Video capture of clinical care to enhance patient safety

Using body cameras to quantify the duration of a Code Stroke and identify workflow issues: a continuous observation workflow time study

OBJECTIVE

'Code Stroke' (Code) is used in health services to streamline hyperacute assessment and treatment delivery for patients with ischaemic stroke. However, there are few studies that detail the time spent on individual components performed during a Code. We sought to quantify the time taken for each process during a Code and investigate associations with modifiable and non-modifiable factors.

DESIGN

Continuous observation workflow time study.

SETTING AND PARTICIPANTS

Recordings of 100 Codes were performed at a high-volume primary stroke centre in Melbourne, Australia, between January and June 2020 using a body camera worn by a member of the stroke team.

MAIN OUTCOME MEASURES

The main measures included the overall duration of Codes and the individual processes within the Code workflow. Associations between variables of interest and process times were explored using linear regression models.

RESULTS

100 Codes were captured, representing 19.2% of all Codes over the 6 months. The median duration of a complete Code was 54.2 min (IQR 39.1-74.7). Administrative work performed after treatment is completed (median 21.0 min (IQR 9.8-31.4)); multimodal CT imaging (median 13.0 min (IQR 11.5-15.7)), and time between decision and thrombolysis administration (median 8.1 min (IQR 6.1-10.8)) were the longest components of a Code. Tenecteplase was able to be prepared faster than alteplase (median 1.8 vs 4.9 min, p=0.02). The presence of a second junior doctor was associated with shorter administrative work time (median 10.3 vs 25.1 min, p<0.01). No specific modifiable factors were found to be associated with shorter overall Code duration.

CONCLUSIONS

Codes are time intensive. Time spent on decision-making was a relatively small component of the overall Code duration. Data from body cameras can provide granular data on all aspects of Code workflow to inform potential areas for improvement at individual centres.

Addressing the Challenges of Conducting Observational Studies in Sheep Abattoirs

Simple Summary

Collecting data, particularly data on animal behavior, on-site at abattoirs, can be hindered by a series of challenges. These challenges are summarized and recommendations are offered for those planning similar studies. Particular emphasis is placed on examining interactions between dogs, handlers and sheep in animal-processing facilities because this is a significantly under-researched area in the literature. There is significant merit in collecting data via video-recording software, but the subsequent potential for hardware issues and sampling difficulties must be recognized and addressed.

Abstract

The competing needs of maintaining productivity within abattoirs, and maintaining high standards of animal welfare, provide fertile grounds for applied research in animal behavior. However, there are challenges involved in capturing useful behavioral data from the supply chain (from paddock to processing plant). The challenges identified in this report are based on a review of the scientific literature as well as field study observations. This article describes those challenges as they relate to collecting behavioral data on livestock-herding dogs, humans and livestock as they interact in abattoirs, and provides insights and recommendations for others embarking on animal studies in confined spaces, as well as in commercial settings. Direct observation of livestock behavior permits animal-welfare assessments and evaluations of the efficacy of operations in unfamiliar and high-pressure contexts, such as abattoirs. This brief report summarizes the factors that must be considered when undertaking in situ studies in abattoirs. There is merit in passive behavioral data-collection using video-recording equipment. However, the potential for hardware issues and sampling difficulties must be anticipated and addressed. Future research directions and recommendations to avoid such issues are discussed. This information will be highly beneficial to future abattoir studies focusing on efficiency and animal welfare at commercial abattoirs. Furthermore, it may also be relevant to any analyses involving large cohorts of animals in a confined environment.

Is it acceptable to video-record palliative care consultations for research and training purposes? A qualitative interview study exploring the views of hospice patients, carers and clinical staff

BACKGROUND

Research using video recordings can advance understanding of healthcare communication and improve care, but making and using video recordings carries risks.

AIM

To explore views of hospice patients, carers and clinical staff about whether videoing patient-doctor consultations is acceptable for research and training purposes.

DESIGN

We used semi-structured group and individual interviews to gather hospice patients, carers and clinical staff views. We used Braun and Clark's thematic analysis.

SETTING/PARTICIPANTS

Interviews were conducted at one English hospice to inform the development of a larger video-based study. We invited patients with capacity to consent and whom the care team judged were neither acutely unwell nor severely distressed (11), carers of current or past patients (5), palliative medicine doctors (7), senior nurses (4) and communication skills educators (5).

RESULTS

Participants viewed video-based research on communication as valuable because of its potential to improve communication, care and staff training. Video-based research raised concerns including its potential to affect the nature and content of the consultation and threats to confidentiality; however, these were not seen as sufficient grounds for rejecting video-based research. Video-based research was seen as acceptable and useful providing that measures are taken to reduce possible risks across the recruitment, recording and dissemination phases of the research process.

CONCLUSION

Video-based research is an acceptable and worthwhile way of investigating communication in palliative medicine. Situated judgements should be made about when it is appropriate to involve individual patients and carers in video-based research on the basis of their level of vulnerability and ability to freely consent.

A Prospective Randomized Study to Evaluate a New Learning Tool for Ultrasound-Guided Regional Anesthesia

Objective

To evaluate the effectiveness of a new learning tool for needle insertion accuracy skills during a simulated ultrasound-guided regional anesthesia procedure.

Methods

Thirty participants were included in this randomized controlled study. After viewing a prerecorded video of a single, discreet, ultrasound-guided regional anesthesia task, all participants performed the same task three consecutive times (pretest), and needle insertion accuracy skills in a phantom model were recorded as baseline. All participants were then randomized into two groups, experimental and control. The experimental group practiced the task using the new tool, designed with two video cameras, a monitor, and an ultrasound machine where the images from the ultrasound and video of hand movements are viewed simultaneously on the monitor. The control group practiced the task without using the new tool. After the practice session, both groups repeated the same task and were evaluated in the same manner as in the pretest.

Results

Participants in both group groups had similar baseline characteristics with respect to previous experience with ultrasound-guided regional anesthesia procedures. The experimental group had significantly better needle insertion accuracy scores ( P  < 0.01) than the control group. Using the new learning tool, inexperienced participants had better needle insertion accuracy scores ( P  < 0.01) compared with experienced participants.

Conclusions

This study demonstrates that the use of this new learning tool results in short-term improvement in hand-eye, motor, and basic needle insertion skills during a simulated ultrasound-guided regional anesthesia procedure vs traditional practice methods. Skill improvement was greater in novices compared with experienced participants.

The utility of live video capture to enhance debriefing following transcatheter aortic valve replacement

Background:

The surgical and procedural specialties are continually evolving their methods to include more complex and technically difficult cases. These cases can be longer and incorporate multiple teams in a different model of operating room synergy. Patients are frequently older, with comorbidities adding to the complexity of these cases. Recording of this environment has become more feasible recently with advancement in video and audio capture systems often used in the simulation realm.

Aims:

We began using live capture to record a new procedure shortly after starting these cases in our institution. This has provided continued assessment and evaluation of live procedures. The goal of this was to improve human factors and situational challenges by review and debriefing.

Setting and Design:

B-Line Medical's LiveCapture video system was used to record successive transcatheter aortic valve replacement (TAVR) procedures in our cardiac catheterization/laboratory. An illustrative case is used to discuss analysis and debriefing of the case using this system.

Results and Conclusions:

An illustrative case is presented that resulted in long-term changes to our approach of these cases. The video capture documented rare events during one of our TAVR procedures. Analysis and debriefing led to definitive changes in our practice. While there are hurdles to the use of this technology in every institution, the role for the ongoing use of video capture, analysis, and debriefing may play an important role in the future of patient safety and human factors analysis in the operating environment.

Perceived versus Observed Patient Safety Measures in a Critical Care Unit from a Teaching Hospital in Southern Colombia

Introduction. Patient safety is an important topic. The purpose of this study is to evaluate the perceived versus observed patient safety measures (PSM) in critically ill patients in a teaching hospital in Latin America. Materials and Methods. The level of perceived patient safety was evaluated with the patient safety hospital survey. Three months later, a qualitative study was conducted, including video recording of procedures, graded according to adherence to PSM. Levels of adherence were scored during patient mobilization (PM), placement of central catheters (PCC), other invasive procedures (OIP), infection control (IC), and endotracheal intubation (ETI). Results. The perceived adherence of PSM in the prestudy survey was considered fair by 89.1% of the ICU staff. After the survey, 829 ICU procedures were video-recorded. Mean observed adherence for fair patient safety measures was 20.8%. Perceived adherence was higher than the real patient safety protocol measures observed in the videos. Conclusion. Perception of PSM was higher than observed in the management of critically ill patients in a teaching hospital in southern Colombia.

Observation for assessment of clinician performance: a narrative review

BACKGROUND

Video recorded and in-person observations are methods of quality assessment and monitoring that have been employed in high risk industries. In the medical field, observations have been used to evaluate the quality and safety of various clinical processes. This review summarises studies utilising video recorded or in-person observations for assessing clinician performance in medicine and surgery.

METHODS

A search of MEDLINE (PubMed) was conducted using a combination of medical subject headings (MeSH) terms. Articles were included if they described the use of in-person or video recorded observations to assess clinician practices in three categories: (1) teamwork and communication between clinicians; (2) errors and weaknesses in practice; and (3) compliance and adherence to interventions or guidelines.

RESULTS

The initial search criteria returned 3215 studies, 223 of which were identified for full text review. A total of 69 studies were included in the final set of literature. Observations were most commonly used in data dense and high risk environments, such as the emergency department or operating room. The most common use was for assessing teamwork and communication factors.

CONCLUSIONS

Observations are useful for the improvement of healthcare delivery through the identification of clinician lapses and weaknesses that affect quality and safety. Limitations of observations include the Hawthorne effect and the necessity of trained observers to capture and analyse the notes or videos. The comprehensive, subtle and sensitive information observations provided can supplement traditional quality assessment methods and inform targeted interventions to improve patient safety and the quality of care.

A Data Hiding Technique to Synchronously Embed Physiological Signals in H.264/AVC Encoded Video for Medicine Healthcare

The recognition of clinical manifestations in both video images and physiological-signal waveforms is an important aid to improve the safety and effectiveness in medical care. Physicians can rely on video-waveform (VW) observations to recognize difficult-to-spot signs and symptoms. The VW observations can also reduce the number of false positive incidents and expand the recognition coverage to abnormal health conditions. The synchronization between the video images and the physiological-signal waveforms is fundamental for the successful recognition of the clinical manifestations. The use of conventional equipment to synchronously acquire and display the video-waveform information involves complex tasks such as the video capture/compression, the acquisition/compression of each physiological signal, and the video-waveform synchronization based on timestamps. This paper introduces a data hiding technique capable of both enabling embedding channels and synchronously hiding samples of physiological signals into encoded video sequences. Our data hiding technique offers large data capacity and simplifies the complexity of the video-waveform acquisition and reproduction. The experimental results revealed successful embedding and full restoration of signal's samples. Our results also demonstrated a small distortion in the video objective quality, a small increment in bit-rate, and embedded cost savings of −2.6196% for high and medium motion video sequences.

Using video-based observation research methods in primary care health encounters to evaluate complex interactions

OBJECTIVE

The purpose of this paper is to describe the use of video-based observation research methods in primary care environment and highlight important methodological considerations and provide practical guidance for primary care and human factors researchers conducting video studies to understand patient-clinician interaction in primary care settings.

METHODS

We reviewed studies in the literature which used video methods in health care research, and we also used our own experience based on the video studies we conducted in primary care settings.

RESULTS

This paper highlighted the benefits of using video techniques, such as multi-channel recording and video coding, and compared "unmanned" video recording with the traditional observation method in primary care research. We proposed a list that can be followed step by step to conduct an effective video study in a primary care setting for a given problem. This paper also described obstacles, researchers should anticipate when using video recording methods in future studies.

CONCLUSION

With the new technological improvements, video-based observation research is becoming a promising method in primary care and HFE research. Video recording has been under-utilised as a data collection tool because of confidentiality and privacy issues. However, it has many benefits as opposed to traditional observations, and recent studies using video recording methods have introduced new research areas and approaches.

Survey of WBSNs for Pre-Hospital Assistance: Trends to Maximize the Network Lifetime and Video Transmission Techniques

This survey aims to encourage the multidisciplinary communities to join forces for innovation in the mobile health monitoring area. Specifically, multidisciplinary innovations in medical emergency scenarios can have a significant impact on the effectiveness and quality of the procedures and practices in the delivery of medical care. Wireless body sensor networks (WBSNs) are a promising technology capable of improving the existing practices in condition assessment and care delivery for a patient in a medical emergency. This technology can also facilitate the early interventions of a specialist physician during the pre-hospital period. WBSNs make possible these early interventions by establishing remote communication links with video/audio support and by providing medical information such as vital signs, electrocardiograms, etc. in real time. This survey focuses on relevant issues needed to understand how to setup a WBSN for medical emergencies. These issues are: monitoring vital signs and video transmission, energy efficient protocols, scheduling, optimization and energy consumption on a WBSN.

Using video capture to investigate the causes of falls in long-term care

PURPOSE

Falls and their associated injuries represent a significant cost and care burden in long-term care (LTC) settings. The evidence base for how and why falls occur in LTC, and for the design of effective interventions, is weakened by the absence of objective data collected on falls.

DESIGN AND METHODS

In this article, we reflect on the potential utility of video footage in fall investigations. In particular, we report on findings from a Canadian Institute for Health Research-funded research project entitled "Technology for Injury Prevention in Seniors," detailing 4 distinct methodological approaches where video footage of real-life falls was used to assist in identifying the circumstances and contributory factors of fall events in LTC: questionnaire-driven observational group analysis; video-stimulated recall interviews and focus groups; video observations of the resident 24hr before the fall; and video incorporated within a comprehensive systemic falls investigative method.

RESULTS AND IMPLICATIONS

We describe various ways in which video footage offers potential for both care providers and researchers to help understand the cause and prevention of falls in LTC. We also discuss the limitations of using video in fall investigations, including the logistical, practical, and ethical concerns arising from such an approach.

Implications of the law on video recording in clinical practice

BACKGROUND

Technological developments allow for a variety of applications of video recording in health care, including endoscopic procedures. Although the value of video registration is recognized, medicolegal concerns regarding the privacy of patients and professionals are growing. A clear understanding of the legal framework is lacking. Therefore, this research aims to provide insight into the juridical position of patients and professionals regarding video recording in health care practice.

METHODS

Jurisprudence was searched to exemplify legislation on video recording in health care. In addition, legislation was translated for different applications of video in health care found in the literature.

RESULTS

Three principles in Western law are relevant for video recording in health care practice: (1) regulations on privacy regarding personal data, which apply to the gathering and processing of video data in health care settings; (2) the patient record, in which video data can be stored; and (3) professional secrecy, which protects the privacy of patients including video data. Practical implementation of these principles in video recording in health care does not exist.

CONCLUSION

Practical regulations on video recording in health care for different specifically defined purposes are needed. Innovations in video capture technology that enable video data to be made anonymous automatically can contribute to protection for the privacy of all the people involved.

TADAA: Towards Automated Detection of Anaesthetic Activity

BACKGROUND

Task analysis is a valuable research method for better understanding the activity of anaesthetists in the operating room (OR), providing evidence for designing and evaluating improvements to systems and processes. It may also assist in identifying potential error paths to adverse events, ultimately improving patient safety. Human observers are the current 'gold standard' for capturing task data, but they are expensive and have cognitive limitations.

OBJECTIVES

Towards Automated Detection of Anaesthetic Activity (TADAA)--aims to produce an automated task analysis system, employing Radio Frequency Identification (RFID) technology to capture anaesthetists' location, orientation and stance (LOS). This is the first stage in a scheme for automatic detection of activity.

METHODS

Active RFID tags were attached to anaesthetists and various objects in a high fidelity OR simulator, and anesthetic procedures performed. The anaesthetists' LOSs were calculated using received signal strength (RSS) measurements combined with machine learning tools including Self-Organizing Maps (SOMs). These LOSs were compared to those derived from video recordings.

RESULTS

SOM clustering was effective at determining anaesthetists' LOS from RSS data for each procedure. However cross-procedure comparison was less reliable,probably because of changes in the environment.

CONCLUSIONS

Active RFID tags provide potentially useful information on LOS at a low cost and with minimal impact on the work environment. Machine learning techniques may be employed to handle the variable nature of RFID's radio signals. Work on mapping LOS data to activities will involve integration with other sensors and task analysis techniques.

Teamwork and communication in the operating room: relationship to discrete outcomes and research challenges

The literature defining and addressing teamwork and communication is abundant; however, few studies have analyzed the relationship between measures of teamwork and communication and quantifiable outcomes. The objectives of this review are: (1) to identify studies addressing teamwork and communication in the operating room in relation to discrete measures of outcome, (2) to create a classification of studies of the relationship between teamwork and communication and outcomes, (3) to assess the implications of these studies, (4) to explore the methodological challenges of teamwork and communication studies in the perioperative setting, and (5) to suggest future research directions.studies in the perioperative setting, and (5) to suggest future research directions.

Measuring the impact of the computer on the consultation: an open source application to combine multiple observational outputs

A diverse range of tools and techniques can be used to observe the clinical consultation and the use of information technology. These technologies range from transcripts; to video observation with one or more cameras; to voice and pattern recognition applications. Currently, these have to be observed separately and there is limited capacity to combine them. Consequently, when multiple methods are used to analyse the consultation a significant proportion of time is spent linking events in one log file (e.g. mouse movements and keyboard use when prescribing alerts appear) with what was happening in the consultation at that time. The objective of this study was to develop an application capable of combining and comparing activity log-files and with facilities to view simultaneously all data relating to any time point or activity. Interviews, observations and design prototypes were used to develop a specification. Class diagram of the application design was used to make further development decisions. The application development used object-orientated design principles. We used open source tools; Java as the programming language and JDeveloper as the development environment. The final output is log file aggregation (LFA) tool which forms part of the wider aggregation of log files for analysis (ALFA) open source toolkit ( www.biomedicalinformatics.info/alfa/ ). Testing was done using sample log files and reviewed the application's utility for analysis of the consultation activities. Separation of the presentation and functionality in the design stage enabled us to develop a modular and extensible application. The application is capable of converting and aggregating several log files of different formats and displays them in different presentation layouts. We used the Java Media Framework to aggregate video channels. Java extensible mark-up language (XML) package facilitated the conversion of aggregated output into XML format. Analysts can now move easily between observation tools and find all the data related to an activity. The LFA application makes new analysis tasks feasible and established tasks much more efficient. Researchers can now store multiple log file data as a single file isolate and investigate different doctor-computer-patient interaction.

A quantitative study of disruption in the operating room during laparoscopic antireflux surgery

BACKGROUND

Many activities performed by team members in the operating room (OR) are not directly related to the achievement of the surgical goal.

METHODS

A video-aided observational field study was conducted in the OR to examine disruptive events during laparoscopic antireflux surgery. Disruptive events were categorized into one of six groups: instrument change, surgeon position change, nurse duty shift, conversation, phone/pager answering, and extraneous interruption. The frequency and duration of each type of disruptive event were recorded. Events were further categorized based on whether or not they delayed the workflow.

RESULTS

The average procedure time of 12 observed cases was 123 min. On average, a total of 114 disruptive events were recorded per hour. Intraoperative conversations were recorded with the highest frequency (71 episodes/h) and longest duration (16 min/h); however, most conversations did not delay surgical workflow. The events that generated most surgical delays were instrument change (3.4 min/h), which included times for placing essential instruments into the surgical site and time spent waiting for an unavailable instrument. On average, disruptive events performed in the OR caused 4.1 min of delay for each case per hour, corresponding to 6.5% of the procedure time.

CONCLUSIONS

This study demonstrated the feasibility of using video-aided observational studies for developing objective assessment of team quality in the OR. Categorizing disruptive events and examining their negative impact on the OR time will help to develop methods to eliminate inefficiency inside the OR.

Video as a Tool for Improving Tracheal Intubation Tasks for Emergency Medical and Trauma Care

STUDY OBJECTIVE

We illustrate how audio-video data records can improve emergency medical care, using airway management to show how such video data may help to identify unsafe acts, accident precursors, and latent and systems failures and to evaluate performance.

METHODS

This was a retrospective analysis of videos of real patient resuscitation in a trauma center. Participant care providers reviewing their own videos of tracheal intubation identified failures to use diagnostic equipment, fixation errors, and team and communication errors.

RESULTS

Neutral expert observers noted team coordination failures and poor error recovery. Comparison with a consensus guideline for a tracheal intubation task/communication pathway showed that communications were unclear or not made, and key tasks were omitted by team members. Differences were detected between performance of tracheal intubation in elective and emergency circumstances. Revised practices ("3 Cs": clinical examination, communication, carbon dioxide) mitigated task performance and communication deficiencies.

CONCLUSION

Video is complementary to traditional quality improvement methods for improving performance in airway management and emergency medical and trauma care, assessing standard operating procedures, and reviewing communications. Video data identify performance details not found in quality improvement approaches, including medical record review or recall by participant care providers. Weaknesses in using video for data include lengthy video review processes, poor audio, and the inability to adequately analyze events outside the field of view. Opportunities are to use video audit for quality improvement of other emergency tasks. Video buffering reduces personnel requirements for capture and simplifies data extraction. Medicolegal and confidentiality threats are significant.

A framework for comparing video methods used to assess the clinical consultation: a qualitative study

BACKGROUND

Single-channel video is an established method for assessing clinical consultation in training general practitioners; however, it is hard to infer the body language of the doctor or how information in the consultation is being integrated into the medical record. A three-channel video was developed combining the conventional view with a camera looking at the doctor's facial expression and copying the video output from the monitor. However, the choice of three channels and camera angles selected has not been critically appraised.

OBJECTIVE

To develop criteria for comparing single and multi-channel approaches to video recording of the consultation.

METHODS

Single channel and three-channel recordings of simulated consultations were shown to a panel of 12 health professionals and interviews were conducted to gather their opinions on the level of information presented, quality and assessment. The transcripts were analysed thematically.

RESULTS

It was found that in providing visual information the three-channel video was superior to the single channel video. The major elements needed for comparison of the two techniques would be the ability of the video to pick up quantifiable non-verbal communication of the doctor and the patient, and the ability to qualitatively and quantitatively reflect the use and impact of the computer on the consultation. The information provided by the three-channel video could be further classified to essential, desirable and redundant to guide the future development of the multi-channel video.

CONCLUSIONS

Multi-channel methods should be able to capture the following information: body language and facial expression of doctor and patient; and how the doctor's knowledge and information collected in the consultation are synthesized into the medical record.

Comparison of anaesthetists' activity patterns in the operating room and during simulation

This study investigated the behavioural aspects of ecological validity of anaesthesia simulation environments using a task analysis approach. Six anaesthesists were observed during two cases performed in the operating room (OR), one routine and two critical incident simulation scenarios. A two-way MANOVA for repeated measures was performed with the independent variables Case (OR/SIM-R/SIM-CI) and Phase Induction/ Maintenance (Emergence), the latter being a repeated measure. Dependent variables were the proportion of each phase spent on each of the observation categories. Statistically significant main effects for Phase concerning communication, monitoring, manual tasks and documentation, for Case concerning communication and documentation, and a significant interaction effect for Phase x Case concerning manual tasks and other were found. Increased action density (i.e. amount of co-occurring activities) was observed during Induction, Emergence and the Management of simulated critical events. The similarities and differences in anaesthetists' activity patterns identified in this study will help to further improve the ecological validity of simulation environments as research settings.

A prospective study of patient safety in the operating room

BACKGROUND

To better understand the operating room as a system and to identify system features that influence patient safety, we performed an analysis of operating room patient care using a prospective observational technique.

METHODS

A multidisciplinary team comprised of human factors experts and surgeons conducted prospective observations of 10 complex general surgery cases in an academic hospital. Minute-to-minute observations were recorded in the field, and later coded and analyzed. A qualitative analysis first identified major system features that influenced team performance and patient safety. A quantitative analysis of factors related to these systems features followed. In addition, safety-compromising events were identified and analyzed for contributing and compensatory factors.

RESULTS

Problems in communication and information flow, and workload and competing tasks were found to have measurable negative impact on team performance and patient safety in all 10 cases. In particular, the counting protocol was found to significantly compromise case progression and patient safety. We identified 11 events that potentially compromised patient safety, allowing us to identify recurring factors that contributed to or mitigated the overall effect on the patient's outcome.

CONCLUSIONS

This study demonstrates the role of prospective observational methods in exposing critical system features that influence patient safety and that can be the targets for patient safety initiatives. Communication breakdown and information loss, as well as increased workload and competing tasks, pose the greatest threats to patient safety in the operating room.