redundancy), duration, and number of fixations. An eye-tracking pattern analysis determined between-group differences in scanning patterns of the grocery list but similarities in task planning. The selection process was found to be significantly more accurate and efficient for the control group than for the SMI group. Our findings suggest that a combination of perspectives allows us to better understand the behavior of SMI individuals in a regular daily task.

Implementing a comprehensive newborn monitoring chart: Barriers, enablers, and opportunities

Documenting inpatient care is largely paper-based and it facilitates team communication and future care planning. However, studies show that nursing documentation remains suboptimal especially for newborns, necessitating introduction of standardised paper-based charts. We report on a process of implementing a comprehensive newborn monitoring chart and the perceptions of health workers in a network of hospitals in Kenya. The chart was launched virtually in July 2020 followed by learning meetings with nurses and the research team. This is a qualitative study involving document review, individual in-depth interviews with nurses and paediatricians and a focus group discussion with data clerks. The chart was co-designed by the research team and hospital staff then implemented using a trainer of trainers' model where the nurses-in-charge were trained on how to use the chart and they in turn trained their staff. Training at the hospital was delivered by the nurse-in-charge and/or paediatrician through a combined training with all staff or one-on-one training. The chart was well received with health workers reporting reduced writing, consolidated information, and improved communication as benefits. Implementation was facilitated by individual and team factors, complementary projects, and the removal of old charts. However, challenges arose related to the staff and work environment, inadequate supply of charts, alternative places to document, and inadequate equipment. The participants suggested that future implementation should be accompanied by mentorship or close follow-up, peer experience sharing, training at the hospital and in pre-service institutions and wider stakeholder engagement. Findings show that there are opportunities to improve the implementation process by clarifying roles relating to the filing system, improving the chart supply process, staff induction and specifying a newborn patient file. The chart did not meet the need for supporting documentation of long stay patients presenting an opportunity to explore digital solutions that might provide more flexibility and features.

Usability enhancement based on usability heuristics: An examination of the underlying mechanism utilizing the psychological-refractory-period paradigm

User Interface (UI) design practices often abide by popular usability heuristics such as Nielsen's (1994) "10 usability heuristics for user interface design" or Gerhardt-Powals' (1996) cognitive engineering principles. To examine the underlying mechanism of user performance enhancement by following some of these usability heuristics, we compared user performance between two device conditions: one representing design practices following two selected sets of usability heuristics (experimental condition) and the other without following them (control condition). As a research framework, we adopted the psychological-refractory-period (PRP) paradigm along with the locus-of-slack logic, a well-established dual-task paradigm for examining the nature of cognitive benefits caused by experimental manipulations. Results showed that the experimental-device condition that followed the usability heuristics yielded faster performance than the control condition, especially when the stimulus-onset-asynchrony between the two tasks was long than when it was short. According to the locus-of-slack logic, these results suggest that the nature of cognitive benefits caused by following the usability heuristics is more likely to be due to shortening of the response-activation stage (rather than the response-selection stage). These findings suggest that following the two usability heuristics tends to facilitate a specific stage of the information processes more than other stages.

A human factors approach to subcutaneous insulin chart design improves user-performance: An experimental study

Insulin is a high-risk medicine that has been implicated in serious adverse events for hospital inpatients, including medication-error related deaths. Most insulin errors occur during administration, and "wrong dose" is the most common type. A paper-based subcutaneous insulin chart (the "NSIC") was developed for the Australian Commission on Safety and Quality in Health Care, using a range of human factors methods, with the aim of reducing the opportunity for errors. The present lab-based study empirically assessed whether the NSIC's human factors design translates into improved user-performance in the determination of insulin doses, compared with a pre-existing chart. Forty-one experienced nurses and 48 novice chart-users completed 60 experimental trials (30 per chart), in which they determined doses to administer to patients. Both groups determined insulin doses faster, and made fewer dose errors, when using the NSIC. These results support the utility of the usability heuristics employed in developing the chart.

Eye tracking for work-related visual search: a cognitive task analysis

Cognitive Task Analysis (CTA) is an important methodology in ergonomics for studying workplaces and work patterns. Using eye tracking as a CTA methodology, this article explores visual search patterns in complex work environments and situations. It presents a simulated crime scene case study that applies eye tracking-based experiments in foraging and sense-making loops to elicit and represent knowledge on expert versus novice search patterns for complex work. The case probes the visual search task of preliminarily evaluating and documenting potential crime scene evidence. The experimental protocol relies on the ASL Mobile Eye and the analyses of experimental data include preliminary inspections of live-viewing data on eye-movements, precedence matrices detailing scan paths, and gaze charts that illustrate participants' attention based on fixation counts and durations. In line with the CTA methodology, the article uses concept maps to represent knowledge derived from different phases of the study. The article also discusses the research implications and methodologically reflects on the case study. Practitioner summary: This study offers valuable insights for work design. The use of eye tracking as a CTA methodology offers potentials for translating visual search tasks into defined visual search concepts for complex work environments and situations. The ability to model visual attention is valuable for work designs that improve complex work performance, reduce work stress, and promote work satisfaction.

Designing paper-based records to improve the quality of nursing documentation in hospitals: A scoping review

BACKGROUND

Inpatient nursing documentation facilitates multi-disciplinary team care and tracking of patient progress. In both high- and low- and middle-income settings, it is largely paper-based and may be used as a template for electronic medical records. However, there is limited evidence on how they have been developed.

OBJECTIVE

To synthesise evidence on how paper-based nursing records have been developed and implemented in inpatient settings to support documentation of nursing care.

DESIGN

A scoping review guided by the Arksey and O'Malley framework and reported using PRISMA-ScR guidelines.

ELIGIBILITY CRITERIA

We included studies that described the process of designing paper-based inpatient records and excluded those focussing on electronic records. Included studies were published in English up to October 2019.

SOURCES OF EVIDENCE

PubMed, CINAHL, Web of Science and Cochrane supplemented by free-text searches on Google Scholar and snowballing the reference sections of included papers.

RESULTS

12 studies met the eligibility criteria. We extracted data on study characteristics, the development process and outcomes related to documentation of inpatient care. Studies reviewed followed a process of problem identification, literature review, chart (re)design, piloting, implementation and evaluation but varied in their execution of each step. All studies except one reported a positive change in inpatient documentation or the adoption of charts amid various challenges.

CONCLUSIONS

The approaches used seemed to work for each of the studies but could be strengthened by following a systematic process. Human-centred Design provides a clear process that prioritises the healthcare professional's needs and their context to deliver a usable product. Problems with the chart could be addressed during the design phase rather than during implementation, thereby promoting chart ownership and uptake since users are involved throughout the design. This will translate to better documentation of inpatient care thus facilitating better patient tracking, improved team communication and better patient outcomes.

RELEVANCE TO CLINICAL PRACTICE

Paper-based charts should be designed in a systematic and clear process that considers patient's and healthcare professional's needs contributing to improved uptake of charts and therefore better documentation.

Social representations and interface layout: A new way of enhancing persuasive technology applied to organ donation

Although campaigns promoting organ donation have proved their effectiveness, increasing the number of people who explicitly agree to become donors is still difficult. Based on the social marketing notion of persuasive technology, we reasoned that it was timely to focus on the design of this persuasive technology and to analyze its contribution in particularly challenging contexts such as organ donation. More specifically, the originality of the present study lay in the way we linked the field of persuasive technology to the theory of social representations, and combined them with an analysis of the ergonomic aspects of interface layout. This study had two complementary goals. The first was to determine whether the sociocognitive salience of the central elements of social representations (i.e., the most frequent and important themes related to the subject-here, organ donation-for individuals), can be used to achieve persuasive outcomes. The second was to determine whether interface layout, in terms of information location and background characteristics (color and contrast), can strengthen the persuasive impact. University students (N > 200) were exposed to a computer screen displaying a message involving either central or peripheral elements of the social representations of organ donation (status), placed either in the middle or on one side of the screen (location), and shown against either a white or a blue background (background). Eye-tracking data were recorded, in addition to self-reported data. In line with the elaboration likelihood model, results showed that participants who were exposed to central (vs. peripheral) elements of the social representations of organ donation followed the central route in processing information. Moreover, they had stronger attitudes, and more of them stated that they were actual organ donors. Importantly, however, at least for some variables, these status-related effects were not independent of the interface layout. More specifically, the persuasive impact of the central elements was enhanced when the information was displayed in the middle (vs. the side) of the screen and when it was displayed on a white (vs. blue) background. We discuss the theoretical and practical issues raised by these results.

Developing a sociocultural framework of compliance: an exploration of factors related to the use of early warning systems among acute care clinicians

Background

Early warning systems (EWS) are most effective when clinicians monitor patients’ vital signs and comply with the recommended escalation of care protocols once deterioration is recognised.

Objectives

To explore sociocultural factors influencing acute care clinicians’ compliance with an early warning system commonly used in Queensland public hospitals in Australia.

Methods

This interpretative qualitative study utilised inductive thematic analysis to analyse data collected from semi-structured interviews conducted with 30 acute care clinicians from Queensland, Australia.

Results

This study identified that individuals and teams approached compliance with EWS in the context of 1) the use of EWS for patient monitoring; and 2) the use of EWS for the escalation of patient care. Individual and team compliance with monitoring and escalation processes is facilitated by intra and inter-professional factors such as acceptance and support, clear instruction, inter-disciplinary collaboration and good communication. Noncompliance with EWS can be attributed to intra and inter-professional hierarchy and poor communication.

Conclusions

The overarching organisational context including the hospital’s embedded quality improvement and administrative protocols (training, resources and staffing) impact hospital-wide culture and influence clinicians’ and teams’ compliance or non-compliance with early warning system’s monitoring and escalation processes. Successful adoption of EWS relies on effective and meaningful interactions among multidisciplinary staff.

Predicting clinical deterioration with Q-ADDS compared to NEWS, Between the Flags, and eCART track and trigger tools

BACKGROUND

Early warning tools have been widely implemented without evidence to guide (a) recognition and (b) response team expertise optimisation. With growing databases from MET-calls and digital hospitals, we now have access to guiding information. The Queensland Adult-Deterioration-Detection-System (Q-ADDS) is widely used and requires validation.

AIM

Compare the accuracy of Q-ADDS to National Early Warning Score (NEWS), Between-the-Flags (BTF) and the electronic Cardiac Arrest Risk Triage Score (eCART)).

METHODS

Data from the Chicago University hospital database were used. Clinical deterioration was defined as unplanned admission to ICU or death. Currently used NEWS, BTF and eCART trigger thresholds were compared with a clinically endorsed Q-ADDS variant.

RESULTS

Of 224,912 admissions, 11,706 (5%) experienced clinical deterioration. Q-ADDS (AUC 0.71) and NEWS (AUC 0.72) had similar predictive accuracy, BTF (AUC 0.64) had the lowest, and eCART (AUC 0.76) the highest. Early warning alert (advising ward MO review) had similar NPV (99.2-99.3%), for all the four tools however sensitivity varied (%: Q-ADDS = 47/NEWS = 49/BTF = 66/eCART = 40), as did alerting rate (% vitals sets: Q-ADDS = 1.4/NEWS = 3.5/BTF = 4.1/eCART = 3.4). MET alert (advising MET/critical-care review) had similar NPV for all the four tools (99.1-99.2%), however sensitivity varied (%: Q-ADDS = 14/NEWS = 24/BTF = 19/eCART = 29), as did MET alerting rate (%: Q-ADDS = 1.4/NEWS = 3.5/BTF = 4.1/eCART = 3.4). High-severity alert (advising advanced ward review, Q-ADDS only): NPV = 99.1%, sensitivity = 26%, alerting rate = 3.5%.

CONCLUSION

The accuracy of Q-ADDS is comparable to NEWS, and higher than BTF, with eCART being the most accurate. Q-ADDS provides an additional high-severity ward alert, and generated significantly fewer MET alerts. Impacts of increased ward awareness and fewer MET alerts on actual MET call numbers and patient outcomes requires further evaluation.