measuring shared situational awareness at a swedish trauma …€¦ · measuring shared situational...

Measuring Shared Situational Awareness at aSwedish trauma centre

Alexander YnglingRoyal Institute of Technology

Media Technology and Interaction DesignLindstedtsvagen 5100 44 Stockholm

Swedenwww.kth.se

[email protected]

Marcus NilssonRoyal Institute of Technology


Swedenwww.kth.se

[email protected]

Kristina GrothRoyal Institute of Technology


[email protected]

This paper describes a situation in trauma care, which we feel deserves more attention from HCI research.A series of studies was conducted to measure the level of situational awareness within 14 teams (145participants) working on trauma exercises at a Swedish trauma centre. Data was collected throughquestionnaires filled in by all participants, and responses have been analyzed together with transcriptions ofthe video recordings made at each exercise. Our findings show a Fleiss’ kappa of 0.495 over the entiredataset, a strong indicator of opportunities for improvement. We present in detail how the study wasconducted, and discuss opportunities for moving forward.

Interactive systems in healthcare, Designing for collaboration, Socio-technical systems

1. INTRODUCTION

Figure 1: The emergency room at Karolinska UniversityHospital, Huddinge.

Consider Figure 1. It shows a typical situationin trauma care, with medical personnel scurryingaround, working to stabilise the patient and savehis or her life. The image is from a traumaexercise at Karolinska in Huddinge (”Huddinge”),Sweden, one of the two departments we workwith at Karolinska University Hospital. The otherdepartment is Karolinska in Solna (”Solna”). Thelatter is designated as the most advanced traumacentre in Sweden, handling more cases than otherhospitals, and especially difficult ones. The researchbeing undertaken stems from a political motivationin Sweden to improve trauma care at locationslacking Solna’s experience (e.g. rural hospitals orsoldiers on foreign peacekeeping missions) throughtelemedicine. The experienced team at Solna isplanned to be made available to other institutionsthrough a video link (Tachakra, Jaye, Bak, Hayesand Sivakumar, 2000), and the Trauma Leader (i.e.the main authority in the room with the patient) cancommunicate with this team to receive support.

c© The Authors. Published by BISL. 1Proceedings of . . .

Measuring Shared Situational Awareness at a Swedish trauma centreYngling • Nilsson • Groth

A question that emerged in the early phase ofour work was one of situational awareness. If thesupporting expert team at Solna does not have agood grasp of the situation, including how personnelon the scene understand the situation, they may notbe able to provide good support. In fact, it may evenbe dangerous.

The focus of our research group is not only onremote support for trauma centres, but also onthe situational awareness shared within the teamworking on the patient (which is the topic of thispaper). The two may be connected, as the goalwould be to arrive at a socio-technical system thatenables the remote supporter to be part of the on-site team. If the level of situational awareness of theremote supporter would ever match that of the on-site personnel, one could claim that the quality ofcare would at least not have a detrimental effect, andthe expertise of the remote supporter would likelymean the quality of care would increase.

This paper discusses our findings on sharedsituational awareness in the trauma room atHuddinge (i.e. not including the remote expert). Ourmotivation for generating this data is to give usa baseline to compare against in future projectswhen we introduce new technology or changes intheir processes, but we also believe the data tobe interesting on its own. Our goal is not only toarrive at a socio-technical system where the remotesupporter has the situational awareness to providequality care to the patient (a requirement that isdeemed very important), but at a system that alsoimproves the situational awareness of the team onsite with the patient.

The rest of the paper is organised as follows: Firstwe briefly discuss concepts in situational awareness,introducing terms that we will be using later on andgiving some general background on the subject.Following that, we will explain the methods we haveemployed in collecting data and analysis. We then goon to present our results. Lastly, we end the paperwith a discussion.

2. BACKGROUND

This study can be seen in context with workdone in collaborative sense making and informationseeking (Paul and Reddy, 2010,R), where studieswere done at a hospital’s emergency departments.Whereas their studies were ethnographic, focusingon observations and interviews, this study centerson the use of a questionnaire to measure sharedsituational awareness, and the level of consensuswithin each team (Gutwin and Greenberg, 2002).Also, within medicine and IT there have been

an ongoing focus to improve collaboration andsituational awareness between multidisciplinaryteams (Reddy, Paul, Abraham, McNeese, DeFlitchand, Yen, 2009,M), something our work attempts tocontribute to.

Medical systems are an interesting and complexarea for interaction designers (Randell, Wilson andFitzpatrick, 2010). It naturally shares many traitswith other environments where different disciplinescollaborate to some kind of common goal (Reddy,Dourish and Pratt, 2001,M). Work in health care,however, does have some unique aspects, whichcomplicates the design process (Jansson, Mortbergand Mirijamdotter, 2008,F). Design choices have amuch clearer connection to people’s health and in itsmost extreme situation have a real effect on life anddeath for patients. Different kinds of communicationis used for the flow of information in health careand the problems in this area have been looked onfrom many different perspectives (Leonard, 2004,H).Correct flow of information and understanding of thestructure is even more important when designing fortime-critical situations (Landgren, 2006,B) such astrauma treatments in healthcare (Sarcevic, Palenand Burd, 2011).

Situational Awareness is a concept that can berelevant on many levels. Each individual has a levelof situational awareness related to his or her task,and together a team of individuals has a level ofTeam Situational Awareness (”Team SA”) related tothe task they are working to achieve. In addition,in order to achieve Team SA, the team needsto communicate certain information, which yieldsShared Situational Awareness (”Shared SA”). We’lldiscuss each of theses concepts in turn.

Situational Awareness (without the ”Team” or”Shared” prefix) refers to the individual’s ability todetect, comprehend and understand a situation.Many definitions have been given, among themthe popular ”the perception of elements in theenvironment within a volume of time and space,the comprehension of their meaning, and theprojection of their status in the near future” byEndsley (Endsley, 1995a). Other, simpler onesinclude ”knowing what is going on so you can figureout what to do” (Adam, 1993) and ”what you needto know not to be surprised” (Jeannot, Kelly andThompson, 2003).

Endsley’s definition of Team SA is simpler thanfor the individual (but based on it): ”the degreeto which every team member possesses theSituational Awareness required for his or herresponsibilities” (Endsley, 1995a). In order for allteam members to have this situational awareness,

2


the members of the team usually needs tocommunicate. This leads us to Shared SA.

For all individuals in a team to have the requiredsituational awareness, each individual must be giventhe information they need, before they need it. Thismeans that not only must members communicatethe information they have, but they must understandwhich information others need, when, and whoneeds it. If everyone was to communicate everything,all the time, this would lead to a lot of noise, andprobably also to information overload, as everyonewould have to process all information and discardwhatever they do not need. With this in mind, let usnow return to Team SA.

We can divide aspects needed for Shared SA intothe following categories:

• Team SA Requirements – the team members’understanding of which information needs tobe shared with whom, and the status of otherson the team

• Team SA Devices – the ways team memberscan communicate the needed information,such as verbally or shared displays

• Team SA Mechanisms – mechanisms formembers to be able to interpret information inthe same way (e.g. shared mental models) andto predict each other’s actions

• Team SA Processes – the processes in placeto facilitate sharing of the required information(e.g. norms or procedures)

3. METHOD

3.1. The Setting

The trauma unit is part of the gastro-surgicaldepartment at Karolinska University Hospital thathas approximately 120 surgeons. The hospital hasapproximately 15,000 employees and 1600 patientbeds spread out at two different campuses, Solnaand Huddinge, approximately 26 kilometres apartin the city. The trauma unit is a centre for traumacases within the Stockholm county council. InHuddinge, the emergency unit occasionally mayhave to manage cases that are categorised astrauma. The emergency unit is divided into surgery,medicine, orthopedy, and head.

In order to investigate how the participants in traumacare perceive a situation relative to each otherwe chose to focus initially on trauma exercises atHuddinge, which are held about once every threemonths. A trauma exercise is a simulated real case,and from the moment it is announced that a patient

is incoming, the exercise is treated like a real case.As is also normal in a real case, team membersare given approximately two minutes warning to setup and introduce themselves to each other beforethe patient is rolled into the room by ambulancepersonnel.

A trauma resuscitation can be divided into fourphases; preparation, diagnosis and stabilisation,treatment, and discussion/analysis. The preparationphase begins when the alarm arrives indicating typeand level of trauma. The trauma team gathers in thetrauma room, present what roles they have, and theparticipants may put on a name tag (Sarcevic, Palenand Burd, 2011).

The case is then presented by the Trauma Leader,a surgeon acting as the main authority in the careof the patient. The team prepares for the patientto arrive with the ambulance. When the patientarrives, phase two is initiated by the ambulancepersonnel reporting from the accident scene and onthe status of the patient. The focus in this phaseis on diagnosing and first treatment to stabilise thepatient for further examinations and treatment. Thestabilisation is made by constant re-evaluation usinga prioritised list with the mnemonic A B C D E (the listwas developed by the American College of Surgeonsand is named Advanced Trauma Life Support, orATLS).

A Airways. Are the airways free?

B Breathing. Can the patient breathe? If not, theartificial respiration will be started.

C Circulation. Is the patient bleeding internally orexternally?

D Disabilities. Is the patient conscious andcoherent? The Glascow coma scale is used.

E Exposure/Environment. This point has thelowest priority and includes whether the patientis cold, etc.

The aim is to quickly get the patient under thecorrect treatment, phase three. We have focused ourresearch study mainly on the second phase. Thediscussion/analysis phase starts after the patient hasbeen rolled out, when parts of the team gathers in aroom outside the trauma room.

When a person with traumatic injuries is rolled intoa trauma centre, the team receiving the patientis highly structured. The structure of the teammay vary a bit depending on available resources,the circumstances of the accident and the natureof the patient (e.g. a case involving a child willoften result in a larger number of people showing

3


up, including more specialised personnel such aspaediatricians). All our exercises have involvedadults. At Huddinge, a team handling an adult patientconsists of a Trauma Leader, one trauma surgeon,an anaesthesiologist and a team of supportingnurses. In addition to the core team, supportingpersonnel providing CT scans and ultrasound areon hand, as well as a radiologist to interpretthe scans, and an orthopaedic surgeon. Figure 1shows the general layout of the personnel, with theanaesthesiologist at the head of the patient (leftmostperson), trauma surgeon by the patient’s right side(leftmost person with her back towards the viewer),trauma leader by the patient’s feet (standing with herarms crossed, facing the patient, between the twonurses with their back towards the viewer).

The team in a trauma resuscitation may also differdepending on the hospital (or even site as in ourcase) and what routines that have been set up. AtHuddinge, for example, they use a documenter thatkeeps track of what happens to the patient regardingwhat drugs are given, changes of the vital signs etc.The Solna site does not have this role.

3.2. The Study

Our study was initiated in the autumn of 2011 andis still ongoing. Over the course of four exercisesincluding in total 14 cases and 145 participants, wehave used two different types of patients. For tencases a human was used and for four cases anadvanced computerised doll was used (see Table 1).The doll is controlled by a human operator, whichalso acts as the patient’s voice, and has abilitiesthat a human actor does not, such as varying thepupil dilation separately for each eye, and measuringthe amount of fluids and types of medicine thatis injected. The operator’s workstation is shownin Figure 2. In the cases where a human wasused as the patient, no real injections were given,instead the needles were taped to the patient’sarm, but not penetrating the skin. For the doll,injections were given, as the doll has designatedentry points for needles, with the fluid being collectedin a bucket beneath the bed (real medicine orblood was not given, instead bags of colouredwater were used). Despite all of the doll’s features,the medical personnel at Huddinge responsible fortrauma exercises consider a human to give about thesame training value.

All teams were deemed to be at the samecompetence level. Remote support by expert traumapersonnel was used in seven of the cases (seeTable 2). Data was also collected from the remoteexpert, but this data has not been included inthe study (evaluating Shared SA with the remoteexpert will be the subject of another paper). Remote

Figure 2: Doll operator.

support was only included in half the cases inorder to juxtapose the performance of the teamwith and without remote support. When a traumaexercise was held, it usually included two scenarios(i.e. patients) and two or three teams of medicalpersonnel. Typically team A would start with scenario1, with remote support, and then move onto scenario2, without remote support. Team B would start withscenario 2, with remote support, and move on toscenario 1, without remote support. This meansthat most scenarios were handled both with andwithout remote support, and no team handled thesame scenario twice. There was no overlap inpersonnel between teams, so each scenario wasnew to everyone involved. In the cases involvingremote support, the camera angle and zoom couldbe controlled. Figure 3 show this scenario. Thelink included voice and two-way video. The on-sitetrauma leader was designated the main contact pointwith the remote expert, although in practice thetrauma surgeon often also entered the discussion.

In the tables we have opted to designate eachexercise with roman numerals, each case by a letterprefixed with the exercise designator and team by aletter prefixed with the exercise designator.

A trauma exercise is conducted in the same waya real trauma case would be handled. The alarmis simulated by the exercise leader presenting whathas happened, with the same level of coarse detailthat would have been communicated to the traumaleader and the trauma team in a real case. When thetransporters from the ambulance bring in the patientthey communicate to the group the type of trauma,the status of the vital parameters, if the patient hasbeen given any drugs, and other things that canbe of relevance. The trauma leader is in charge.In the cases where tele-consultation was used, ithad not previously been defined if the trauma leaderor the remote expert were in charge. The trauma

4


Exercise Type of patient Visualisation of vital signs Headcam

Comment

I Simulator doll Yes, on a screen by the anaes-thesiology monitor

No A biomedical technician inter-acted with the doll to give feed-back to the trauma team.

II Actor Only presented orally. NoIII Actor One big screen at the far foot

end of the patient.Yes

IV Actor One big screen at the far footend of the patient and one iPadon the anaesthesiology monitor.

No Short of staff, case 5 and 6were only observed, no remotesupport.

Table 1: An overview of the four trauma exercises

Case Team Scenario Remotesupport

Comment

I:1 I:A High-speed car crash NoI:2 I:A Fall from > 5 meters YesI:3 I:B High-speed car crash YesI:4 I:B Fall from > 5 meters NoII:1 II:A Fall from > 5 meters NoII:2 II:A Pedestrian hit by a car YesII:3 II:B Fall from > 5 meters YesII:4 II:B Pedestrian hit by a car NoIII:1 III:A Fall from > 5 meters No Only observed, no data collectedIII:2 III:A Abdominal gunshot wound Yes Head cam on the trauma leaderIII:3 III:B Fall from > 5 meters Yes Head cam on the trauma leader, did

not workIII:4 III:B Abdominal gunshot wound No Only observed, no data collectedIII:5 III:C Abdominal gunshot wound Yes Head cam on the trauma surgeonIII:6 III:C Fall from > 5 meters No Only observed, no data collectedIV:1 IV:A Pedestrian hit by a car NoIV:2 IV:A Fall from > 5 meters No Trauma surgeon from case III:1 is

trauma leader, a new trauma surgeonparticipates

IV:3 IV:B Pedestrian hit by a car No Only observed, no data collectedIV:4 IV:B Fall from > 5 meters NoIV:5 IV:C Pedestrian hit by a car No Only observed, no data collectedIV:6 IV:C Fall from > 5 meters No Only observed, no data collected

Table 2: List of the cases in each of the trauma exercises

5


scenario is controlled by an exercise leader whoinforms everybody in the room what is happeningwith the patient. For example, if the trauma surgeonis listening to the patient’s lungs the exercise leaderwould say out loud ”for the lungs you hear uncleanrespiration, not identical on both sides”. In the lastexercises vital signs were visualised on a screenthat everybody in the trauma room as well as theremote support could see. The parameters wereupdated by the exercise leader using a web browseron a smartphone. In the first exercises the leaderverbally informed the group on the status of theseparameters. In real trauma cases vital signs aredisplayed on the anaesthesiology equipment.

Using trauma exercises to study situational aware-ness when using remote support may not reflect anoptimal situation where tele-consultation would beused. This paper does not discuss the situationalawareness of the remote supporter versus that ofthe remainder of the group, nor whether a remotesupporter influences the situational awareness ofthe group compared to a group with no support.Instead, this paper focuses on the shared situationalawareness of the team on-site with the patient. Asmentioned, data collected from the remote expert isnot included in the dataset, so any lack of situationalawareness at the remote location does not affect ourresults.

Figure 3: Remote support.

3.3. Questionnaires and observations

The study consisted of a series of questionnairesthat was handed out directly after the end of acompleted trauma case, with no communicationallowed before all questionnaires were handed in.Questionnaires were handed out in 14 of the cases inthe four exercises. Video was also taken of all casesbut two, to support our analysis and understanding(necessary for our future work, which will introducetechnology into the setting).

The questionnaire has been developed by aphysician (anaesthesiologist) at Karolinska as part ofa research project to create a tool for evaluating theeffectiveness of remote support in trauma exercises.It attempts to arrive at a set of questions that allparticipants in the emergency room should be ableto answer, regardless of the type of scenario theyhave handled. The quality of the questionnaire isevaluated using Content Validity Index (Polit, Beckand Owen, 2007) using a group of medical expertsand trauma personnel. Refining the questionnaire isongoing work, but as used in this study it consistedof 64 multiple-choice questions, with options beingeither ”Yes”, ”No”or ”Unknown”.

In two cases (5 and 6) in exercise III, the exerciseleader had to take the role of trauma leader becausethey were short staffed. As this person knew thescenario we have not added the data collected tothe dataset, and instead only observed the case.We also observed one trauma exercise conductedbefore those in which we performed our studies. Asummary of all the studies and observations duringtrauma exercises is given in Table 3. All the casesat the four trauma exercises except two have beenvideo recorded.

We have also conducted field studies at theemergency unit in both sites, one observation atHuddinge and three observations at Solna, one ofthem during the night shift. Field notes were takenduring the observations.

A potential criticism is that we do not make useof the Situation Awareness Global AssessmentTechnique (”SAGAT”) (Endsley, 1995b) to measurethe situational awareness. With SAGAT we could usethe same questionnaire, but it would be necessaryto stop the exercise at random times in the middle ofthe trauma case and administer the questionnaire.This would indeed give more detailed results, but wehave unfortunately not been able to do this yet dueto other constraints at the hospital.

3.4. Analysis

To arrive at a measurement for the level of sharedsituational awareness within each group, we havemade use of Fleiss’ kappa (Fleiss, 1971), whichmeasures the level of agreement between ratersabove what would be expected if they made theirratings completely random.

As part of calculating Fleiss’ kappa one has tocalculate the extent to which raters agree on eachquestion (i.e. the number of rater-rater pairs thatare in agreement, relative to the number of possiblerater-rater pairs), for a given patient case. Perfectagreement for a question gives a score of 1.0.

6


κ Interpretation< 0 Poor agreement

0.01 – 0.20 Slight agreement0.21 – 0.40 Fair agreement0.41 – 0.60 Moderate agreement0.61 – 0.80 Substantial agreement0.81 – 1.00 Almost perfect agreement

Table 3: Suggested interpretation table for kappa

A possible criticism here could be that the consensusof the entire team is not important, only betweenthe most important roles (e.g. trauma leader,trauma surgeon and anaesthesiologist). However,the medical view, and official policy, of the hospitalwe work with is that the communication needs to beadequate to involve the entire team, not only doctors,as each member may have valuable observationsand experiences to draw from.

3.5. Qualitative analysis

Eight of the 22 video recordings from the traumaexercises have been transcribed and tagged basedon what happened. The other video recordings havebeen watched and sections of interest, i.e. fittingthe tags, have been transcribed. Field notes fromthe observation studies have been transcribed andtagged based on what happened.

4. RESULTS

4.1. Kappa scores

In Figure 4 we can see the kappa results (y-axis)for the 14 cases (x-axis), for different groupings ofroles in the team. Although it is true that the goal ofthe hospital is that everyone has the same level ofsituational awareness, we find the data interestingin order to understand which parts of the groupmanage to keep a high level of shared SA, and whichdo not.

The series with legend ”All” is the value witheveryone is included (except the remote supporter,which is not included in any result), ”Trio”is a designator for the combination of traumaleader, trauma surgeon and anaesthesiologist(this is considered the three most importantroles in the team). ”Non-trio” is everyone elsebesides the trauma leader, trauma surgeon andanaesthesiologist. ”MDs” is all medical doctors in theteam, and ”Non-MDs” are all non-doctors, such asnurses.

We can see from this chart that except for two cases(III:2 and IV:4), the trio of trauma leader, traumasurgeon and anaesthesiologist scores consistently

higher than the rest (Non-trio), an indication thatthere is more consensus, and thus more Shared SA,in this group. It is important to note, however, thatthe trio-group is much smaller (3 people) than thenon-trio (usually around 8), so it is more prone tochance. Thus, this finding should be backed up byother measures of Shared SA (such as subjectivemeasures, self-assessment, interviews etc).

The lowest agreement (not kappa) for any questionin the dataset was 0.238. To highlight a fewexamples, a team scored 0.267 on a question aboutwhether flail chest (a life critical condition) wassuspected, and another team scored 0.333 for aquestion regarding suspected head injury. 29% ofagreement-levels were perfect agreements, meaningthat everyone on the team chose the same answer toa question.

High disagreement highlights confusion within theteam, something we want to avoid. If a score islow, it is a strong indication that the team has notcommunicated well enough (Mentis, Reddy andRosson, 2010).

Fleiss’ kappa for the whole dataset (i.e. all casescombined) was 0.495. Considering that the scorecould be approaching 1.0, this is a clear indicationthat there is room for improvement. Even using thesuggested interpretation table (Landis and Koch,1977), shown in Table 3, the score ranks at a mere”Moderate agreement” – something we would claimto be a low score considering that this is medicalpersonnel working together to save lives.

4.2. Observations from the exercises

In one of the cases (III:2) it is clear that the traumaleader either does not notice what two other personsare saying, or he has forgotten. One of the nursessays that she has set another peripheral venouscatheter on the patient. The exercise leader repeatsthis out loud. A while after that, when they haveturned the patient to check the wound on the back,the remote trauma support says that they should dothe massive transfusion protocol. The trauma leadersays that they will run the protocol but that theyonly have one peripheral venous catheter. The nurseresponds that they have two, both by saying so andby holding up two fingers in the air.

In the same exercise and case, right after theabove described incident the anaesthesiologist asksabout the plan. An earlier dialogue between thetrauma leader and the remote trauma support hasnot been noticed or heard by the anaesthesiologist.Already six minutes after the patient has arrived,the remote trauma support says that they have anobvious circulation-problem and that the patients

7


Figure 4: Kappa scores for 14 trauma cases.

need surgery as quick as possible, and that theyneed to pack the patient and that the entrances needto be set. The trauma leader repeats this to the team:”We must simply try to set one more entrance tomake the patient stable ... or ... prepare for surgery.We will block turn before, to see if we need to open inanother place, ok.”. They turn the patient and look atthe wound on the back. The remote trauma supportrepeats that the patient should be packed and go tosurgery.

In case IV:5 (only observed) it was quite obvious thatit is important to make re-evaluations of the patient’sstatus continuously in order for everybody to knowwhat has happened and what will happen. In caseIV:5 the exercise leader acted as a trauma leadertogether with the trauma surgeon, and it was theexercise leader who, in the role of a trauma leader,suggested that they should do a final re-evaluationbefore rolling out the patient to the CT-scan andOR in order to treat a diagnosed orthopaedic injury:”Let’s re-evaluate once more before we leave so thatwe are sure that everything feels ok”. Hence, there-evaluations are considered important enough tobe motivated a delay of transporting the patient forfurther treatment.

Each participant has a specific role, but there isflexibility in who does what. For example, if thetrauma leader needs to perform a specific activitybecause she is the one with those skills, anotherperson may take over the trauma leader role. Thisdid not happen in any of the cases we collected datafrom, but it happened in a single case when we wereonly observing.

After a trauma exercise the participants gatherand go through the case. In the first exercise weobserved they had this discussion and the firstquestion asked was what kind of accident the patienthad been involved in. Everybody in the team gets torespond to the question. Two of the participants said

that it was a motorbike accident while the others saidit was a belted driver in a car. The two people whowere wrong, may not have had central roles in theresuscitation, but still, all persons participating in atrauma resuscitation must have the same picture ofwhat has happened and is happening.

In informal interviews, trauma surgeons and othershave stated a heartfelt need for introducing displaysand connectivity throughout the chain of care, fromthe ambulance to the operating theatre. At Huddingethey had a test system some years ago whereambulance personnel took a picture of the placeof the accident with a mobile phone. This wassomething they still want implemented, alongsidestreams of vital signs from an ambulance or ahelicopter, as it may provide an important context.Similarly, personnel in the operating theatre say theycould benefit from being able to follow the events inthe trauma room (or even earlier information fromthe transit phase, as the progression of the patient’sstate is important). On the other hand, one of thetrauma experts in Solna says that he only believesthe vital signs would be important to send fromthe ambulance or helicopter. Images of the accidentwould not be of any help for the trauma resuscitation.

5. DISCUSSION

Throughout this study we have worked closelywith personnel at the hospitals. We have metlittle resistance towards the idea of introducingtechnology into this setting. In fact, most seem to seethis as inevitable, and positive. The resistance wehave faced has been from nurses worrying that theirtrauma exercises would be too experimental andnot match the current setting with less technology.There has been no resistance from someonebelieving technology would hinder them in their work.Instead, we believe the current political ambitionof supporting trauma care through telemedicineprovides an opportunity for the HCI community to

8


gain entry to personnel, facilities and resources, inorder to help shape tomorrow’s systems for savinglives.

Our aim with the study has been to investigate theshared situational awareness among the participantsin the trauma room during resuscitation. In ordinarytrauma exercises questionnaires with 64 multiple-choice questions have been handed out at the endof each case. The results from our study showa rather low shared situational awareness amongthe participants. When analysing recordings fromthe exercises we identified a correspondence in theresults from teams with high situational awarenessas being more organised and clear during theresuscitation. Similarly, in teams with low situationalawareness we could identify misunderstandings orinformation spoken not being registered by personswith central roles. For example, if the trauma leader,with the most central role during the resuscitation,does not register what is said, important issues maynot be communicated. There is a lot of noise in thetrauma room that can explain why the trauma leadermissed important information.

Apart from two cases we can see a correspondencein high and low levels of shared situationalawareness among the medical doctors and thegroup of nurses. This is not surprising, butemphasises the importance of a structured andorganised trauma leader. If the trauma leaderfails to communicate important information to theteam, the less experienced will be the group ofparticipants that may not have a clear picture ofwhat happens. The medical doctors appear to havea better understanding of the case even if the traumaleader fails to communicate important information.The trauma leader should, if necessary, continuouslyre-evaluate the status of the patient according to theATLS protocol. This is practiced during the exercises.

REFERENCES

Adam, E.C. (1993). Fighter cockpits of the future.Proceedings of 12th IEEE/AIAA Digital AvionicsSystems Conference (DASC), 318323.

Bardram, J.E., Hansen, T.R., Soegaard, M.: Aware-Media: a shared interactive display support-ing social, temporal, and spatial awareness insurgery. Computer supported cooperative work.pp. 109118. ACM (2006).

Bolstad, C. A. & Endsley, M. R. (2000). Shareddisplays and team performance. Proc. of HumanPerformance, Situation Awareness and Automa-tion Conference.

Endsley, M.R. (1995). Toward a theory of situationawareness in dynamic systems. Human Factors37(1), 3264.

Endsley, M.R. (1995). Measurement of situationawareness in dynamic systems. Human Factors,37(1), 6584.

Endsley, M. R., Bolte, B., & Jones, D. G. (2003).Designing for situation awareness: An approach tohuman-centered design. London: Taylor & Francis.

Fleiss, J. L. (1971) ”Measuring nominal scaleagreement among many raters.” PsychologicalBulletin, Vol. 76, No. 5 pp. 378382

Frykholm, O., Nilsson, M., Groth, K., Yngling,A.: Interaction design in a complex con-text.Proceedings of the 7th Nordic Conferenceon Human-Computer Interaction Making SenseThrough Design - NordiCHI 12. p. 341. ACMPress, New York, New York, USA (2012).

Gutwin, C., & Greenberg, S. (2002). A descriptiveframework of workspace awareness for real-timegroupware. Computer Supported CooperativeWork (Vol. 11, pp. 411446). Springer. Retrievedfrom http://www.springerlink.com/index/h51l362v34870961.pdf

Hill, K.: The sound of silence - nurses non-verbalinteraction within the ward round. Nursing inCritical Care. 8, 231239 (2003).

Hornbæk, K., Hertzum, M.: The notion of overview ininformation visualization. Interna-tional Journal ofHuman-Computer Studies. 69, 509525 (2011).

Jansson, M., Mortberg, C., Mirijamdotter, A.:Participation in e-home healthcare @ NorthCalotte. Proceedings of the 5th Nordic conferenceon Human-computer interaction build-ing bridges -NordiCHI 08. p. 192. ACM Press, New York, NewYork, USA (2008).

Jeannot, E., Kelly, C. & Thompson, D. (2003). Thedevelopment of situation awareness measures inATM systems. Brussels: Eurocontrol.

Landgren, J.: Making action visible in time-criticalwork. Proceedings of the SIGCHI con-ference onHuman Factors in computing systems CHI 06. 201(2006).

Landis, J. R., and Koch, G. G. The measurementof observer agreement for categorical data.Biometrics 33, 1 (1977), 159174.

Leonard, M.: The human factor: the critical impor-tance of effective teamwork and communication inproviding safe care. Quality and Safety in HealthCare. 13, i85i90 (2004).

9


McCurdy, N. J., Griswold, W. G., and Lenert,L. A. Realityflythrough: Enhancing situ-ationalawareness for medical response to disastersusing ubiquitous video. AMIA Annual Symposiumproceedings AMIA Symposium AMIA Symposium2005, 510514.

Mentis, H.M., Reddy, M., Rosson, M.B.: Invisibleemotion. Proceedings of the 2010 ACM confer-ence on Computer supported cooperative work -CSCW 10. p. 311. ACM Press, New York, NewYork, USA (2010).

Morrison, C., Fitzpatrick, G., Blackwell, A.: Multi-disciplinary collaboration during ward rounds:embodied aspects of electronic medical recordusage. International journal of medical informatics.80, e96111 (2011).

Paul, S.A., Reddy, M.C.: Understanding together.Proceedings of the 2010 ACM conference onComputer supported cooperative work - CSCW10. p. 321. ACM Press, New York, New York, USA(2010).

Polit D.F., Beck C.T., Owen S.V.: Is the CVI anacceptable indicator of content validity? Appraisaland recommendations. Res Nurs Health. 2007Aug;30(4):459-67. Review.

Randell, R., Wilson, S., Fitzpatrick, G.: EditorialEvaluating New Interactions in Health Care:Challenges and Approaches. International Journal

of Human-Computer Interaction. 26, 407413(2010).

Reddy, M.C., Spence, P.R.: Collaborative informationseeking: A field study of a multidis-ciplinarypatient care team. Information Processing &Management. 44, 242255 (2008).

Reddy, M.C.M., Dourish, P., Pratt, W.: Coordinatingheterogeneous work: Information and represen-tation in medical care. In: Prinz, W., Jarke, M.,Rogers, Y., Schmidt, K., and Wulf, V. (eds.) EC-SCW 2001. pp. 239258. Springer (2001).

Reddy, M.C., Paul, S. A, Abraham, J., McNeese, M.,DeFlitch, C., Yen, J.: Challenges to effective crisismanagement: using information and communica-tion technologies to coordinate emergency med-ical services and emergency department teams.International journal of medical informatics. 78,25969 (2009).

Sarcevic, A., Palen, L.A., Burd, R.S.: Coordinatingtime-critical work with role-tagging. Proceedingsof the ACM 2011 conference on Computersupported cooperative work - CSCW 11. p. 465.ACM Press, New York, New York, USA (2011).

Tachakra, S., Jaye, P., Bak, J., Hayes, J., Sivakumar,a: Supervising trauma life support by telemedicine.Journal of telemedicine and telecare. 6 Suppl 1,S711 (2000).

10

measuring shared situational awareness at a swedish trauma …€¦ · measuring shared situational...

Documents